Post-stroke dizziness, depression and anxiety.

OBJECTIVE: Vestibular and psychiatric disorders are very closely related. Previous research shows that the discomfort and dysfunction caused by dizziness in patients can affect psychological processes, leading to anxiety and depression, and the irritation of anxiety and depression can aggravate the discomfort of dizziness. But the causal relationship between dizziness in the recovery period of stroke and Post-stroke depression (PSD) / Post-stroke anxiety (PSA) is not clear. Identifying the causal relationship between them can enable us to conduct more targeted treatments. METHODS: We review the epidemiology and relationship of dizziness, anxiety, and depression, along with the related neuroanatomical basis. We also review the pathophysiology of dizziness after stroke, vestibular function of patients experiencing dizziness, and the causes and mechanisms of PSD and PSA. We attempt to explore the possible relationship between post-stroke dizziness and PSD and PSA. CONCLUSION: The treatment approach for post-stroke dizziness depends on its underlying cause. If the dizziness is a result of PSD and PSA, addressing these psychological factors may alleviate the dizziness. This can be achieved through targeted treatments for PSD and PSA, such as psychotherapy, antidepressants, or anxiolytics, which could indirectly improve dizziness symptoms. Conversely, if PSA and PSD are secondary to vestibular dysfunction caused by stroke, a thorough vestibular function assessment is crucial. Identifying the extent of vestibular impairment allows for tailored interventions. These could include vestibular rehabilitation therapy and medication aimed at vestibular restoration. By improving vestibular function, secondary symptoms like anxiety and depression may also be mitigated.

Sense of direction in vestibular disorders.

BACKGROUND: Our sense of direction (SOD) ability relies on the sensory integration of both visual information and self-motion cues from the proprioceptive and vestibular systems. Here, we assess how dysfunction of the vestibular system impacts perceived SOD in varying vestibular disorders, and secondly, we explore the effects of dizziness, migraine and psychological symptoms on SOD ability in patient and control groups. METHODS: 87 patients with vestibular disorder and 69 control subjects were assessed with validated symptom and SOD questionnaires (Santa Barbara Sense of Direction scale and the Object Perspective test). RESULTS: While patients with vestibular disorders performed significantly worse than controls at the group level, only central and functional disorders (vestibular migraine and persistent postural perceptual dizziness), not peripheral disorders (benign-paroxysmal positional vertigo, bilateral vestibular failure and Meniere's disease) showed significant differences compared to controls on the level of individual vestibular groups. Additionally, orientational abilities associated strongly with spatial anxiety and showed clear separation from general dizziness and psychological factors in both patient and control groups. CONCLUSIONS: SOD appears to be less affected by peripheral vestibular dysfunction than by functional and/or central diagnoses, indicating that higher level disruptions to central vestibular processing networks may impact SOD more than reductions in sensory peripheral inputs. Additionally, spatial anxiety is highly associated with orientational abilities in both patients and control subjects.

Effect of vestibular rehabilitation games in patients with persistent postural perceptual dizziness and its relation to anxiety and depression: prospective study.

PURPOSE: To evaluate the efficacy of vestibular rehabilitation therapy (VRT) for management of patients with persistent postural perceptual dizziness (PPPD) utilizing subjective and objectives outcome measures and to study the effect of degree of both anxiety and depression in patients on the response of vestibular rehabilitation therapy. METHODS: Thirty-three PPPD patients participated in this study. Selection of patients was based on the diagnostic criteria for PPPD stated by Barany society in the International Classification of Vestibular Disorders (2017). Every patient was subjected to history taking, anxiety and depression assessment, Arabic version of Dizziness Handicap Inventory (DHI), and sensory organization test (SOT). All patients received vestibular rehabilitations therapy. Assessment of VRT outcome was conducted after 6 weeks of VRT. RESULTS: The mean patients' age was 40.9 ± 16.3 years, and nearly equal gender distribution. Vestibular migraine was the most precipitating condition (24.2%) in patients with PPPD. (39.4%) of patients had abnormal scores of anxiety and depression tests, all patients had from moderate to severe degrees of handicap caused by dizziness as measured by DHI, most of patients had abnormal findings in all conditions of SOT. After vestibular rehabilitation therapy, DHI and SOT scores showed significant improvement after VRT. More improvement was found among the group with no anxiety and depression. CONCLUSION: VRT were effective in improving balance abnormalities in patients with PPPD evidenced by subjectively by DHI scores and objectively by SOT results. PPPD patients with concomitant psychiatric disorders; anxiety and depression experienced the least degree of improvement.

Psychometric Properties of the Persian Dizziness Handicap Inventory - Screening Version.

OBJECTIVES: The Dizziness Handicap Inventory (DHI) is the most popular and widely used questionnaire in evaluating patients with vertigo. This questionnaire has a screening version with a high correlation with DHI. This study aimed to assess the psychometric properties of the Persian DHI - Screening version (DHI-S). METHODS: This cross-sectional and methodological study was conducted on 300 patients at the central vestibular clinic in Mashhad, Iran, from 2020 to 2021. First, the DHI-S was translated into Persian using the backward-forward translation method. Subsequently, the following types of validity and reliability were examined: content validity based on content validity index and content validity ratio, face validity based on impact score, construct validity based on confirmatory factor analysis, internal consistency based on Cronbach's α and Ω, and test-retest stability based on intraclass correlation coefficient and smallest detectable change. RESULTS: The DHI-S had high content and face validity. Score 8 was selected for the cutoff point between patients and the normal group with a sensitivity of 63.67% and specificity of 96.08%. The construct validity indicated that the questionnaire is one-dimensional. The Cronbach's α and Ω for internal consistency were 0.855 and 0.851, respectively. The intraclass correlation coefficient was 0.981 and the smallest detectable change was 5.521. CONCLUSIONS: The DHI-S in the Persian language has high and acceptable psychometric properties. This questionnaire can be used in research and clinical settings.

Anxiety and physical impairment in patients with central vestibular disorders.

BACKGROUND: There is increasing evidence for close interrelations between vestibular and emotional brain networks. A study in patients with bilateral peripheral vestibulopathy (BVP) showed relatively low vertigo-related anxiety (VRA), despite high physical impairment. The current working hypothesis proposes the integrity of the peripheral vestibular system as a prerequisite for development of VRA. Here we contribute by evaluating VRA and vestibular-related handicap in central vestibular disorders. METHODS: Of 6396 patients presenting in a tertiary vertigo centre, 306 were identified with four clear central vestibular disorders: pure cerebellar ocular motor disorder (COD; 61), cerebellar ataxia (CA; 63), atypical parkinsonian syndromes (APS; 28), vestibular migraine (VM; 154). Their results of the Vertigo Handicap Questionnaire (VHQ), with its subscales for anxiety and handicapped activity, were compared to those of 65 BVP patients. Postural instability was measured on a force-plate. Multivariate linear regression was used to adjust for patient demographics. RESULTS: Patients with chronic central vestibular disorders (COD, CA, APS) had relatively low VRA levels comparable to those in BVP, independent of increased handicapped activity or postural instability. Only VM patients showed significantly higher VRA, although their activity impairment and postural instability were lowest. No significant differences within chronic central vestibular disorders were found for VRA and subjective activity impairment. CONCLUSIONS: Subjective and objective vestibular-related impairment are not necessarily correlated with vestibular-related anxiety in central vestibular disorders. Our findings rather support the hypothesis that, in addition to an intact peripheral, an intact central vestibular system could also serve as a prerequisite to develop specific VRA.

Is Biofeedback for Vertigo Effective in Ordinary Medical Centers? A Controlled Trial in Northern Italy.

The aim of this study was to assess the therapeutic effectiveness of biofeedback, in a medical center's routine for treating vestibular disorders, reducing emotional, functional, and physical disability at three-month follow-up. A total of 197 outpatients were recruited from a medical center to treat vestibular disorders. Patients in the control group received treatment as usual, consisting of one monthly visit with an otolaryngologist and pharmacological treatment specific for vertigo, while the experimental group attended biofeedback training. Patients in the experimental group received pharmacological therapy only in the phase before the start of biofeedback in order to stabilize the acute phase. During the three-month follow-up, the experimental group did not receive any booster sessions of biofeedback. At three-month follow-up there was a statistically significant difference between the groups, both in the mean total score of the dizziness handicap inventory and in the three subscales: physical, emotional, and functional. Moreover, the biofeedback group had reduced psycho-physiological parameters for all average values at three-month follow-up compared to the baseline. This is one of few studies assessing the effectiveness of biofeedback in a naturalistic setting for vestibular disorder treatment. The data confirmed that biofeedback can impact illness course, in terms of self-perceived disability reduction, assessed on emotional, functional, and physical aspects of daily living.

Somatic symptom distress and gender moderate the effect of integrative group psychotherapy for functional vertigo on vertigo handicap: A moderation analysis of a randomised controlled trial.

OBJECTIVE: Psychotherapeutic treatments for functional vertigo have shown promising results in recent years but it is still to be determined for whom these treatments work best. The aim of this study was to run a moderation analysis to identify which baseline factors may moderate the success of integrative psychotherapeutic group treatment (IPGT) as compared to a self-help group (SHG) active control. METHODS: Data from 159 patients included in a 16-week randomised controlled trial were analysed. The outcome was vertigo-related handicap at post-treatment and gender, age, baseline somatisation, depression and anxiety were taken as putative moderators. RESULTS: We found that baseline somatic symptoms (i.e. PHQ-15 score, p = 0.04, ∆R2 = 0.02) and gender (p = 0.04, ∆R2 = 0.02) significantly moderated the effect of treatment type on post-treatment vertigo handicap. Patients with higher PHQ-15 scores at baseline and women reduced their vertigo handicap more in IPGT as compared to in the control condition. CONCLUSION: A possible explanation for this result is that somatic symptom distress is the central aetiopathogenetic factor of functional vertigo, while depressiveness and anxiety are rather epiphenomena in the sense of comorbidity. Although the results are not entirely consistent, according to some studies, female gender seems to be a favourable predictor of better therapy outcome. Given the high impairment and healthcare costs in those with vertigo/dizziness and psychiatric comorbidity, it is important to effectively treat these patients as early as possible. This study provides a prescriptive tool for practitioners, allowing for more patient-tailored treatment decisions.

Persistent-postural perceptual dizziness (PPPD): Yes, it is a psychosomatic condition!

The Barany society published recently the consensus document for the diagnostic criteria of persistent postural perceptual dizziness (PPPD). In this commentary we highlight the benefits of this new diagnosis and possible problems that can arise during the use of the criteria in day to day clinical practice at a University Clinic for Psychosomatic Medicine. The diagnostic criteria of PPPD are compared to those of somatic symptom disorder and bodily distress disorder. We think that a discussion from a psychosomatic point of view is important to improve the understanding between different specialties and how PPPD fits into the broader framework of psychosomatic medicine.

Prevalence and Risk Factors of Sarcopenia in Patients with Dizziness.

OBJECTIVE: This study aimed to investigate the prevalence of sarcopenia and factors associated with sarcopenia in patients with dizziness. STUDY DESIGN: This is a cross-sectional study. PATIENTS: A total of 162 patients 65 years or older with the chief complaint of dizziness or vertigo (dizziness group) and 132 community-dwelling elderly (control group) were recruited during their visit to the otolaryngology clinic between May 2020 and October 2021. RESULTS: Of the 162 patients with dizziness (dizziness group), 53 (32.7%) were classified as sarcopenia according to the 2019 criteria of the Asian Working Group for Sarcopenia. There were significant differences in the prevalence of sarcopenia between the dizziness group and the control group ( p < 0.01). The factors that significantly affected the sarcopenia, in order of greater odds ratio, were HADS_A, age, and DHI_Total (odds ratio = 1.223, 1.130, and 1.022, respectively). CONCLUSIONS: The present study shows that (i) the prevalence of sarcopenia in patients with dizziness is higher than a community-dwelling elderly; (ii) patients with dizziness and sarcopenia have higher DHI_functional, DHI_emotional, DHI_total, and HADS_A compared with patients with dizziness but without sarcopenia; and (iii) age, HADS_A, and DHI were associated with sarcopenia in patients with dizziness.

Translation, Cross-Cultural Adaptation, and Validation of the Polish Version of the Dizziness Handicap Inventory.

OBJECTIVES: The Dizziness Handicap Inventory (DHI) questionnaire is used to assess the severity of vertigo. In clinical practice, it is a good indicator for understanding the patient's feelings and can be used as a quantitative measure for monitoring ongoing treatment and rehabilitation. This study involved the translation, cultural adaptation, and validation of the Polish DHI questionnaire (DHI-POL). METHODS: We recruited 127 subjects (mean age 55.1 years) who experienced vertigo, dizziness, and imbalance resulting from a disturbance to their vestibular system that had lasted longer than 1 month and 56 subjects (mean age 51.8 years) without any vestibular symptoms. All subjects performed a posturography Sensory Organization Test and completed the questionnaire twice. RESULTS: Cronbach's alpha for the overall DHI-POL was α = 0.93. The questions were divided into 3 subgroups (functional [F], emotional [E], and physical [P]) for which the internal consistency was as follows: DHI-F, α = 0.84; DHI-E, α = 0.85; and DHI-P, α = 0.81. Reproducibility, as measured by interclass correlation coefficient for the overall DHI-POL, was 0.91. For each interclass correlation coefficient subgroup, the results were as follows: DHI-F, 0.90; DHI-E, 0.93; and DHI-P, 0.83. CONCLUSIONS: DHI-POL has a high consistency and repeatability; therefore, it is a fully functional questionnaire that meets all the validation criteria and is a tool ready for use on Polish patients with vertigo.

Relationship between physical activity and dizziness handicap inventory in patients with dizziness -A multivariate analysis.

OBJECTIVE: A few studies have analyzed the physical activity in patients with dizziness. Levels of physical activity using 3-axial accelerometer were reported to be lower in patients with chronic dizziness compared to healthy adults. However, the sample size was small and confounding factors were not adjusted in the study. As the age, balance, anxiety, and depression likely contribute to dizziness, the contribution of physical activity to dizziness should be evaluated after adjusting for these potential confounders. We investigated the relationship between physical activity, postural stability, anxiety, and handicap in patients with dizziness using multivariate analysis. METHODS: This cross-sectional study included 59 patients with dizziness. The physical activity was measured using a 3-axial accelerometer. We also assessed the Dizziness Handicap Inventory (DHI), Hospital and Anxiety and Depression Scale (HADS), and the total center of pressure path length eyes open and eyes closed (COP_EO, COP_EC). To be eligible for analysis, the participants were required to wear the accelerometer for at least four days, with at least 10 h/day of wear time each day. RESULTS: There were significant differences in the light physical activity (LPA) and moderate to vigorous intensity physical activity (MVPA) between the mild (DHI ≦30) and severe (DHI > 60) groups. Factors that significantly affected the DHI_T score, in order of greater ß, were LPA, COP_EC, female, and HADS_A (ß = -0.546, 0.459, 0.437, 0.239, respectively). CONCLUSIONS: The present study demonstrated that the patients in the severe group had shorter LPA and MVPA times than that of the patients in the mild group. Additionally, LPA was associated with DHI_T in patients with dizziness. Therefore, physical activity, especially LPA (e.g., activities of daily living), may need to be assessed in patients with dizziness.

Validated argentine version of the visual vertigo analogue scale.

BACKGROUND: Visual vertigo (VV), triggered by environmental or dynamic visual stimuli and repetitive visual patterns, can affect daily life activities. The Visual Vertigo Analogue Scale (VVAS) is a valid and reliable self-administered questionnaire to assess VV, which has been culturally adapted to the Argentine population but has not been validated. OBJECTIVE: To validate the Argentine version of VVAS (VVAS-A) by confirming its psychometric properties in patients with vestibular disorders. METHODS: Vestibular patients (n = 82) completed the VVAS-A and the Dizziness Handicap Inventory Argentine version (DHI-A) during their initial visit and one week later. The VVAS-A's internal consistency, test retest reliability, ceiling and floor effects, and construct validity were determined. Test-retest data (n = 71) was used to calculate reliability using the intraclass correlation coefficient (ICC 2.1). RESULTS: A ceiling effect was observed in 12 patients (14.6%). Internal consistency was acceptable (Cronbach's alpha: 0.91). The reliability was r = 0.764 [CI 95%: 0.7 -0.86]). Correlations were observed between the VVAS-A and the total DHI-A score (rho = 0.571), the DHI-A physical subscale (rho: 0.578), and DHI-A functional and emotional subscales of the DHI-A (rho: 0.537 and 0.387, respectively). CONCLUSION: The VVA-A is a valid, reliable tool to evaluate VV in patients with vestibular disorders.

Translation and Validation of the Dizziness Handicap Inventory into Thai Language.

OBJECTIVE: To translate and evaluate psychometric properties of Thai version of the Dizziness Handicap Inventory (DHI-TH). STUDY DESIGN: A cross-sectional study. SETTING: Ambulatory. PATIENTS: Fifty patients with dizziness at a vestibular clinic. MAIN OUTCOME MEASURES: Translation and cross-cultural adaptation of the original English version of the DHI was performed according to published guidelines. Psychometric evaluation included internal consistency, content validity, test-retest reliability, convergent validity, discriminant ability, and responsiveness. Responsiveness was examined in 28 patients with vestibular dysfunction who received vestibular rehabilitation for 6 to 8 weeks. RESULTS: There were no floor and ceiling effects. The Cronbach's alpha was good for the total score (0.87) and subscale scores (0.70 physical, 0.73 emotional, and 0.71 functional). Excellent test-retest reliability was demonstrated for the total and subscales (ICC ranged from 0.91 to 0.97, p < 0.001). The SEM was 3.50 and the MDC was 9.68. The total and subscales of DHI-TH were moderately correlated with the SF-36-TH scores (r ranged from -0.40 to -0.63). An optimal cut-off point for detection of dizziness was 21 points (98% sensitivity, 94% specificity). Responsiveness of the DHI-TH was excellent. The ES and SRM were large (1.25 and 1.59, respectively). The DHI-TH discriminated well between patients with self-perceived improved dizziness versus unchanged dizziness (AUC = 0.87). The MCID was 17 points (82.0% sensitivity, 82.0% specificity). CONCLUSION: The DHI-TH demonstrated good psychometric properties for patients with dizziness. The DHI-TH is a valid and reliable instrument recommended as a measure of disability and quality of life in Thai patients with dizziness.

Understanding Dizzy Patients a Cross-Sectional Analysis of Attitudes toward Diagnosis, Providers, and Treatment.

OBJECTIVE: To evaluate patients' attitudes regarding their dizziness, provider capabilities, and receptiveness toward treatment. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care vestibular clinic. PATIENTS: Ages 18 years or older, fluent in English, and who presented with a chief complaint of dizziness or vertigo. INTERVENTION(S): N/A. MAIN OUTCOMES MEASURE(S): Non-validated questionnaire surveying patients' beliefs regarding the cause of their dizziness, likelihood of successful treatment, and openness to various treatment modalities. RESULTS: Patients were asked to complete an online non-validated survey regarding their dizziness prior to being evaluated in neurotology clinic. About 67 surveys were completed between January 2017 and September 2018. A majority of patients attributed their dizziness to their ears (n = 47, 70%), followed by the brain (n = 29, 43%). Most subjects chose "neither agree nor disagree" about whether their provider could identify the cause of their dizziness (27%). Most subjects also chose "neither agree nor disagree" that their dizziness would resolve with treatment (31%). These attitudes were not influenced by demographics, dizziness severity, anxiety, depression, or quality of life on multivariate ordinal regression modeling. CONCLUSIONS: Patients who experience dizziness have neutral attitudes with regards to believing that their provider will be able to identify the cause of their dizziness and whether their dizziness will resolve with treatment. These neutral attitudes are experienced by a plurality of patients and do not differ by demographic information, dizziness handicap, quality of life, depression, or anxiety.

Episodic versus Chronic Dizziness: An Analysis of Predictive Factors.

OBJECTIVES: To elucidate differences in demographic and clinical characteristics between patients with episodic and chronic dizziness. METHODS: A cross-sectional, observational study of 217 adults referred for dizziness at 1 tertiary center was undertaken. Subjects were split into a chronic dizziness group (>15 dizzy days per month) and an episodic dizziness group (<15 dizzy days per month). RESULTS: 217 adults (average age, 53.7 years; 56.7% female) participated. One-third (n = 74) met criteria for chronic dizziness. Dizziness handicap inventory (DHI) scores were significantly higher in those with chronic dizziness compared to those with episodic dizziness (53.9 vs 40.7; P < .001). Comorbid depression and anxiety were more prevalent in those with chronic dizziness (44.6% and 47.3% vs 37.8% and 35.7%, respectively; P > .05). Abnormal vestibular testing and abnormal imaging studies did not differ significantly between the 2 groups. Ménière's disease and BPPV were significantly more common among those with episodic dizziness, while the prevalence of vestibular migraine did not differ according to chronicity of symptoms. A multivariate regression that included age, sex, DHI, history of anxiety and/or depression, associated symptoms, and dizziness triggers was able to account for 15% of the variance in the chronicity of dizziness (pseudo-R2 = 0.15; P < .001). CONCLUSIONS: Those who suffer from chronic dizziness have significantly higher DHI and high comorbid rates of depression and anxiety than those with episodic dizziness. Our findings show that factors other than diagnosis alone are important in the chronification of dizziness, an observation that could help improve on multimodal treatment options for this group of patients.

Fear Avoidance Beliefs Are Associated With Perceived Disability in Persons With Vestibular Disorders.

OBJECTIVE: The purpose of this study was to determine the association between fear-avoidance beliefs and disability in 3 months in people with vestibular disorders while accounting for demographic and clinical characteristics. METHODS: This prospective cohort study included people aged 18 to 100 years who reported dizziness. Participants were recruited from a balance disorders clinic and outpatient physical therapy clinics. All participants completed the Vestibular Activities Avoidance Instrument (VAAI) and the Hospital Anxiety and Depression Scale at baseline and the Vestibular Activities and Participation measure (VAP), dizziness Visual Analogue Scale (VAS), and 12-item Short Form Health Questionnaire at baseline and 3-month follow-up. A modified version of the VAAI included 9 items abstracted from the 81-item VAAI. The relationships between 9-item VAAI scores and follow-up measures of disability were assessed using Spearman correlation coefficients. Linear regression models were analyzed to determine the effect of fear-avoidance beliefs on follow-up VAP score while accounting for baseline outcome measures. RESULTS: All participants (n = 404) completed the baseline assessment (mean age = 54 years), and 286 (71%) completed the 3-month assessment. The mean 9-item VAAI score was 25 (SD = 14) at baseline and was significantly associated with VAP (ρ = 0.54), 12-item Short Form Health Questionnaire component scores (ρ = -0.53; -0.44), and dizziness VAS at follow-up (ρ = 0.37). Approximately 38% of the variation in VAP score at follow-up was predicted by age, number of medications, 9-item VAAI score, dizziness VAS, and Hospital Anxiety and Depression Scale-depression score when considered together (R2 = 0.38). CONCLUSION: Fear-avoidance beliefs are associated with measures of disability at 3 months and are predictive of activity limitations and participation restrictions at 3 months when controlling for age, medications, baseline dizziness, and depression symptom severity in people with vestibular disorders. IMPACT: Measurement of fear-avoidance beliefs may provide important prognostic information, suggesting that an assessment of fear-avoidance beliefs could be used by clinicians to identify individuals at greater risk of disability after a vestibular disorder. LAY SUMMARY: Fear-avoidance beliefs in people who have vestibular disorders are associated with disability at 3 months and predict limitations in daily activities at 3 months.

Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: A randomized controlled trial.

OBJECTIVE: Secondary analysis, testing the effect on change in health-related quality of life of group-based vestibular rehabilitation in patients with mild-moderate traumatic brain injury, dizziness and -balance problems. DESIGN: A single-blind randomized controlled trial. SUBJECTS: A total of 65 patients aged 16-60 years with a Rivermead Post-concussion Symptoms Questionnaire dizziness score ≥2, and Dizziness Handicap Inventory score >15 points. Data collection was performed at baseline 3.5 (standard deviation (SD) 2.1) months post-injury, end of intervention, and 4.4 (SD 1.0) months after baseline. METHODS: Quality of Life after Brain Injury was the main outcome. Independent variables were demographic and injury variables, Hospital Anxiety and Depression Scale, changes on the Rivermead Post-concussion Symptoms Questionnaire (RPQ3 physical and RPQ13 psychological/cognitive), and Vertigo Symptom Scale-Short Form. RESULTS: Mean age of participants was 39.4 years (SD 13.0); 70.3% women. Predictors of change in the Quality of Life after Brain Injury were receiving the vestibular rehabilitation (p=0.049), baseline psychological distress (p=0.020), and change in RPQ3 physical (p=0.047) and RPQ13 psychological/cognitive (p=0.047). Adjusted R2 was 0.399, F=6.13, p<0.001. CONCLUSION: There was an effect in favour of the intervention group in improvement in health-related quality of life. Changes on the Rivermead Post-concussion Symptoms Questionnaire were also associated with change on the Quality of Life after Brain Injury.

Factors associated with dynamic balance in people with Persistent Postural Perceptual Dizziness (PPPD): a cross-sectional study using a virtual-reality Four Square Step Test.

BACKGROUND: Persistent postural-perceptual dizziness (PPPD) is a condition characterized by chronic subjective dizziness and exacerbated by visual stimuli or upright movement. Typical balance tests do not replicate the environments known to increase symptoms in people with PPPD-crowded places with moving objects. Using a virtual reality system, we quantified dynamic balance in people with PPPD and healthy controls in diverse visual conditions. METHODS: Twenty-two individuals with PPPD and 29 controls performed a square-shaped fast walking task (Four-Square Step Test Virtual Reality-FSST-VR) using a head-mounted-display (HTC Vive) under 3 visual conditions (empty train platform; people moving; people and trains moving). Head kinematics was used to measure task duration, movement smoothness and anterior-posterior (AP) and medio-lateral (ML) ranges of movement (ROM). Heart rate (HR) was monitored using a chest-band. Participants also completed a functional mobility test (Timed-Up-and-Go; TUG) and questionnaires measuring anxiety (State-Trait Anxiety Inventory; STAI), balance confidence (Activities-Specific Balance Confidence; ABC), perceived disability (Dizziness Handicap Inventory) and simulator sickness (Simulator Sickness Questionnaire). Main effects of visual load and group and associations between performance, functional and self-reported outcomes were examined. RESULTS: State anxiety and simulator sickness did not increase following testing. AP-ROM and HR increased with high visual load in both groups (p < 0.05). There were no significant between-group differences in head kinematics. In the high visual load conditions, high trait anxiety and longer TUG duration were moderately associated with reduced AP and ML-ROM in the PPPD group and low ABC and  high perceived disability were associated with reduced AP-ROM (|r| = 0.47 to 0.53; p < 0.05). In contrast, in controls high STAI-trait, low ABC and longer TUG duration were associated with increased AP-ROM (|r| = 0.38 to 0.46; p < 0.05) and longer TUG duration was associated with increased ML-ROM (r = 0.53, p < 0.01). CONCLUSIONS: FSST-VR may shed light on movement strategies in PPPD beyond task duration. While no main effect of group was observed, the distinct associations with self-reported and functional outcomes, identified using spatial head kinematics, suggest that some people with PPPD reduce head degrees of freedom when performing a dynamic balance task. This supports a potential link between spatial perception and PPPD symptomatology.

Efficacy of Yokukansan, a traditional Japanese herbal medicine, in patients with dizziness and irritability.

OBJECTIVE: Irritability is an emotional stress symptom that causes or exacerbates dizziness. Antidepressants may be helpful for some conditions that are accompanied by irritability; however, they do not completely inhibit irritability. Yokukansan (YKS), a traditional Japanese herbal medicine, has been used for neurosis, insomnia, and children's irritability and night crying. The study investigated the efficacy of YKS in nystagmus in patients with chronic dizziness and irritability. METHODS: Twenty-two cases with chronic dizziness and irritability were reviewed retrospectively. The patients were divided into two groups: control patients (0-7 days of treatment) and YKS-treated patients (YKS cases; >7 days of treatment). Dizziness before and during (after, in the controls) YKS treatment was evaluated by scoring the nystagmus intensity on a 5-point scale. The average scores were calculated within a maximum of 6 months before and during or after treatment. The normalized scores were also calculated. The optimal treatment regimen was calculated via receiver operating characteristic (ROC) curve analysis. RESULTS: There were six control cases (1 male, 5 females; mean age: 59.5 years). There were 16 YKS cases (3 males, 13 females; mean age: 61.8 years). While the group mean nystagmus intensity scores significantly decreased from 1.18 to 0.73 in the YKS cases, it did not change in the control cases. The group mean of the normalized nystagmus intensity scores during treatment was 0.73 in the YKS cases. The results of the ROC curve analysis indicated the optimal cut-off period of the YKS treatment was 10 days. CONCLUSION: The oral administration of YKS for more than 10 days was optimal. The treatments with YKS could be a good option for the treatments of vertigo.

Analysis of neurotransmitters associated with neuropsychiatric status in workers following lead exposure.

OBJECTIVE: To explore the correlation between neuropsychiatric status and blood neurotransmitter in lead workers, and to provide theoretical basis for the prevention and treatment of lead workers. SUBJECTS AND METHODS: The study applied cross-sectional survey, 74 occupational lead exposed workers in a battery factory in a city of Hebei province were selected as the lead exposed group, and 62 workers (non-lead workers) were selected as the control group. The occupational health symptoms questionnaire and health examination and POMS (Profile of Mood State, POMS) emotional test questionnaire were applied to investigate the nearly emotional status of the studied objects, ICP-MS was used to determine the blood lead level of all subjects, HPLC (High performance liquid chromatography, HPLC) was applied to determine the concentration of neurotransmitter in peripheral blood of all studied subjects, and all results were applied the Pearson's correlation analysis. RESULTS: The blood lead concentration of the lead workers group (163.23±40.77 ug/L) was significantly higher than that in the control group (43.62±14.50 ug/L), and the difference was statistically significant. From the analysis of neuropsychiatric status, the neurological symptoms in the lead workers group were higher than that in the control group, among which the symptoms of sleep disturbance, dizziness, fatigue, numbness of limbs and dampness and coldness of limbs were more obvious. Among the symptoms of digestive system, the incidence of abdominal pain, abdominal distension, constipation and nausea and vomiting were higher. According to the POMS emotion questionnaire, the scores of 5 negative emotions and 1 positive emotion in the lead exposure group were higher than that in the control group, and the difference was statistically significant. Related to the control group, the concentration of neurotransmitters such as DA, 5-HT, GABA, Gly, Trp and Glu were statistically decreased, p<0.001. There was a negative correlation between neurotransmitters in peripheral blood and blood lead levels in lead workers, among which 5-HT had the greatest correlation with lead levels (r=-0.569, p<0.001). 5-HT and Trp were significantly correlated with tension-anxiety (T), depression-depression (D), anger-hostility (A), Vigor-hyperactivity (V), fatigue-inertia (F), and confusion-confusion (C). 5-HT, Trp and GABA were significantly correlated with the survey symptoms, among which, the sleep disorder, constipation and fatigue had most significantly positive correlation with 5-HT or Trp, r-value was respectively 0.373, 0.233 and 0.563. CONCLUSIONS: Lead exposure not only causes the alteration of neuropsychiatric behavior of lead workers, but also changes gastrointestinal symptoms. Serotonin may be involved as the main neurotransmitter synthesized in intestinal, and the synthesis and metabolism may be regulated by intestinal flora.