A Pilot Study to Assess Visual Vertigo in People with Persistent Postural-Perceptual Dizziness with a New Computer-Based Tool.

BACKGROUND: Visual vertigo (VV) is a common symptom in people with persistent postural-perceptual dizziness (PPPD). Few subjective scales are validated for assessing the intensity of VV, yet these scales are limited by recall bias, as they require individuals to rate their symptoms from memory. The computer-Visual Vertigo Analogue Scale (c-VVAS) was developed by adapting five scenarios from the original paper-VVAS (p-VVAS) into 30 s video clips. The aim of this pilot study was to develop and test a computerized video-based tool for the assessment of visual vertigo in people with PPPD. METHODS: PPPD participants (n = 8) and age- and sex-matched controls (n = 8) completed the traditional p-VVAS and the c-VVAS. A questionnaire about their experiences using the c-VVAS was completed by all participants. RESULTS: There was a significant difference between the c-VVAS scores from the PPPD and the control group (Mann-Whitney, p < 0.05). The correlation between the total c-VVAS scores and the total c-VVAS scores was not significant (r = 0.668, p = 0.07). The study showed a high acceptance rate of the c-VVAS by participants (mean = 91.74%). CONCLUSION: This pilot study found that the c-VVAS can distinguish PPPD subjects from healthy controls and that it was well-received by all participants.

Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series.

BACKGROUND: When a new guideline is published there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings. METHODS: Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change. RESULTS: Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location. CONCLUSIONS: The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model. TRIAL REGISTRATION: This study does not report the results of a health care intervention on human participants.

Feasibility and Preliminary Effects of a 1-Week Vestibular Rehabilitation Day Camp in Children with Developmental Coordination Disorder.

AIM: This pilot study investigated the feasibility and preliminary effects of an intensive 1-week day camp program for children with Developmental Coordination Disorder (DCD) that focused on vestibular rehabilitation. METHODS: Ten participants (6-10 years) were assessed twice pre-intervention, post intervention, and at 8-week follow-up. Videonystagmography, Video Head Impulse Tests (vHIT), and Modified Emory Clinical Vestibular Chair Test (m-ECVCT) test were assessed at baseline. Outcomes measures were gaze stability (Dynamic Visual Acuity; DVA), functional gait (Functional Gait Assessment; FGA), balance (Sensory Organization Test), motor function (Bruininks-Oseretsky Test), and participation (Miller Function and Participation). RESULTS: No abnormal results were detected from the videonystagmography, vHIT and m-ECVCT. There was a 100% attendance rate at the camp and assessment sessions. FGA scores significantly improved following intervention and changes were maintained at follow-up. The number of children with abnormal DVA scores decreased from 3 to 1 to 0 between pre-intervention, post-intervention, and follow-up. There were no significant changes in any of the other outcomes following intervention. CONCLUSIONS: Intensive vestibular rehabilitation delivered in a day camp format is feasible and show positive preliminary effects on functional gait and dynamic visual acuity in children with DCD.

Validity and Responsiveness of the Visual Vertigo Analogue Scale.

BACKGROUND AND PURPOSE: People with visual vertigo have dizziness provoked by visual stimulation. We have developed a Visual Vertigo Analogue Scale (VVAS) to evaluate their symptoms and response to rehabilitation. Our goal was to validate the VVAS against the Situation Characteristics Questionnaire (SITQ) score and determine its responsiveness to treatment. METHODS: Participants (n = 115) completed 3 questionnaires: Dizziness Handicap Inventory (DHI), VVAS, and the SITQ at their initial and final sessions of vestibular rehabilitation. The SITQ was analyzed using the Space Motion Discomfort (SMD1) outcome measure and by calculating the average score of all the items (SMDavg). The results were stratified into those who had a significant clinical change in their DHI score posttreatment and those who did not. Associations of the VVAS with SMD scores and change scores were determined by Pearson and Spearman correlations. Nonparametric t tests were used to compare the 2 DHI groups on the clinical outcomes. RESULTS: There were significant associations between VVAS scores (P < 0.0001) and both SMD1 (ßVVAS = 0.02) and SMDavg scores (ßVVAS = 0.03). Significant differences existed between the 2 DHI groups for all scores: VVAS (P = 0.0002), SMD1 (P = 0.02), and SMDavg (P = 0.0001). DISCUSSION AND CONCLUSIONS: VVAS scores correlated well with SMD1 and SMDavg scores. Changes in VVAS pre- and posttreatment scores corresponded to the changes seen in SMD1 and SMDavg scores. The VVAS shows validity and responsiveness to change. The VVAS can be used to detect clients with visual vertigo and to verify the progression of the client's symptoms.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A258).

Prevalence of Vestibular Dysfunction in Children With Neurological Disabilities: A Systematic Review.

Background: In children with neurological or neurodevelopmental conditions, vestibular disorders may co-exist with the primary condition and further contribute to disability and restriction in functional independence and participation. Awareness of their existence may favor an early diagnosis and better treatment outcomes. Objectives: To determine the prevalence of vestibular dysfunction in children and adolescents (3-21 years old) diagnosed with either cerebral palsy (CP), traumatic brain injury (TBI), sensorineural hearing loss (SNHL), or cochlear implantations (CI). Methods: Four researchers systematically reviewed the literature from three databases (EMBASE, MEDLINE, CINAHL) until June 2018. Results: Twenty-four studies were analyzed in this systematic review. A single, high-quality study reports a prevalence of 48.4% of spastic CP children having a saccular dysfunction. Three fair-quality studies report a prevalence of 14.6-81%, 21 days post-TBI. Twelve poor-to-high quality studies demonstrate a prevalence of 18.7-96.1% in children with SNHL. A prevalence range of 3-84% in children with CI is reported by nine fair-to-high quality studies. Conclusion: Clinicians should be aware of the prevalence of vestibular dysfunction in these populations and implement appropriate assessments to improve treatment outcomes.

2015 Section on Pediatrics Knowledge Translation Lecture: Pediatric Vestibular-Related Impairments.

KEY POINTS: Until recently, the incidence and effect of vestibular system impairments in children has been grossly underidentified and thus not addressed. Because of incidence reports (approximately 10% of the US population younger than 21 years) and evidence of the efficacy of evaluation methods and interventions, researchers and clinicians are focusing on development of optimal interventions to enhance function, thus minimizing the negative effect of vestibular hypofunction on reading, motor development, and postural control. However, research progress has been slow. How can clinicians and researchers collaborate so that (1) vestibular deficits and related impairments can be identified in children, and (2) optimal interventions can be identified and implemented so that children with peripheral and/or central vestibular dysfunction can benefit? SUMMARY: Our participation in knowledge translation is presented, to include discussion of possible barriers, challenges, and opportunities for facilitating collaboration and joint efforts of clinical and research practice.

Vestibular Assessments in Children With Global Developmental Delay: An Exploratory Study.

PURPOSE: To compare results of 3 clinical vestibular tests between children with global developmental delay (GDD) and children with typical development (TD) and investigate the test-retest reliability. METHODS: Twenty children with GDD (aged 4.1-12.1 years) and 11 age-matched controls with TD participated. Participants with GDD underwent 2 sessions of testing. Each session consisted of the Clinical Test of Sensory Interaction and Balance (CTSIB), Dynamic Visual Acuity (DVA) test, and the modified Emory Clinical Vestibular Chair Test (m-ECVCT). RESULTS: Up to 33% of the children with GDD had abnormal DVA scores. m-ECVCT results of children with GDD demonstrated larger variance than children with TD. The CTSIB score was significantly reduced in the group with GDD. The test-retest reliability varied, with good reliability for the m-ECVCT and CTSIB, and fair reliability for the DVA. CONCLUSIONS: Findings suggest vestibular involvement in children in GDD. The clinical tests demonstrated moderate test-retest reliability.

Anxiety among individuals with visual vertigo and vestibulopathy.

PURPOSE: Visual vertigo (VV) is a type of dizziness triggered by visual stimuli. Despite a high incidence, its relationship with anxiety is not well-defined or understood. This study evaluated anxiety levels in subjects with VV compared to vestibulopathic subjects without VV and healthy individuals. METHODS: A cross-sectional study to evaluate anxiety among individuals with VV was conducted twice. The first study included 72 participants (66 to 83 years of age) from senior residential centers. The second included 31 participants from a vestibular rehabilitation program (age range 35-82 years). Study 1 also used the Activities-Specific Balance Confidence (ABC) scale and study 2 the Dizziness Handicap Inventory (DHI). RESULTS: Subjects were classified as VV positive (27 in study 1, 10 in study 2) or vestibulopathic without VV (30 in study 1, 11 in study 2) based on Head Impulse or Dynamic Visual Acuity Tests and the Dizziness Questionnaire. The remaining were age-matched healthy controls. The outcome of each study demonstrated significantly higher anxiety levels (p = 0.0001) in the VV group compared to the other groups. The results of the ABC test demonstrated that subjects in the VV group had significantly lower self-confidence (p = 0.001) than those in the Vest and Cont groups and performed fewer balance-related activities of daily life. DHI results showed that VV group expressed higher (p < 0.001) mean scores for self-perceived feelings of dizziness and imbalance (54%), compared to the Vest (9%) and Cont groups (1%). CONCLUSIONS: Anxiety related to VV requires special attention when assessing and managing vestibulopathy, regardless of patient age. IMPLICATIONS FOR REHABILITATION: Anxiety is a characteristic of subjects with visual vertigo (VV) and vestibulopathy. Anxiety in subjects with VV is not related to age. VV should be considered when subjects with anxiety complain of imbalance. Anxiety and vestibulopathy are often interrelated and should be considered in diagnostic evaluations.

The influence of visual vertigo and vestibulopathy on oculomotor responses.

OBJECTIVE: Dynamic visual inputs can cause visual vertigo (VV) in patients with vestibulopathy, leading to dizziness and falls. This study investigated the influence of VV on oculomotor responses. METHODS: In this cross-sectional, single-blind study, with experimental and control groups, 8 individuals with vestibulopathy and VV, 10 with vestibulopathy and no VV, and 10 healthy controls participated. Oculomotor responses were examined with 2-dimensional video-oculography. Participants were exposed to dynamic visual inputs of vertical stripes sweeping across a screen at 20 deg/sec, while seated or in Romberg stance, with and without a fixed target. Responses were quantified by optokinetic nystagmus frequency (OKNf) and gain (OKNg). RESULTS: Seated with no target, VV participants had higher OKNf than controls (37 ± 9 vs. 24 ± 9 peaks/sec; P < 0.05). In Romberg stance with no target, they had higher OKNf than controls (41 ± 9 vs. 28 ± 10 peaks/sec; P < 0.05). With a target, OKNf was higher in VV participants compared to controls (7 ± 7 vs. 1 µ 2 peaks/sec; P < 0.05). In Romberg with no target, OKNg was higher in the VV group (0.8 ± 0.1) compared to controls (0.6 ± 0.2; P=0.024). OKNf and OKNg did not differ according to VV status. CONCLUSIONS: VV participants had increased OKNf and OKNg compared to healthy participants. Visual dependency should be considered in vestibular rehabilitation.

Arm-trunk coordination as a measure of vestibulospinal efficiency.

When arm and trunk segments are involved in reaching for objects within arm's reach, vestibulospinal pathways compensate for trunk motion influence on arm movement. This compensatory arm-trunk synergy is characterised by a gain coefficient of 0 to 1. Vestibular patients have less efficient arm-trunk synergies and lower gains. To assess the clinical usefulness of the gain measure, we used a portable ultrasound-based device to characterize arm-trunk coordination deficits in vestibular patients. Arm-trunk coordination without vision was measured in a Stationary Hand Task where hand position was maintained during trunk movement, and a Reaching Task with and without trunk motion. Twenty unilateral vestibular patients and 16 controls participated. For the Stationary Hand task, patient gains ranged from g=0.94 (good compensation) to 0.31 (poor compensation) and, on average, were lower than in controls (patients: 0.67 ± 0.19; controls: 0.85 ± 0.07; p< 0.01). Gains were significantly correlated with clinical tests (Sensory Organization; r=0.62, p< 0.01, Foam Romberg Eyes Closed; r=0.65, p< 0.01). For the Reaching Task, blocking trunk movement during reaching modified hand position significantly more in patients (8.2 ± 4.3 cm) compared to controls (4.5 ± 1.7 cm, p< 0.02) and the amount of hand position deviation was correlated with the degree of vestibular loss in a sub-group (n=14) of patients. Measurement of the Stationary Task arm-trunk gain and hand deviations during the Reaching Task can help characterize sensorimotor problems in vestibular-deficient patients and track recovery following therapeutic interventions. The ultrasound-based portable device is suitable for measuring vestibulospinal deficits in arm-trunk coordination in a clinical setting.

Visual vertigo analogue scale: an assessment questionnaire for visual vertigo.

A common symptom for people with vestibulopathy is dizziness induced by dynamic visual input, known as visual vertigo (VV). The goal of this study is to present a novel method to assess VV, using a nine-item analog scale. The subjects rated the intensity of their dizziness on each item of the Visual Vertigo Analogue Scale (VVAS), which represented a daily situation typically inducing VV. The questionnaire was completed by participants with vestibulopathy (n=102) and by subjects receiving out-patient orthopaedic physiotherapy (n=102). The dizziness handicap inventory (DHI) was also completed by the vestibulopathic group. The Cronbach's Alpha index indicated the VVAS is internally consistent and reliable (Cronbach's Alpha=0.94). The study also found that the VVAS severity scores from vestibular and a non-vestibular population were significantly different (Wilcoxon-Mann Whitney test p < 0.0001). Spearman correlation analysis conducted between DHI and VVAS scores for the clients with vestibulopathy showed positive moderate correlations between the VVAS score and the total DHI score (r=0.67, p< 0.0001). This study showed that the VVAS scale may be useful in providing a quantitative evaluation scale of visual vertigo.

Clinical evaluation of dynamic visual acuity in subjects with unilateral vestibular hypofunction.

OBJECTIVES: The objectives of this study are threefold: 1) to examine the effect of frequency of head motion on the clinical dynamic visual acuity (DVA) score in subjects with unilateral vestibular hypofunction (UVH); 2) to compare DVA scores between subjects with UVH and subjects with a complete unilateral vestibular deficit; and 3) to establish whether a relationship exists between the extent of the vestibular deficit and the DVA score. DESIGN: Experimental study. SETTING: Vestibular outpatient rehabilitation program. METHODS: A convenience sample of 10 subjects with UVH. MAIN OUTCOME MEASURES: Dynamic visual acuity scores were recorded using 2 standard acuity charts: Snellen and E-chart. The DVA scores were obtained at slow (0.5 Hz), moderate (1 and 1.5 Hz), and fast (2.0 Hz) frequencies of head motion in the horizontal and the vertical planes. Percentage of caloric weakness was compared with DVA scores in each subject to test whether a relationship exists between the two. RESULTS: As the frequency of head motion increased, the number of UVH subjects with an abnormal DVA score increased. Subjects with an abnormal DVA score at 1 Hz had the same or higher score as the frequency of the head motion was increased. Spearman correlation analyses revealed low-correlation coefficients between percentage of vestibular paresis at the caloric test and DVA scores (horizontal direction: r = 0.31, p = 0.38 for Snellen chart and r = -0.33, p = 0.35 for the E-chart; vertical: r = 0.05, p = 0.91 for the Snellen chart and r = -0.28, p = 0.50 for the E-chart). CONCLUSION: Subjects with UVH manifest impaired DVA. The frequency of head motion has an impact on clinical DVA scores in UVH subjects.

Optimal parameters for the clinical test of dynamic visual acuity in patients with a unilateral vestibular deficit.

OBJECTIVE: To determine the influence of frequency and direction of head movement and type of vision chart on the score of a clinical test of dynamic visual acuity (DVA). METHODS: The subjects were 31 healthy individuals (22 to 79 years old) and 10 patients (19 to 70 years old) with a unilateral vestibular deficit owing to surgical resection of an acoustic neuroma. They read a Snellen or an E-chart while their head was passively moved +/- 20 degrees back and forth in the horizontal or vertical direction at one of four frequencies (0.5, 1.0, 1.5, and 2.0 Hz). The DVA score was the difference in the number of lines on the vision chart that could be read with the head passively moved versus with the head immobile. RESULTS: Four healthy subjects had a low DVA score during horizontal head movements at the fastest frequency (2.0 Hz) with the Snellen chart. In patients, DVA scores significantly decreased as head movement frequency increased from 0.5 to 1.0 Hz and from 1.0 to 1.5 Hz, during horizontal and vertical movements, and with both vision charts (p < .001). The DVA scores of healthy subjects were more consistent across three trials with the E-chart than with the Snellen chart at 1.0 and 0.5 Hz (horizontal movements, p < .01) and at 1.5 and 1.0 Hz (vertical movements, p < .01). CONCLUSIONS: This study provides new indications on the optimal parameters for the clinical test of DVA. From the results, it is recommended that DVA be tested during horizontal and vertical head movements at a frequency of 1.5 Hz with the E-chart.

2-year review of a novel vestibular rehabilitation program in Montreal and Laval, Quebec.

OBJECTIVE: To evaluate the benefits of a vestibular rehabilitation program (VRP) in the Montreal-Laval area. DESIGN: The VRP was conceptualized by a panel of experts including otolaryngologists, physiotherapists, and researchers from McGill University and its teaching hospitals. From February 1999 to December 2001, 117 patients were seen, and 88 of them completed the VRP. SETTING: The VRP has been established at the Jewish Rehabilitation Hospital in Laval, PQ, to provide specialized rehabilitation to clients suffering from vertigo, dizziness, and/or impaired balance owing to lesions or disorders of the vestibular system. MAIN OUTCOME MEASURES: Presence or absence of nystagmus or vertigo during the Dix-Hallpike test, Dizziness Handicap Inventory (DHI), and Dynamic Gait Index (DGI). RESULTS: Thirty-five patients with benign paroxysmal positional vertigo of the posterior canal were treated with canalith repositioning manoeuvres. All of the patients (100%) had absence of nystagmus or vertigo after one to four treatment sessions. Forty-six patients with vestibular deficits or dizziness-disequilibrium completed the VRP, which consisted mainly of individualized eye-head and balance home exercise programs. At the end of the VRP, there was a significant decrease in DHI score (31 vs 57; p < .01) and a significant increase in DGI score (18.4 vs 22.6; p < .01). CONCLUSIONS: A range of modest to major improvements was shown by comparing initial and discharge scores of patients who had completed vestibular rehabilitation. The VRP appears to be beneficial for patients with a variety of vestibular disorders. Further research is needed to continue optimizing vestibular rehabilitation.