Barriers and Facilitators of Vestibular Rehabilitation: Patients and Physiotherapists' Perspectives.

BACKGROUND AND PURPOSE: Poor adherence to vestibular rehabilitation protocols is a known barrier to optimal care. Vestibular clinicians' comprehensive understanding of the barriers and facilitators to vestibular home exercise programs (VHEP) is a key element to achieving optimal care in the context of vestibular rehabilitation. The aims of this study are as follows: (1) to identify primary barriers and facilitators to VHEP from the perspective of patients with vestibular dysfunction and vestibular physical therapists (PTs); and (2) to provide strategies for clinicians to improve adherence and outcomes of VHEP. METHODS: A qualitative research with single-session focus groups conducted separately for: (1) patients with vestibular disorders and (2) vestibular PTs. Six focus groups were conducted, 3 for each population, with a total of 39 participants. An online survey was conducted to evaluate the estimates of adherence rates, followed by a structured discussion over barriers and facilitators to VHEP as perceived by patients and PTs. Thematic data analyses were performed using a mixed deductive-inductive approach. RESULTS: Eighteen patients with vestibular disorders and 21 experienced vestibular PTs participated in this study. Six barrier categories and 5 facilitator categories were identified. Barriers included motivation aspects, provocation of symptoms, time management, associated impairments, missing guidance and feedback, and psychosocial factors. Facilitators included motivation aspects, time management, patient education and exercise instructions, exercise setting, and associated symptom management. DISCUSSION AND CONCLUSIONS: Clinicians who prescribe home exercise to patients with vestibular disorders can use this information about common barriers and facilitators for patient education and to provide optimal care and improve rehabilitation outcomes. VIDEO ABSTRACT AVAILABLE: for more insights from the authors (see the video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A467 ).

Impact of Subarachnoid Hemorrhage on the Cardiac Autonomic Function During Rehabilitation in Children After Severe Traumatic Brain Injury.

This study aimed to investigate the impact of traumatic subarachnoid hemorrhage (tSAH) on cardiac autonomic control system (CACS) function in children after severe traumatic brain injury (TBI) during the subacute rehabilitation period. Thirty-three participants, 8-18 years of age, 42 (14-149) days after severe TBI at the beginning of the subacute rehabilitation, were included in the study. Six participants were diagnosed with tSAH during acute medical care (tSAH group). Heart rate variability (HRV) was assessed by the standard deviation of the N-N interval (SDNN) and the square root of the mean square differences of successive R-R interval (RMSSD) using a Polar RS800CX device while sitting at rest for 5 min. A second assessment was performed 8 weeks later. No significant difference between the tSAH and non-tSAH groups were found in the demographic and functional characteristics or injury severity. However, in comparison to the non-tSAH group, the tSAH group had lower SDNN (23.9 [10.5-47.3] vs. 43.9 [21.8-118.8], respectively; p = 0.005) and RMSSD values (11.8 [5.9-24.5] vs. 29.6 [8.9-71.7], respectively; p = 0.004). Neither group demonstrated changes in HRV values at rest in the second assessment, whereas the significant difference in SDNN (p = 0.035) and RMSSD (p = 0.008) remained. Children diagnosed with SAH after severe TBI presented poorer CACS function during the subacute rehabilitation. Given that reduced HRV values may be a marker for potential heart disease, the medical team should be aware of the influence of existing tSAH. Future studies with larger sample sizes and longer follow-up periods are warranted to further investigate this topic. ClinicalTrials.gov number: NCT03215082.

Changes in the cardiac autonomic control system during rehabilitation in children after severe traumatic brain injury.

BACKGROUND: One of the sequalae of severe traumatic brain injury (TBI) in children is impaired function of the cardiac autonomic control system (CACS) at rest. The CACS response to conventional autonomic tests is little known. OBJECTIVE: To examine the CACS response to conventional autonomic tests in children after severe TBI during the rehabilitation period and to compare with typically developing (TD) children. METHODS: This study combined a case-control and follow-up design. The severe TBI group (cases) consisted of 33 children aged 9-18 years, 14-142 days after severe TBI who were followed for 8 weeks during rehabilitation. The control group consisted of 19 TD children matched for age and sex. Heart rate (HR) and heart rate variability (HRV) were evaluated with the Polar RS800CX device at rest (sitting), during a handgrip test and during a paced breathing test. RESULTS: At the first assessment, we found lower HRV values at rest and a lower HRV response during the paced breathing and handgrip tests in the TBI group than the TD group (p<0.01). After 8 weeks, HRV values did not change at rest in the TBI group, but the response to the autonomic tests improved significantly, with increased HRV values in response to the paced breathing test (p<0.01) and the handgrip test (p = 0.01). CONCLUSIONS: After severe TBI, children exhibited an impaired CACS response to autonomic tests, with parasympathetic suppression and sympathetic arousal. After 8 weeks of rehabilitation, CACS function recovered partially and the response to the autonomic tests improved with no change in CACS function at rest.

The cardiac autonomic control system response to vestibular stimulation in subjects with BPPV compared with healthy controls.

BACKGROUND: Vestibulo-sympathetic reflexes (VSR) demonstrate the autonomic interaction between the vestibular system and the cardiovascular system, however little is known about this interaction in patients with benign paroxysmal positional vertigo (BPPV). Although the main complaint of patients with BPPV is vertigo, additional symptoms such as nausea and sweating raise questions whether patients with BPPV have impaired VSR. OBJECTIVE: The aim of this study is to assess the cardiac autonomic control system (CACS) response to vestibular stimulation in subjects with BPPV compared with healthy controls. METHODS: This is a case-control study. Heart-rate variability (HRV) parameters were monitored in two groups (30-70 years old)- subjects with BPPV (N = 18) and gender and age-matched healthy controls (N = 18), at rest and during vestibular stimulation. RESULTS: No significant differences were found between groups in HRV parameters during rest. Both groups demonstrated an autonomic response to vestibular stimulation, yet no differences were found between groups. CONCLUSIONS: Patients with BPPV seem to have an intact cardiac response to vestibular stimulation. Over-activation of the Vestibular Semicircular Canals, as shown in BPPV, doesn't seem to alter the VSR in the cardiac autonomic control system.

The distinction between state and trait anxiety levels in patients with BPPV in comparison with healthy controls.

Introduction: An association exists between vestibular dysfunction and anxiety, yet a distinction between state and trait anxiety in patients with Benign Paroxysmal Positional Vertigo (BPPV) in comparison with healthy subjects has not been well established. The aim of this study is to assess both state and trait anxiety levels in patients with BPPV in comparison with healthy controls, and their relations with cardiac autonomic parameters. Materials and methods: A case-control study, that included patients with BPPV (N = 18) referred to vestibular physiotherapy and gender and age matched healthy controls (N = 18). All participants completed the State-Trait Anxiety Inventory (STAI) questionnaire, while heart-rate (HR) and heart-rate variability (HRV) measures were recorded. Results: Patients with BPPV (age range 32-66 years; 12 women and 6 men) showed a higher state anxiety level (10 points median difference, p = 0.001) in comparison with healthy controls (age range 34-66 years; 12 women and 6 men), yet no differences were found in trait anxiety score or total STAI score. Only among patients with BPPV, a positive-moderate correlation was found between state anxiety and HR (r = 0.53, p < 0.05), and a negative moderate-strong correlation was found between state anxiety and HRV (r = -0.67, p < 0.01). Discussion: Patients with BPPV do not differ from healthy subjects in terms of predisposition to feel anxious, and only their temporary state anxiety levels are higher in comparison with healthy controls. We recommend researchers and clinicians who assess anxiety levels in patients with BPPV to distinguish between anxiety as a temporary state (state anxiety) and anxiety as a personality trait (trait anxiety).

The Cardiac Autonomic Response Recovery to the Modified Tilt Test in Children Post Moderate-Severe Traumatic Brain Injury.

OBJECTIVE: To assess the recovery of the cardiac autonomic control system (CACS) response to the modified tilt-test during rehabilitation, in children post moderate-severe TBI at the subacute phase post-injury. METHOD: Thirty-seven children aged 6-18 years, 14-162 days post moderate-severe TBI, participated in the study. The assessment included CACS values evaluation (heart rate (HR), heart rate variability (HRV) and blood pressure) during the modified tilt-test: five minutes lying supine and five minutes passive standing. Re-assessment was performed after eight weeks of rehabilitation. RESULTS: In both assessments, only four children reported symptoms associated with orthostatic intolerance during the modified tilt-test. No change was found over time in the HR and HRV values at rest. In response to the modified tilt-test, the systolic blood pressure showed change over time, with a significant interaction effect (p=0.04); while in the first assessment the SBP values showed a hypertension trend in the second assessment the SBP values showed a hypotension trend. CONCLUSIONS: Children post moderate-severe TBI at the sub-acute phase post-injury, have a better systolic blood pressure response during the modified tilt-test after eight weeks of individually tailored rehabilitation program, despite no change in the CACS values at rest. CLINICAL TRIAL GOV. NUMBER: NCT03215082.

The development and the inter-rater agreement of a treatment protocol for vestibular/oculomotor rehabilitation in children and adolescents post-moderate-severe TBI.

Introduction:There is limited evidence investigating the effect of vestibular/oculomotor rehabilitation programs in children and adolescents post moderate-severe TBI at the sub-acute stage.Objective:To describe the development of a treatment protocol for vestibular/oculomotor interventions in this population, and to assess the inter-rater agreement of this protocol as an initial step of a clinical trial.Method:The protocol was developed by 10 health professionals, address the high variability of balance performance, the high prevalence of vestibular/oculomotor abnormalities and the low prevalence of symptoms reported in this population.Results:The protocol enables the clinician to use the assessment during the treatment exercise selection. The training position was defined by the Pediatric Balance Scale. Vestibular/oculomotor exercises were selected using a quantified version of the Vestibular/Ocular Motor Screening. The exercise protocol was selected based on impairment in function or reproduction of symptoms. The protocol planning was implemented by two assessors in 27 children and adolescents post-moderate-severe TBI (median age 14.1 [6-18.4] years) in the sub-acute stage (median 40 [14-162] days since injury). Very high agreement was found (k > 0.72) in all the parameters.Conclusion: This protocol could reliably be used in a randomized control trial that assesses the effect of vestibular/oculomotor rehabilitation program in children and adolescents post moderate-severe TBI at the sub-acute stage.

The integrated functions of the cardiac autonomic and vestibular/oculomotor systems in adolescents following severe traumatic brain injury and typically developing controls.

INTRODUCTION: The cardiac autonomic control system (CACS) is frequently impaired post-traumatic brain injury (TBI). However, the prevalence of vestibular/oculomotor impairment is less studied. These two systems interact during position change and contribute to blood-pressure regulation through the vestibulo-sympathetic reflex. Aim: To assess the CACS, the vestibular/oculomotor systems and their integrative function in adolescents post-TBI compared to typically-developing (TD) adolescents. Methods: 19 adolescents in the subacute stage following a severe TBI (14-117 days post injury) and 19 age and sex matched TD controls were recruited. Heart Rate Variability (HRV) was assessed at rest and during a modified tilt-test. A quantified version of the Vestibular/Ocular-Motor Screening (VOMS) was also administered. Results: At rest, the TBI group had higher HR and lower HRV values (p < .001). All participants with TBI demonstrated impairments in the VOMS (median of positive tests: 5 [range 2-9]) compared to only 6 out of 19 in the TD participants (median 0 [0-2]) (z = -5.34; p < .001). In response to the modified tilt test, the HRV increased significantly in the lifting period and decreased significantly once in standing only in the TBI group (z = -2.85, p = .025). Conclusion: Adolescents post severe TBI demonstrated impairments in the CACS, positive tests on the VOMS and significantly greater changes in the modified tilt test as compared to TD. Clinical trial gov. number: NCT03215082.