Vestibular rehabilitation in cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS)- A case report.

Background and purpose: Cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (CANVAS) is a neurodegenerative disease of the cerebellum. The disease progression is slow, with up to 25% of people diagnosed needing to use a wheelchair after 15 years from diagnosis. Vestibular symptoms arise from centrally-mediated ocular movement degradation and the reduced vestibular-ocular reflex functioning bilaterally. To date, no report has shown an improvement in VOR gain or gait outcome measures in someone with CANVAS after a course of vestibular physical therapy. Case description: A 65-year-old male, Patient X, first noticed symptoms in his fourth decade of life and was diagnosed with (CANVAS) in his seventh decade. Patient X reported numbness and tingling in his hands and feet, decreased ability to perform daily activities, and several falls. Intervention: Patient X completed a four-month course of vestibular physical therapy, including vestibular ocular reflex exercises, balance training, gait training, and the VestAid application for eye gaze compliance monitoring. The Vestaid application uses eyes and facial recognition software to record the percentage of time that the patient kept their eyes on the target. Outcomes: After vestibular therapy, Patient X had a clinically meaningful improvement in gait speed: from 1.02 m/s to 1.13 m/s and in the Functional Gait Assessment from 20/30 to 27/30. Patient X's eye gaze compliance improved from a median of 43% (range 25-68%) to a median of 67% (58-83%). Discussion: This case study demonstrates that vestibular rehabilitation improved eye gaze compliance and functional outcomes in a person living with CANVAS.

Curriculum for Vestibular Medicine (VestMed) proposed by the Bárány Society.

This document presents the initiative of the Bárány Society to improve diagnosis and care of patients presenting with vestibular symptoms worldwide.The Vestibular Medicine (VestMed) concept embraces a wide approach to the potential causes of vestibular symptoms, acknowledging that vertigo, dizziness, and unsteadiness are non-specific symptoms that may arise from a broad spectrum of disorders, spanning from the inner ear to the brainstem, cerebellum and supratentorial cerebral networks, to many disorders beyond these structures.The Bárány Society Vestibular Medicine Curriculum (BS-VestMed-Cur) is based on the concept that VestMed is practiced by different physician specialties and non-physician allied health professionals. Each profession has its characteristic disciplinary role and profile, but all work in overlapping areas. Each discipline requires good awareness of the variety of disorders that can present with vestibular symptoms, their underlying mechanisms and etiologies, diagnostic criteria and treatment options. Similarly, all disciplines require an understanding of their own limitations, the contribution to patient care from other professionals and when to involve other members of the VestMed community. Therefore, the BS-VestMed-Cur is the same for all health professionals involved, the overlaps and differences of the various relevant professions being defined by different levels of detail and depth of knowledge and skills.The BS-VestMed-Cur defines a Basic and an Expert Level Curriculum. The Basic Level Curriculum covers the VestMed topics in less detail and depth, yet still conveys the concept of the wide net approach. It is designed for health professionals as an introduction to, and first step toward, VestMed expertise. The Expert Level Curriculum defines a Focused and Broad Expert. It covers the VestMed spectrum in high detail and requires a high level of understanding. In the Basic and Expert Level Curricula, the range of topics is the same and runs from anatomy, physiology and physics of the vestibular system, to vestibular symptoms, history taking, bedside examination, ancillary testing, the various vestibular disorders, their treatment and professional attitudes. Additionally, research topics relevant to clinical practice are included in the Expert Level Curriculum. For Focused Expert proficiency, the Basic Level Curriculum is required to ensure a broad overview and additionally requires an expansion of knowledge and skills in one or a few specific topics related to the focused expertise, e.g. inner ear surgery. Broad Expert proficiency targets professionals who deal with all sorts of patients presenting with vestibular symptoms (e.g. otorhinolaryngologists, neurologists, audiovestibular physicians, physical therapists), requiring a high level of VestMed expertise across the whole spectrum. For the Broad Expert, the Expert Level Curriculum is required in which the minimum attainment targets for all the topics go beyond the Basic Level Curriculum. The minimum requirements regarding knowledge and skills vary between Broad Experts, since they are tuned to the activity profile and underlying specialty of the expert. The BS-VestMed-Cur aims to provide a basis for current and future teaching and training programs for physicians and non-physicians. The Basic Level Curriculum could also serve as a resource for inspiration for teaching VestMed to students, postgraduate generalists such as primary care physicians and undergraduate health professionals, or anybody wishing to enter VestMed. VestMed is considered a set of competences related to an area of practice of established physician specialties and non-physician health professions rather than a separate clinical specialty. This curriculum does not aim to define a new single clinical specialty. The BS-VestMed-Cur should also integrate with, facilitate and encourage translational research in the vestibular field.

The role of sensory augmentation for people with vestibular deficits: Real-time balance aid and/or rehabilitation device?

This narrative review highlights findings from the sensory augmentation field for people with vestibular deficits and addresses the outstanding questions that are critical to the translation of this technology into clinical and/or personal use. Prior research has demonstrated that the real-time use of visual, vibrotactile, auditory, and multimodal sensory augmentation technologies can improve balance during static and dynamic stance tasks within a laboratory setting. However, its application in improving gait requires additional investigation, as does its efficacy as a rehabilitation device for people with vestibular deficits. In some locomotor studies involving sensory augmentation, gait velocity decreased and secondary task performance worsened, and subjects negatively altered their segmental control strategies when cues were provided following short training sessions. A further question is whether the retention and/or carry-over effects of training with a sensory augmentation technology exceed the retention and/or carry-over effects of training alone, thereby supporting its use as a rehabilitation device. Preliminary results suggest that there are short-term improvements in balance performance following a small number of training sessions with a sensory augmentation device. Long-term clinical and home-based controlled training studies are needed. It is hypothesized that sensory augmentation provides people with vestibular deficits with additional sensory input to promote central compensation during a specific exercise/activity; however, research is needed to substantiate this theory. Major obstacles standing in the way of its use for these critical applications include determining exercise/activity specific feedback parameters and dosage strategies. This paper summarizes the reported findings that support sensory augmentation as a balance aid and rehabilitation device, but does not critically examine efficacy or the quality of the research methods used in the reviewed studies.

An overview of vestibular rehabilitation.

Data related to the efficacy of vestibular rehabilitation and its evolution as an intervention are provided. Concepts and various treatment strategies are described, with explanations of why people with uncompensated peripheral and central vestibular disorders might improve with rehabilitation. Various tests and measures are described that are commonly used to examine patients and determine their level of ability to participate in their environment. Factors that affect recovery, both positively and negatively, are described in order to better prognosticate recovery. A case utilizing many of the principles discussed is included to provide insight into how to utilize vestibular rehabilitation with a person with an uncompensated peripheral vestibular loss.

A Conceptual Framework for the Progression of Balance Exercises in Persons with Balance and Vestibular Disorders.

There is little information in peer-reviewed literature to specifically guide the choice of exercise for persons with balance and vestibular disorders. The purpose of this study is to provide a rationale for the establishment of a progression framework and propose a logical sequence in progressing balance exercises for persons with vestibular disorders. Our preliminary conceptual framework was developed by a multidisciplinary team of physical therapists and engineers with extensive experience with people with vestibular disorders. Balance exercises are grouped into six different categories: static standing, compliant surface, weight shifting, modified center of gravity, gait, and vestibulo-ocular reflex (VOR). Through a systematized literature review, interviews and focus group discussions with physical therapists and postural control experts, and pilot studies involving repeated trials of each exercise, exercise progressions for each category were developed and ranked in order of degree of difficulty. Clinical expertise and experience guided decision making for the exercise progressions. Hundreds of exercise combinations were discussed and research is ongoing to validate the hypothesized rankings. The six exercise categories can be incorporated into a balance training program and the framework for exercise progression can be used to guide less experienced practitioners in the development of a balance program. It may also assist clinicians and researchers to design, develop, and progress interventions within a treatment plan of care, or within clinical trials. A structured exercise framework has the potential to maximize postural control, decrease symptoms of dizziness/visual vertigo, and provide "rules" for exercise progression for persons with vestibular disorders. The conceptual framework may also be applicable to persons with other balance-related issues.

Effect of chewing on postural stability during quiet standing in healthy young males.

BACKGROUND AND AIMS: There is an important role of the neck sensory motor system in control of body posture and balance, and it is reasonable to believe that the jaw sensory motor system can directly and indirectly influence the modulation of the postural control system. The purpose of this study was to evaluate possible effects of dynamic jaw position while chewing on the postural control system. MATERIALS AND METHODS: We compared the mean center of gravity (COG) velocity during quite standing on a foam surface with eyes closed during three test conditions: (i) with resting jaw position, (ii) with open jaw position, and (iii) while chewing standard bolus of chewing gum. One hundred and sixteen normal healthy male subjects (average age 31.56 ± 8.51 years; height 170.86 ± 7.26 cm) were recruited for the study. Their COG velocity (deg/s) was measured using the NeuroCom® Balance Master Version 8.5.0 (Clackamas, OR, USA). STATISTICAL ANALYSIS: Data was tested by the Friedman test. RESULTS AND CONCLUSIONS: The results show that COG velocity decreased significantly while chewing in comparison to both open and resting jaw position (p < 0.0001). Our finding corroborates previous studies and suggests that the jaw sensory motor system can modulate postural control mechanisms. Gum chewing activity can enhance the postural stability during upright standing on an unstable surface and in the absence of visual input in healthy young adults. Our results should be taken into consideration in treatment and rehabilitation planning for patients with postural instability.

A comparison of accelerometry and center of pressure measures during computerized dynamic posturography: a measure of balance.

Accelerometry (ACC) shows promise as an easily implemented clinical measure of balance. The purpose of the study was to estimate test-retest reliability of ACC measures and determine the relationship between ACC measured at the pelvis and underfoot center of pressure (COP) measures during sensory organization test (SOT) conditions. Eighty-one subjects were recruited from the community with no known orthopedic or vestibular deficits (19-85 years). Subjects completed three consecutive, ninety second trials for each of the six SOT conditions, while wearing the accelerometer. ACC and COP time series were described by calculating the normalized path length, root mean square (RMS), and peak-to-peak values. The test-retest reliability of the three measures within each SOT condition was estimated over three trials using the intraclass correlation coefficient. ACC and COP test-retest reliability were similar, ranging from 0.63 to 0.80 using ACC and 0.42 to 0.81 using COP for the measure of normalized path length. Linear regression between ACC and COP measures showed significant correlation under almost every SOT condition using both single and average measures across trials. The degree of association between COP and ACC was equivalent when using the first trial or the 3-trial average, suggesting that one trial may be sufficient. The use of accelerometry may have value in estimating balance function and minimizing clinical evaluation time.

Vestibular rehabilitation using a wide field of view virtual environment.

This paper presents a theoretical justification for using a wide field of view (FOV) virtual reality display system for use in vestibular rehabilitation. A wide FOV environment offers some unique features that may be beneficial to vestibular rehabilitation. Primarily, optic flow information extracted from the periphery may be critical for recalibrating the sensory processes used by people with vestibular disorders. If this hypothesis is correct, then wide FOV systems will have an advantage over narrow field of view input devices such as head mounted or desktop displays. Devices that we have incorporated into our system that are critical for monitoring improvement in this clinical population will also be described.

Vestibular rehabilitation for patients with agoraphobia and vestibular dysfunction: a pilot study.

This study examined whether physical therapy with vestibular rehabilitation exercises would benefit patients with agoraphobia and vestibular dysfunction. Nine patients went through a 2-week no-treatment baseline phase, a 4-week behavioral treatment phase focusing on self-directed exposure, and an 8-12-week vestibular rehabilitation phase (weekly sessions). On the main outcome measure, clinical global impressions (CGI) ratings of severity, behavioral treatment was accompanied by a reduction in severity (effect size d=0.8; P<.10). On the supplementary measures, the Hamilton Anxiety Scale (Hamilton-A) and the Chambless Mobility Inventory (MI), no significant improvements were noted. After vestibular rehabilitation therapy, further improvement occurred in CGI severity (d=0.65; two-tailed P<.10), and significant improvements occurred in the supplementary measures. The physical therapist identified motion-induced dizziness and disturbances in balance in most patients. These improved with rehabilitation. Although the results can be attributed to other explanations, they are not inconsistent with the hypothesis that vestibular dysfunction maintains agoraphobic symptoms in some patients.

Physical therapy outcomes for persons with bilateral vestibular loss.

OBJECTIVE: The purpose of the study was to assess the efficacy of physical therapy for patients with bilateral vestibular loss. STUDY DESIGN: Retrospective case series. METHODS: Twenty-four patients with a diagnosis of bilateral vestibular loss were identified by a retrospective chart review. Thirteen of the 24 patients met the inclusion criteria of having a moderate or greater loss of vestibular function bilaterally as rated by an otoneurologist based on the patient's vestibular function tests. These patients were treated with a custom-designed physical therapy program for a mean of 4.6 visits over an average period of 3.8 months. Patients completed the Dizziness Handicap Inventory and the Activities-specific Balance Confidence Scale at initial evaluation and discharge. Patients were asked to perform the balance and gait tasks of the Dynamic Gait Index, Sensory Organization Test of computerized dynamic posturography, and the Timed "Up and Go" test at their first and last physical therapy sessions. The number of falls in the previous 4 weeks and the use of an assistive device at initial evaluation and discharge were reported. Composite score, an overall score of clinical outcome, was calculated to determine clinically significant changes in physical performance and subjective information. RESULTS: On a population basis, statistically significant improvement was observed after physical therapy for each of the outcome measures including the composite score (P < .05). Clinically significant changes were demonstrated by 33% to 55% of the patients on the various outcome measures. No change was noted in the patients' risk of falling, their number of falls, and the use of assistive devices. CONCLUSION: Many patients with bilateral vestibular loss benefit from an individualized vestibular physical therapy exercise program based on improved physical function and reduced self-perceived levels of handicap.

Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine.

OBJECTIVES/HYPOTHESIS: To assess the efficacy of physical therapy for patients with a diagnosis of migraine-related vestibulopathy (MRV) or vestibular dysfunction with a history of migraine headache. STUDY DESIGN: Retrospective case series METHODS: Thirty-nine patients were identified through a retrospective chart review, 14 with a diagnosis of MRV and 25 with migraine headache. The patients were treated with a custom-designed physical therapy exercise program for a mean of 4.9 visits over a mean duration of 4 months. Patients completed the Dizziness Handicap Inventory (DHI), the Activities-Specific Balance Confidence Scale (ABC), and the Dynamic Gait Index (DGI), reported the number of falls they had experienced in the past 4 weeks, and rated the severity of their dizziness on an analogue scale of 0 to 100 at initial evaluation and at discharge. RESULTS: Significant differences were seen before and after therapy in each of the outcome measures used. The average decrease in DHI score was 12 points (P < .01). ABC scores increased an average of 14 points (P < .01). Subjects increased their DGI scores an average of 4 points (P < .01). The number of patients reporting more than one fall decreased by 78% at discharge. (P < .05). Baseline symptoms of dizziness decreased an average of 11 points (P < .05). CONCLUSIONS: Patients with MRV and migraine headache demonstrated improvement in physical performance measures and self-perceived abilities after vestibular physical therapy.

The dynamic gait index relates to self-reported fall history in individuals with vestibular dysfunction.

The purpose of this study was to determine the relationship between gait instability and falls history in people with vestibular disorders. A total of 247 people (164 women, 83 men) participated in the study (mean age = 62.5). Falls history within the last 6 months and scores on the Dynamic Gait Index (DGI) were compared using the Mantel-Hantzel Chi-square statistic. Thirty-seven percent of all subjects reported falling within the last 6 months. Odds ratios in favor of falls with DGI scores of 19 or lower was 2.58 (95% C.I. 1.47-4.53). Subjects with DGI scores of 19/24 or less were 2.58 times more likely to have reported a fall in the previous 6 months than subjects with scores above 19. Younger subjects (those under 65 years of age) with vestibular disorders reported more falls than persons 65 years of age or over. Younger people may be more willing to risk a fall while actively having a vestibular disorder. The DGI appears to be a good indicator of fall status in persons with vestibular disorders, regardless of age.

Efficacy of vestibular rehabilitation.

This article is a summary of the research on the effectiveness of vestibular rehabilitation in patients with vestibular disorders. The literature on patients with peripheral, central, combined peripheral and central disorders, and panic and anxiety disorders is reviewed. The positive outcomes of intervention are highlighted.

Cervicogenic dizziness: a review of diagnosis and treatment.

The diagnosis of cervicogenic dizziness is characterized by dizziness and dysequilibrium that is associated with neck pain in patients with cervical pathology. The diagnosis and treatment of an individual presenting with cervical spine dysfunction and associated dizziness complaints can be a challenging experience to orthopaedic and vestibular rehabilitation specialists. The purpose of this article is to review the incidence and prevalence, historical background, and proposed pathophysiology underlying cervicogenic dizziness. In addition, we have outlined the diagnostic criteria, evaluation, and treatment of dizziness attributed to disorders of the cervical spine. The diagnosis of cervicogenic dizziness is dependent upon correlating symptoms of imbalance and dizziness with neck pain and excluding other vestibular disorders based on history, examination, and vestibular function tests. When diagnosed correctly, cervicogenic dizziness can be successfully treated using a combination of manual therapy and vestibular rehabilitation. We present 2 cases, of patients diagnosed with cervicogenic dizziness, as an illustration of the clinical decision-making process in regard to this diagnosis.

The activities-specific balance confidence scale and the dizziness handicap inventory: a comparison.

Vestibular dysfunction can have a tremendous impact on an individual's quality of life. The purpose of this paper is to determine if the level of handicap reported by individuals on the Dizziness Handicap Inventory (DHI), an inventory developed for use with individuals with complaints of dizziness symptoms, will be consistent with that reported on the Activities-specific Balance Confidence Scale (ABC), a tool developed for use with elderly individuals that attempts to assess a person's confidence level in performing activities of daily living (ADL's). A sample of convenience was used consisting of 71 subjects (15 males and 56 females) from a local Balance and Vestibular Clinic. The subjects ranged in age from 26 to 88 years of age. Both the DHI and the ABC were administered as part of an initial physical therapy evaluation to new patients at the clinic. A moderately strong negative correlation was found between the scores of the two inventories (Ts = -0.6350). The results suggest that the ABC is a valid tool for use with individuals with complaints of dizziness.

The influence of dynamic visual environments on postural sway in the elderly.

Postural sway during stance has been found to be sensitive to moving visual scenes in young adults, children, and those with vestibular disease. The effect of visual environments on balance in elderly individuals is relatively unknown. The purpose of this study was to compare postural sway responses of healthy elderly to those of young subjects when both groups were exposed to a moving visual scene. Peak to peak, root mean squared, and mean velocity of the center of pressure were analyzed under conditions combining four moving scene amplitudes (2.5o, 5o, 7.5o, 10o) and two frequencies of scene movement (0.1 Hz, 0.25 Hz). Each visual condition was tested with a fixed floor and sway referenced platform. Results showed that elderly subjects swayed more than younger subjects when experiencing a moving visual scene under all conditions. The elderly were affected more than the young be sway referencing the platform. The differences between the two age groups were greater at increased amplitudes of scene movement. These results suggest that elderly are more influenced by dynamic visual information for balance than the young, particularly when cues from the ankles are altered.

A review of balance instruments for older adults.

OBJECTIVE: The purpose of this article is to review balance instruments developed within the past 10 years that can be used in the clinic or home environment. The use of such instruments may assist in identifying older adults who are at risk for falling, a major problem that can result in impaired function and loss of independence. METHOD: Six instruments were reviewed: the Berg Balance Scale (Berg), the Clinical Test of Sensory Interaction and Balance (CTSIB), the Functional Reach Test, the Tinetti Balance Test of the Performance-Oriented Assessment of Mobility Problems (Tinetti), the Timed "Up and Go" Test (TU>), and the Physical Performance Test (PPT). Considered were what aspects of balance are assessed, time needed to administer the instrument, tools or equipment needed, evidence of reliability and validity, advantages and disadvantages, and the target population. RESULTS: The Berg, Tinetti, and PPT measure a variety of aspects of balance, whereas the Functional Reach, TU>, and CTSIB measure more narrow aspects of balance. All six instruments have been used with older adults and do not require much equipment. The instruments differ in their reliability and validity. CONCLUSION: Familiarity with balance instruments can be helpful in selecting the one most appropriate for clinical setting and clients in order to institute appropriate prevention programs, such as environmental modifications and lifestyle adaptations.

Functional reach and single leg stance in patients with peripheral vestibular disorders.

The purpose of this study was to compare functional reach distance and right single leg stance time in patients who had peripheral vestibular disease. Twenty-eight patients (15 female, 13 male) between the ages of 35 and 84 were asked to perform 3 trials each of functional reach (FR) and right single leg stance (SLS). SLS times were measured by a Kistler static force platform on line with a Caspar personal computer. FR distance was measured by using a free-standing 147-cm rule. In addition, each subject filled out the Dizziness Handicap Inventory (DHI). Trials were randomized to prevent fatigue or practice effects. A Pearson product-moment correlation was performed between FR and SLS (r = 0.59, P = 0.001). Post hoc analyses of the first, the best, and the average scores highlighted the importance of using means for comparison in a population as variable as the vestibularly impaired. Post hoc analyses showed no correlation between the DHI score and either functional reach distance or single leg stance time. However, when the subjects were divided into groups based on DHI score (group 1 with DHI < or = 49/100, group 2 with DHI > or = 50/100) and a pooled two-sample t-test was performed, a significant difference (P = 0.05) was found in functional reach distance; the subjects who reported less perception of handicap reached farther than those who reported more perception of handicap. No difference was found between the two DHI groups in single leg stance time. Post hoc correlations of functional reach and single leg stance time. Post hoc correlations of functional reach and single leg stance within the two DHI groups showed a higher correlation in group 1 (DHI < or = 49/100), with r equals 0.65 (P < or = 0.01), than in group 2 (DHI > or = 50/100), with r equals 0.38 (P = 0.20). The study found a highly significant, moderate correlation between functional reach distance and single leg stance times in patients with peripheral vestibular disease. These results support the use of FR as an additional assessment tool with patients who have peripheral vestibular disease.

Shoulder kinesthesia in healthy unilateral athletes participating in upper extremity sports.

Shoulder kinesthesia has not been extensively studied in upper extremity athletes. The purpose of this study was to determine if there were differences in threshold to detection of passive motion between dominant and nondominant shoulders of healthy overhead athletes in two positions, 0 degrees and 75 degrees of external rotation. In addition, the study attempted to determine if there was a relationship between the range of external rotation (ER) and internal rotation (IR) and the threshold to detection of passive motion values. Shoulder kinesthesia was assessed in the dominant and nondominant shoulders of 20 collegiate athletes participating in unilateral upper extremity sports. A proprioceptive testing device passively moved the shoulder into internal and external rotation. The dominant shoulder had a significantly greater difficulty detecting motion compared with the nondominant arm at both 0 degrees and 75 degrees of external rotation. Both shoulders exhibited enhanced kinesthesia (lower threshold to detection of passive motion scores) at 75 degrees of external rotation compared with 0 degrees, where the glenohumeral joint capsule is relatively taut. The results of this study suggest that healthy upper extremity athletes may have kinesthetic deficits in their throwing shoulder compared with their nondominant shoulder.