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Objectives: To analyse the effectiveness of optokinetic stimulation (OKS) for improving symptoms and function in patients with vestibular and balance disorders., Methods: PubMed (MEDLINE), SCOPUS, Web of Science (WOS), CINAHL Complete, and PEDro databases were searched to identify randomized controlled trials (RCTs) that included patients with vestibular and balance disorders and compared the effects of OKS versus other interventions or no intervention on subjective or objective functional outcomes. Data were analysed by the standardized mean difference (SMD) and its 95% confidence interval., Results: A total of 10 studies were selected including 468 patients, 177 of whom received OKS. There were no significant differences in scores on the Dizziness Handicap Inventory (DHI) (SMD = 0.02; 95% CI - 0.18 to 0.23; p = 0.83) or the visual analogue scale (VAS) for vertigo (SMD = 0.16; 95% CI - 1.25 to 1.58; p = 0.82). However, there were statistically significant differences in the timed up and go (TUG) test, with a large effect (SMD = - 1.13; 95% CI -2 to - 0.28; p = 0.009), and in the sensory organization test (SOT), with a medium effect (SMD = - 0.7; 95% CI - 1.21 to - 0.19; p = 0.007). Subgroup analysis showed significant effects of OKS on VAS (p = 0.017), TUG (p = 0.009) and SOT (p = 0.001) only in patients with balance disorders without vestibular disease (p > 0.05)., Conclusions: OKS may improve dizziness intensity measured with VAS or dynamic balance measured whit TUG and SOT in patients with balance disorders not due to vestibular disease. The quality of the evidence was low or very low due to the small number of included studies., Prospero Registry Number: CRD42023445024., (© 2024. The Author(s).)

Objective: Persistent postural-perceptual dizziness classifies patients with chronic dizziness, often triggered by an acute episode of vestibular dysfunction or threat to balance. Unsteadiness and spatial disorientation vary in intensity but persist for over three months, exacerbated by complex visual environments., Method: Literature suggests diagnosis relies on a clinical history of persistent subjective dizziness and normal vestibular and neurological examination findings. Behavioural diagnostic biomarkers have been proposed, to facilitate diagnosis., Results: Research has focused on understanding the neural mechanisms that underpin this perceptual disorder, with imaging data supporting altered connectivity between neural brain networks that process vision, motion and emotion. Behavioural research identified the perceptual and motor responses to a heightened perception of imbalance., Conclusion: Management utilises head and body motion detection, and downregulation of visual motion excitability, reducing postural hypervigilance and anxiety. Combinations of physical and cognitive therapies, with antidepressant medications, help if the condition is associated with mood disorder.

Objective: The purpose of this study was to assess the static balance of children with sensorineural hearing loss (SNHL) according to the degrees of SNHL and the function of the vestibular system., Methods: This cross-sectional study was conducted in public schools located in Caruaru, Pernambuco state, Brazil, with 130 children (65 with normal hearing and 65 with SNHL as documented by air and bone conduction audiometry) of both sexes between 7 and 11 years old. Static balance was assessed by a stabilometric analysis using a force platform consisting of the circular area of center-of-pressure displacement of the children evaluated in 3 positions: bipedal support with feet together and parallel (PF), tandem feet (TF), and 1 foot (OF), carried out under 2 sensory conditions each, with eyes open and eyes closed. After balance assessments, the children with SNHL received examinations of auditory and vestibular functions-through audiometry and computerized vectoelectronystagmography, respectively-to compose the groups according to degrees of SNHL and vestibular function., Results: The children with severe and profound SNHL demonstrated more static balance instabilities than the children with normal hearing in 5 positions assessed with eyes open (PF, TF, and OF) and eyes closed (PF and TF). The same phenomenon occurred in children with SNHL and associated vestibular dysfunction in all of the positions assessed with eyes open and eyes closed (PF, TF, and OF)., Conclusion: The larger the degree of SNHL, the greater the balance instability of the children. The children with SNHL and associated vestibular dysfunction showed the highest balance instabilities in this study., Impact: Children with larger degrees of SNHL and associated vestibular dysfunction might require prolonged periods to rehabilitate their balance., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Patients with fibromyalgia syndrome (FMS) often have sleep problems and balance disorders., Objective: The aim of the study was to examine sleep quality and balance disorders and the relationship between sleep quality and balance, functional status and the frequency of falls in patients with FMS., Methods: Fifty women with FMS and 50 healthy women were included in the study. Sleep quality was assessed with the numeric rating scale (NRS) and the Pittsburgh Sleep Quality Index (PSQI) and balance and balance self-confidence were assessed with the Berg Balance Scale (BBS) and Activities-Specific Balance Confidence (ABC) Scale, respectively. Functional status and symptom severity of patients were assessed with the Fibromyalgia Impact Questionnaire (FIQ) and the Symptom Impact Questionnaire (SIQR). The number of falls in the last six months were recorded., Results: In the patient group, sleep quality scores were significantly higher, and BBS and ABC scores were significantly lower than the control group. NRS scores were significantly correlated with the BBS, FIQ, and SIQR scores, and the PSQI scores were significantly correlated with the BBS and ABC scores and the number of falls in FMS., Conclusion: This study showed that the prevalence of sleep and balance disorders is higher in FMS patients. A relationship was reported between the sleep quality and balance and functional status and frequency of falls.

Objective: The aim of this study is to compare the balance ability, anxiety level and motion sickness susceptibility in Vestibular Migraine (VM) patients, migraineurs without history of vertigo (Migraine-only, MO) and healthy controls (HC). We tested the hypothesis that VM patients have worse balance performance and higher anxiety level and motion sickness than MO and HC group., Methods: This cross-sectional study included of 123 definite VM patients, 58 MO patients and 49 HCs. All subjects were evaluated with the Dynamic Gait Index (DGI), the modified Clinical Test of Sensory Integration and Balance (mCTSIB), the Motion Sickness Susceptibility Questionnaire Short-Form (MSSQ-Short), the Panic Agoraphobic Spectrum Self-Report version (PAS-SR) and the Dizziness Handicap Inventory (DHI)., Results: The main balance outcomes indicated that DGI and mCTSIB scores were worse in VM than in MO patients and worse in MO patients than in HCs. Almost 50% of the VM patients fell in the most challenging mCTSIB conditions compared with 20% of MO patients and none of the HCs. VM patients had more marked motion sickness susceptibility, higher anxiety and DHI scores than MO patients and HCs. VM patients who fell had higher DHI and anxiety scores than those who did not., Conclusion: Balance problems, motion sickness, anxiety, and disability are more marked in VM patients than in MO patients and more marked in MO patients than in HCs. Focused treatments of these problems which could help VM patients need further study., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

Background: People with vestibular disorders often have abnormalities in gait and balance. The Dynamic Gait Index (DGI) is a relatively effective clinical gait measure that has been validated for use in patients with vestibular disorders. The modified version of the DGI (M-DGI) is based on the original DGI., Research Question: The objective of this study was to refine and test the clinical application of the M-DGI, and to investigate whether it is an effective indicator of dynamic gait in patients with vestibular disorders., Methods: A reliability and validity study. All raters reviewed the instructions and scoring criteria for each M-DGI item prior to the initial test. The raters simultaneously scored two M-DGI tasks for the 75 subjects, and the two tasks were completed with an interval of two hours in-between. Reliability of total M-DGI scores was assessed using intraclass correlation coefficients (2,1). Internal consistency of the M-DGI was evaluated using Cronbach's alpha. Concurrent validity of the M-DGI with Dizziness Handicap Inventory (DHI) and Timed "Up & Go" Test (TUG) was assessed using Spearman's rank order correlation coefficient., Results and Significance: Interrater and intrarater reliability of the total M-DGI scores were reflected by ICCs of 0.99 and 0.97. Internal consistency of the M-DGI score was 0.9975. Spearman's rank order correlation coefficient of the M-DGI score with the Dizziness Handicap Inventory (DHI) and the Timed "Up & Go" Test (TUG) was 0.72 and 0.65, respectively.The M-DGI demonstrates acceptable reliability, internal consistency, and concurrent validity for use as a clinical gait measurement for patients with vestibular disorders., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Migraine is a primary headache with high levels of associated disability that can be related to a variety of symptoms and comorbidities. The role of physical therapy in the management of migraine is largely unknown. Therefore, the aim of this review is to highlight and critically discuss the current literature and evidence for physical therapy interventions in individuals with migraines., Methods: A narrative review of the literature was performed., Results: Physical therapists assessing and treating patients with migraine should focus on two primary aspects: (1) musculoskeletal dysfunctions, and (2) vestibular symptoms/postural control impairment. Signs and symptoms of musculoskeletal and/or vestibular dysfunctions are prevalent among individuals with migraines and different disability levels can be observed depending on the presence of aura or increment of the migraine attacks., Conclusion: A proper physical examination and interview of the patients will lead to a tailored treatment plan. The primary aim regarding musculoskeletal dysfunctions is to reduce pain and sensitization, and physical therapy interventions may include a combination of manual therapy, exercise therapy, and education. The aim regarding postural control impairment is to optimize function and reduce vestibular symptoms, and interventions should include balance exercises and vestibular rehabilitation. However, consistent evidence of benefits is still lacking due to the lack of and therefore need for tailored and pragmatic clinical trials with high methodological quality., (Copyright © 2019 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: Approximately 30% of the elderly population is falling each year, resulting in a major health problem. Cognitive decline is an independent risk factor for fall. Mild cognitive impairment (MCI) is a cognitive decline that is higher than expected in the subjects' age but does not affect the activities of daily living OBJECTIVE: In the study, vestibulo-ocular reflexes, dynamic visual acuities and postural balances of subjects with mild cognitive impairment were evaluated and compared with the healthy control group., Methods: For this purpose, 10 subjects with mild cognitive impairment and 10 healthy subjects from the same age group were included in the study. After the hearing test was applied to the subjects, videonistagmography, dynamic visual acuity and computerized dynamic posturography measurements were performed., Results: Computerized Dynamic Posturography VEST parameter, SOT (Sensory Organization Test) 2, SOT 3, SOT 6 and Composite Balance Scores were significantly lower in the MCI group. There was no significant difference between the two groups in terms of videonistagmographic measurements. Dynamic Visual Acuity Perception Time Test scores of the subjects with mild cognitive impairment were significantly longer compared to the control group (p < 0.05)., Conclusion: As a result of the study, it was concluded that subjects with mild cognitive impairment were more prone to fall compared to control group and that these subjects should be included in fall prevention rehabilitation programs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Vertigo is a complex symptom which imposes diagnostic and treatment challenges. Laboratory evaluation of vertigo includes video-nystagmography (VNG) and computerized dynamic posturography (CDP) for the evaluation of different aspects of this complaint. There are vague indications for each test and potential disagreements between them. The aim of this study is to examine the association between the test results of the VNG and sensory organization test (SOT) of CDP in patients referred for both vestibular tests., Methods: Retrospective data regarding 56 patients age 17-82 years were collected. Patients suffered vestibular complaints and were referred for VNG and CDP evaluation on the same day. The level of agreement between VNG (including caloric test) and the vestibular input of the SOT for each patient was calculated., Results: Among the study group, 10 showed abnormal caloric test results, of which 3 (5.4%) had normal vestibular input in the SOT, and 7 (12.5%) had impaired input (p = 0.724). Spontaneous nystagmus was recorded in 13 patients by VNG, of which 2(3.6%) had normal vestibular input and 11(19.6%) had impaired vestibular input (p = 0.056)., Conclusions: This study shows no statistically significant association between the VNG test and SOT test results. Our results emphasize the difference between the tested aspects in each laboratory test, and the need to define specific indications for each of them. There is a marginally significant association between impaired vestibular input and spontaneous nystagmus, demonstrating the non-localizing nature of this sign.

Objectives: To evaluate the influence of auditory cues on postural sway in normal-hearing (NH) individuals, hearing-impaired individuals with vestibular impairment (HIVL), or hearing-impaired (HI) individuals without vestibular impairment., Design: Thirty-two participants received a hearing and a vestibular evaluation (vHIT, oVEMP, cVEMP) and then were separated in to three groups (NH, HI, HIVL). All participants had to stand on a force platform in four postural conditions (A: EO/firm, B: EC/firm, C: EO/Foam, D: EC/Foam) under two auditory conditions, with or without auditory cues., Results: Results revealed that first, there was a significant difference between HIVL and both HI and NH groups in conditions C and D without auditory cues. Second, greater improvement for HIVL compared to NH and HI groups in condition C and D was observed with auditory cues. Finally, somatosensory reliance significantly decreased for the HIVL participants using hearing aids compared to NH and HI., Conclusions: Our results suggest that hearing aids benefit for postural control may be modulated by vestibular function.

Objective: To evaluate the association between hearing and postural balance., Study Design: Retrospective cross-sectional study., Setting: Tertiary care otolaryngology clinic., Subjects and Methods: Patients examined for suspected vestibular disorder were included in this study. The outcome variable was postural sway measured by static posturography during quiet standing with eyes closed. The predictor variable was pure-tone average hearing threshold on the best hearing ear at 0.5, 1, 2, and 3 kHz. Covariates were age, sex, and vestibular disease or vestibular asymmetry assessed by bithermal caloric irrigation., Results: In total, 1075 patients were included. Increased hearing threshold was a strong predictor of increased postural sway (path length) after correcting for age and sex. A 10-dB increase in hearing loss on the best hearing ear predicted a mean 6.0% increase in path length (confidence interval, 2.9%-9.3%, P < .001). Of the covariates, increasing age ( P < .001) and male sex ( P = .009) were significant predictors of increased postural sway. The effect of increased hearing threshold was also significant after adjusting for vestibular disease., Conclusion: Increased hearing threshold was an independent predictor of increased postural instability, and this effect was strongest for the best hearing ear. Unilateral vestibular disease did not seem to explain this association between hearing and postural balance. Reduced hearing is associated with impaired balance, and interventions to prevent falls should be considered for patients at risk.

Falls are a major health care concern in individuals with Alzheimer disease (AD) and their caregivers. Vestibular impairment is a known risk factor for falls, and individuals with AD have been shown to have an increased prevalence of vestibular loss compared with age-matched controls. Vestibular physical therapy (VPT) is effective in improving balance and reducing fall risk in cognitively-intact persons with vestibular impairment. However, the effectiveness of VPT in improving balance and reducing falls in individuals with AD who have vestibular loss has never been explored. SUMMARY OF KEY POINTS:: In this article, we apply prevailing ideas about rehabilitation and motor learning in individuals with cognitive impairment (IwCI) to VPT. RECOMMENDATIONS FOR CLINICAL PRACTICE:: We propose a modification of current evidence-based VPT protocols for IwCI using the strength-based theoretical framework that emphasizes the motor learning abilities of IwCI. In addition, we highlight the importance of establishing an excellent rapport with IwCI, and present key strategies for optimizing the therapeutic relationship. In ongoing work, we are assessing the efficacy of this modified VPT protocol in IwCI to improve balance and reduce falls.

Objective: Considering the altered multisensory signal compensation during senescence, the aim of the present study was to evaluate the integration rearrangements in unilateral vestibular hypofunction (UVH) during age-related cognitive decline., Study Design: Cross-sectional study., Setting: Longitudinal cohort study unit and of University tertiary referral center., Patients: Older UVH individuals ≥ 55 years with Mild Cognitive Impairment (MCI) or Alzheimer Disease (AD) and matched UVH control group with age-appropriate cognitive function., Intervention: Vestibulo-ocular reflex, postural sway examination (respectively performed by means of video head impulse test and static posturography), and dizziness-related and quality of life scores were collected in all three groups of UVH patients cognitively evaluated by means of Mini Mental State Examination and Alzheimer's Disease Assessment Scale (ADAS-cog)., Main Outcome Measures: Vestibulo-ocular reflex gain, length, surface, and spectral values of body oscillation were measured. Dizziness Handicap Inventory, Activities-specific Balance Confidence scale, and Dynamic Gait Index scores were collected., Results: A significant (p < 0.05) increase in surface and length values during both eyes closed and eyes open conditions was found when comparing scores for AD to both MCI and control group patients, respectively. These patients demonstrated significantly (p < 0.05) lower spectral values of body oscillation on posturography platform in both eyes closed and eyes open condition within the low-frequency interval than MCI and AD patients., Conclusion: This is the first study reporting an association between cognitive decline and posturography parameters with possible preventive clinical implications in evaluating the risk for falls in high-risk patients, such as older adults with common neuro-otological disorders.

Aims: This case-control study was designed to compare static postural stability between women with stress urinary incontinence and continent women and it was hypothesized that women with incontinence aged around 50 years also have balance disorders., Methods: Eighteen women with incontinence and twelve women without incontinence aged 50-55 years participated in two 60-s trials of each of four different testing conditions: eyes open/full bladder, eyes open/empty bladder, eyes closed/full bladder, eyes closed/empty bladder. The center of foot pressure (COP): sway range, root mean square, velocity (in the antero-posterior and medio-lateral directions), and COP area were recorded. The stabilograms were decomposed into rambling and trembling components., Results: The groups of women with and without incontinence differed during the full bladder condition in antero-posterior COP sway range, COP area, and rambling trajectory (range in the antero-posterior and medio-lateral directions, root mean square in the antero-posterior and medio-lateral directions and velocity in the antero-posterior direction)., Conclusion: The women with incontinence had more difficulty controlling their postural balance than continent women while standing with a full bladder. Therefore, developing therapeutic management focused on strengthening the women's core muscles and improving their postural balance seems advisable., (© 2017 Wiley Periodicals, Inc.)

Objective: To characterize the stability limits and region in patients with unilateral vestibulopathy according to the side of the lesion and determine if that imposes any bias. To analyze if the stability limits and region depend on the functional deficit as evaluated in the sensory organization test., Methods: Forty patients with chronic dizziness and without any vertigo spell for least 6 months prior to testing. In all of them, a unilateral vestibulopathy was diagnosed clinically and at vestibular testing. A computerized dynamic posturography system was used to test for the ability of patients and controls to displace their center of pressure (COP) to the corresponding LOS. The area was calculated and compared to other data from vestibular tests., Results: The area of stability among patients shows a reduction to 35-62% of the expected total. That reduction was not found to be dependent on age., Conclusion: There is a symmetric reduction in the limits of stability (LOS) in patients with unilateral vestibulopathy who suffer chronic instability. None of the areas measured were correlated with the composite score of the sensory organization test and, as such, must be considered as an adjunct measure to characterize the postural limitations in those patients.

Posturography is used to assess balance in clinical settings, but its relationship to gait stability is unclear. We assessed if dynamic gait stability is associated with standing balance in 12 patients with unilateral vestibulopathy. Participants were unexpectedly tripped during treadmill walking and the change in the margin of stability (MoS change ) and base of support (BoS change ) relative to nonperturbed walking was calculated for the perturbed and first recovery steps. The center of pressure (COP) path during 30-s stance with eyes open and closed, and the distance between the most anterior point of the COP and the anterior BoS boundary during forward leaning (A Dist ), were assessed using a force plate. Pearson correlations were conducted between the static and dynamic variables. The perturbation caused a large decrease in the BoS, leading to a decrease in MoS. One of 12 correlations was significant (MoS change at the perturbed step and A Dist ; r = -.595, P = .041; nonsignificant correlations: .068 ≤ P ≤ .995). The results suggest that different control mechanisms may be involved in stance and gait stability, as a consistent relationship was not found. Therefore, posturography may be of limited use in predicting stability in dynamic situations.

Background: Dizziness is a frequently reported symptom in older people that can markedly impair quality of life. This manuscript presents the protocol for a randomised controlled trial, which has the main objective of determining the impact of comprehensive assessment followed by a tailored multifaceted intervention in reducing dizziness episodes and symptoms, improving associated impairments to balance and gait and enhancing quality of life in older people with self-reported significant dizziness., Methods: Three hundred people aged 50 years or older, reporting significant dizziness in the past year will be recruited to participate in the trial. Participants allocated to the intervention group will receive a tailored, multifaceted intervention aimed at treating their dizziness symptoms over a 6 month trial period. Control participants will receive usual care. The primary outcome measures will be the frequency and duration of dizziness episodes, dizziness symptoms assessed with the Dizziness Handicap Inventory, choice-stepping reaction time and step time variability. Secondary outcomes will include health-related quality of life measures, depression and anxiety symptoms, concern about falling, balance and risk of falls assessed with the physiological fall risk assessment. Analyses will be by intention-to-treat., Discussion: The study will determine the effectiveness of comprehensive assessment, combined with a tailored, multifaceted intervention on dizziness episodes and symptoms, balance and gait control and quality of life in older people experiencing dizziness. Clinical implications will be evident for the older population for the diagnosis and treatment of dizziness., Trial Registration: The study is registered with the Australia New Zealand Clinical Trials Registry ACTRN12612000379819 .

Objective: To determine if children with unilateral sensorineural hearing loss (UHL) demonstrate impaired balance compared with their normal hearing (NH) peers., Study Design: Prospective, case-control study., Methods: Balance was assessed in14 UHL and 14 NH children using the Bruininks-Oseretsky Test-2 (BOT-2) and time to fall (TTF) in an immersive, virtual-reality laboratory. Postural control was quantified by center of pressure (COP) using force plates. The effect of vision on balance was assessed by comparing scores and COP characteristics on BOT-2 tasks performed with eyes open and closed., Results: Balance ability as measured by the BOT-2 score was significantly worse in children with UHL compared with NH children (p = 0.004). TTF was shorter in children with UHL compared with NH children in the most difficult tasks when visual and somatosensory inputs were limited (p < 0.01). Visual input improved postural control (reduced COP variability) in both groups in all tasks (p < 0.05) but postural control as measured by COP variability was more affected in children with UHL when visual input was removed while performing moderately difficult tasks (i.e., standing on one foot) (p = 0.02)., Conclusion: In this pilot study, children with UHL show poorer balance skills than NH children. Significant differences in TTF between the two groups were only seen in the most difficult tasks and therefore may be missed on routine clinical assessment. Children with UHL appear to rely more on vision for maintaining postural control than their NH peers. These findings may point to deficits not only in the hearing but also the vestibular portion of the inner ear.

Objective: The therapeutic use of ototoxic drugs is relatively common, particularly in patients with severe diseases. It is likely that disturbances of balance in these patients are underestimated by clinicians., Materials and Methods: The purpose of this study was to identify drugs involved in the vestibulotoxic origin of instability in a group of 18 patients., Results: Six patients showed both cochlear and vestibular damage, while 12 were affected only by posterior labyrinthine damage. Four groups of drugs were identified: antibiotics (nine patients), cytostatics (four), anti-tuberculosis medicinal products (three), and other drugs (two). Cytostatics were involved in many cases studied, a fact scarcely reported before., Conclusion: It is important to ensure an early diagnosis to prevent ototoxic effects induced by drugs. We propose that patients receiving potential ototoxic drugs undergo cochlear and vestibular assessments. Further, we recommend that patients with instability undergo vestibular rehabilitation.

Preserving upright stance requires central integration of the sensory systems and appropriate motor output from the neuromuscular system to keep the centre of pressure (COP) within the base of support. Unilateral peripheral vestibular disorder (UPVD) causes diminished stance stability. The aim of this study was to determine the limits of stability and to examine the contribution of multiple sensory systems to upright standing in UPVD patients and healthy subjects. We hypothesized that closure of the eyes and Achilles tendon vibration during upright stance will augment the postural sway in UPVD patients more than in healthy subjects. Seventeen UPVD patients and 17 healthy subjects performed six tasks on a force plate: forwards and backwards leaning, to determine limits of stability, and upright standing with and without Achilles tendon vibration, each with eyes open and closed (with blackout glasses). The COP displacement of the patients was significantly greater in the vibration tasks than the controls and came closer to the posterior base of support boundary than the controls in all tasks. Achilles tendon vibration led to a distinctly more backward sway in both subject groups. Five of the patients could not complete the eyes closed with vibration task. Due to the greater reduction in stance stability when the proprioceptive, compared with the visual, sensory system was disturbed, we suggest that proprioception may be more important for maintaining upright stance than vision. UPVD patients, in particular, showed more difficulty in controlling postural stability in the posterior direction with visual and proprioceptive sensory disturbance.

Conclusions: Postural control is dependent on the visual system in normal conditions. Shift from visual to somatosensory dependence in dizzy patients suggests that utilizing the stable visual references is recommended for the rehabilitation of dizzy patients., Objectives: To investigate which of the visual or somatosensory system is mainly used for substitution of the impaired spatial orientation in dizzy patients., Methods: We recruited 189 consecutive patients with or without dizziness and vestibular dysfunction. Dizzy patients were divided into three groups: acute, episodic, and chronic dizziness. Vestibular function was assessed by caloric test, traditional head impulse test, and head shaking nystagmus. Visual or somatosensory dependence of spatial orientation was assessed by posturography on a solid surface or on foam in eyes open or closed condition. The foam ratio (posturography with/without foam) when eyes were closed was indicative of somatosensory dependence of postural control, whereas the Romberg ratio on foam showed visual dependence. (Romberg ratio on foam)/(foam ratio with eyes closed) was calculated and used as an index of the visual/somatosensory dependence of postural control., Results: The visual/somatosensory ratio of postural control was significantly lower in dizzy patients as well as patients with vestibular dysfunction, however, no differences were found between acute, episodic, and chronic dizziness.

Background: A standardized diagnostic protocol for children's vestibular assessment is still missing in daily clinical life. As rotatory chair testing and caloric test are usually not tolerated well by children, the aim of our study was not only to evaluate the importance and practicability of the video head impulse test performed in children with and without balance problems, but also to outline a diagnostic algorithm for children with balance problems., Methods: Fifty-five children aged 3-16 years have been included in this prospective monocentric study. Balance was assessed using results from health screening examinations of the participants and results from a specific dizziness questionnaire for children. The children were then divided in two groups: group I without any sign of vestibular development disorder and group II with possible signs for a pathological equilibrium development. Horizontal vestibulo-ocular reflex (HVOR) was assessed using a video-oculography system device (EyeSeeCam(©)). Gain at 40, 60, and 80ms and gain variance has been measured. Furthermore, it was evaluated how calibration of the system was tolerated by the participants, how the test itself was accomplishable in children, and which difficulties arose during testing., Results: Reproducible test results were accomplished in 42 children (75%). Children with no balance problems in history showed a median gain of 1.02 (±0.28). A significant gain reduction between 40 and 80ms was found (P<0.05). Catch-up saccades were found in none of the children. Children with balance problems had a significantly reduced gain. (0.47±0.3; P<0.05) In this group, catch-up saccades could be detected in 4 out of 6 patients. For both groups, performing the test approximately took 20min, which is significantly longer than in adults (P<0.05). Calibration of the system with laser dots was easily doable in children aged 6 and older, whereas children between 3 and 5 years had better calibration results using colorful little icons., Conclusions: Video head impulse test is a sensitive and efficient vestibular test in children, which is tolerated well by children aged 3-16 years. Therefore, video head impulse test can be easily used as a screening tool to detect vestibular dysfunction in the pediatric population., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine the role of vestibular and balance dysfunction in children with cochlear implant (CI) failure., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Thirty-five children with CI failure were compared to 165 children who did not experience CI failure., Main Outcome Measures: Vestibular function was compared between groups by horizontal canal function (measured by caloric, rotational, video Head Impulse Testing [vHIT]), saccular function (vestibular evoked myogenic potentials [VEMP]), and balance (measured by Bruininks-Oseretsky Test [BOT-2])., Results: Twenty-one patients completed vestibular and balance testing. Patients with CI failure demonstrated significantly more abnormal horizontal canal function than those who did not experience CI failure (caloric: 81 vs. 47%, p = 0.004; rotational/vHIT: 71 vs. 35%, p = 0.001). Absence of bilateral horizontal canal function increased the odds of CI failure 7.6 times. A greater proportion of children with CI failure had abnormal saccular function compared to those without CI failure (81 vs. 46%, p = 0.003). Children with CI failure had significantly worse balance (BOT-2 score: 7.8) than children who did not experience CI failure (BOT-2 score: 12.2) (p < 0.0001)., Conclusions: Vestibular end-organ dysfunction and its resulting balance impairment have been identified as important risk factors for CI failure in children. Early identification and treatment of such impairments may avoid or delay implant failures and prevent children from experiencing periods of sound deprivation that could impact speech and language acquisition.

Treatment of anxiety disorders by either pharmacological or behavioral means is applied with the intention to directly target the limbic system or high brain centers that down-regulate limbic activity. In spite of intense and long treatment, remission is not achieved in many patients, suggesting that their pathophysiology is not addressed by either of the above treatments. An alternative pathophysiology may be a disordered vestibular system, which may be studied in the context of comorbidity of balance and anxiety disorders. Here we studied whether mutant vestibular Headbanger (Hdb) mice demonstrate elevated anxiety and whether physical treatment of balance alleviates the behavioral symptoms of anxiety. Hdb and wildtype (Wt) mice were raised in either balance training or standard cages and were subjected repeatedly at 1-3 months of age to balance and anxiety-related tests. Results demonstrated progressive deterioration of balance performance and parallel elevation of anxiety in untrained Hdb as compared to untrained Wt mice. Training significantly improved balance performance of Hdb mice and in parallel, decreased the level of anxiety compared to untrained Hdb mice. These findings confirm that vestibular pathophysiology may be causally related to development of anxiety and suggest that in some clinical cases of anxiety, the appropriate treatment is physical rehabilitation of balance., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Fall-related fractures are an increasing problem for society. Dizziness is identified as a risk factor for falls and vestibular asymmetry is often found among patients with fall-related fractures. An option to prevent fall-related fractures may be to identify patients with vestibular asymmetry and to improve their balance and asymmetry by exercise., Objective: To examine whether vestibular rehabilitation improves vestibular function, balance and self-rated health among patients with fall-related wrist fractures., Methods: Sixty-eight persons (65 women) with fall-related wrist fractures, mean age 72 years (54-89) participated in this randomized controlled trial. The following tests and measurements were performed: head shake test to evaluate vestibular asymmetry as primary outcome measure, five clinical balance measures, a force plate to measure postural sway, a tuning fork to measure vibration and the EQ5D questionnaire to measure self-rated health. The intervention comprised group-based vestibular rehabilitation sessions conducted twice a week for 9 weeks., Results: Nystagmus occurred in the head shake test in 65% (44 of 68) of the patients, indicating vestibular asymmetry. More patients in the intervention group (6 of 21) than in the control group (0 of 23) changed from having nystagmus in the head shake test at baseline (indicating vestibular asymmetry) to not having nystagmus at follow-up, and more patients in the control group (3 of 9) than in the intervention group (0 of 3) changed from not having nystagmus at baseline to have nystagmus at follow-up (p < 0.00). No other changes occurred between the two groups between baseline and follow-up. At baseline, patients with vestibular asymmetry had more balance deficits and increased postural sway compared to patients without (p = 0.00-0.05)., Conclusion: Group sessions with vestibular rehabilitation twice a week for 9 weeks affected the occurrence of vestibular asymmetry positively among patients having vestibular asymmetry. Patients with vestibular asymmetry had more balance deficits and increased postural sway than patients without vestibular asymmetry. Vestibular assessment is important, and, in patients with diagnosed vestibular asymmetry, vestibular rehabilitation may prove beneficial on balance and possibly reduce the risk of future falls., (© 2014 S. Karger AG, Basel.)

Background: Bilateral vestibular dysfunction causes serious disabilities and handicaps. Patients with bilateral dysfunction often restrict their activities and tend to be unsocial., Aim: To compare the effects of vestibular rehabilitation on disability, balance, and postural stability in patients with unilateral and bilateral vestibular dysfunction., Design: Retrospective study., Setting: Outpatient rehabilitation center., Population: Patients with unilateral (group 1, N.=42) and bilateral vestibular dysfunction (group 2, N.=19)., Methods: All patients were evaluated before and after eight weeks of customized vestibular rehabilitation for disability (Dizziness Handicap Inventory [DHI], Activities-specific Balance Confidence Scale [ABC]), dynamic balance (Timed Up and Go Test [TUG], Dynamic Gait Index [DGI]), and postural stability (static posturography)., Results: The differences between DHI, TUG, DGI, and falling index (as assessed by static posturography) scores before and after the exercise program were statistically significant in both groups (P<0.05). There were no significant intergroup differences in any of the parameters evaluated (P>0.05)., Conclusion: In this study, vestibular rehabilitation was found to be equally effective in unilateral and bilateral vestibular dysfunction patients for improving disability, dynamic balance, and postural stability., Clinical Rehabilitation Impact: Patients with bilateral dysfunction, causing more disability and greater handicap may indeed regain their functions as in patients with unilateral vestibular dysfunction by receiving appropriate and adequate vestibular rehabilitation.

Children with hearing impairment have balance and motor deficits primarily due to concomitant damage to the vestibular structures. Although early intervention focused on the development of communication skills, investigations of intervention for the amelioration of balance deficits in children with hearing loss have been minimal and inconclusive. Therefore, using an experimental design, the present study investigated the effect of a 12-session exercise balance program based on proprioception training on balance and gait in deaf as compared with hearing schoolchildren. The subjects, 10 deaf and 10 typically developing children were assigned to an experimental and a control group respectively. Taking up the initial differences between the groups through a pretest under different conditions, the participants in the experimental group went through a 12-session intervention program including static and dynamic training with emphasis on proprioceptive system. After this, the participants were tested again. The data obtained was analyzed using repeated measure. A comparison between the control and experimental groups revealed that the intervention program had not significantly increased gait velocity while it had significantly decreased the amount of sway. Thus, it was concluded that an exercise program that enhances somatosensory ability can result in improved balance in deaf children., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To assess vestibular deficits in response to disequilibrium in ambulatory individuals with amyotrophic lateral sclerosis (ambALS)., Design: All participants completed standard protocols for the Sensory Organization Test (SOT) by computerized dynamic posturography., Setting: Multidisciplinary amyotrophic lateral sclerosis clinic at an academic medical center., Participants: Study participants (N=34) consisted of ambALS (n=19) and healthy controls (HC) (n=15)., Interventions: Not applicable., Main Outcome Measures: Equilibrium scores (ESs) obtained from averaged sway amplitude in condition 5 (ES5) and condition 6 (ES6) of the SOT., Results: In conditions of altered somatosensory information with vision absent or vision sway-referenced, the mean ± SD scores for ambALS (ES5=51.4±22.5; ES6=50.8±22.1) were lower than those for HC (ES5=65.4±11.7, P≤.03; ES6=58.9±12.5, P>.05). Seven ambALS (37%) experienced a total of 19 falls during the sway-referenced support test conditions. There were no falls in the HC., Conclusions: Nearly 37% of ambALS with normal clinical balance testing have decreased ability to use the vestibular input and required increased reliance on visual input for postural orientation to sustain equilibrium. The mechanism of this alteration in sensory preference is not completely clear. Extrapyramidal involvement early in ALS may be indicated., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Although psoriatic arthritis (PsA) is a common chronic inflammatory rheumatic disease, little is known about audiovestibular impairment in this condition. We aimed to establish whether audiovestibular manifestations were present in patients with PsA., Methods: A set of 60 consecutive patients who fulfilled the Moll and Wright criteria for PsA and 60 matched controls were studied. During the period of recruitment, individuals were excluded who had a history of cardiovascular disease, cerebrovascular complications, peripheral artery disease, renal insufficiency, syphilis, Meniere disease and other vestibular syndromes, infections involving the inner ear, barotrauma, or were in treatment with ototoxic drugs., Results: Most patients with PsA were men (63%). The mean age at the time of our study was 52.9 years and the mean age at the onset of symptoms was 33 years. Thirty-six (60%) of the 60 patients showed abnormal hearing loss in the audiogram compared to only 5 (8.3%) of the 60 controls (p < 0.001). Values of audiometric tests (pure-tone average and speech reception threshold) yielded significant differences between patients and controls (p < 0.001). The audiogram disclosed a bilateral and symmetrical sensorineural hearing loss (SNHL) in PsA with predominant pattern of high frequency SNHL in patients with PsA (46.7%) compared to controls (8.3%, p < 0.001). Patients with PsA exhibited abnormal vestibular tests more commonly than controls. A significantly increased frequency of abnormal computerized dynamic posturography with a predominant vestibular loss pattern was also observed in patients (23.3%) compared to controls (0%, p < 0.001)., Conclusion: Our current study demonstrates strong evidence for inner ear damage in patients with PsA.

Background and Purpose: Persistent dizziness and balance problems have been reported in some patients with unilateral vestibular pathology. The purpose of this case series was to address the examination and treatment of musculoskeletal dysfunction in patients with unilateral vestibular hypofunction., Case Description: The musculoskeletal system was evaluated with the Global Physiotherapy Examination, dynamic balance was measured during walking with triaxial accelerometers positioned on the lower and upper trunk, and symptoms and functional limitations were assessed with standardized self-report measures. The 4 included patients had symptoms of severe dizziness that had lasted more than 1 year after the onset of vestibular dysfunction and a moderate level of perceived disability. Musculoskeletal abnormalities typically included postural misalignment, restricted abdominal respiration, restricted trunk movements, and tense muscles of the upper trunk and neck. The patients attended a modified vestibular rehabilitation program consisting of body awareness exercises addressing posture, movements, and respiration., Outcomes: After the intervention, self-reported symptoms and perceived disability improved. Improvements in mobility and positive physical changes were found in the upper trunk and respiratory movements. The attenuation of mediolateral accelerations (ie, body oscillations) in the upper trunk changed; a relatively more stable upper trunk and a concomitantly more flexible lower trunk were identified during walking in 3 patients., Discussion: The recovery process may be influenced by self-inflicted rigid body movements and behavior strategies that prevent compensation. Addressing physical dysfunction and enhancing body awareness directly and dizziness indirectly may help patients with unilateral vestibular hypofunction break a self-sustaining cycle of dizziness and musculoskeletal problems. Considering the body as a functional unit and including both musculoskeletal and vestibular systems in examination and treatment may be important., (© 2014 American Physical Therapy Association.)

Objective: To examine the effect of an imperceptible level of galvanic vestibular stimulation (GVS), delivered as zero-mean current noise (noisy GVS), on postural performance in healthy subjects as well as in patients with bilateral peripheral vestibular dysfunction., Methods: White noise GVS with an amplitude ranging from 0 to 1,000 μA was applied in 21 healthy subjects and 11 patients with bilateral vestibular dysfunction. Two-legged stance tasks were performed with the eyes closed during a 60-second period, which consisted of a baseline period without stimulation and a stimulation period with GVS. We examined 3 parameters: the velocity, the envelopment area, and the root mean square (RMS) of the center of pressure., Results: White noise GVS improved all 3 parameters in 76% of healthy subjects. The amplitude of the optimal stimulus was 281 ± 40 μA, and it improved the velocity, area, and RMS by 18.4% ± 2%, 37.9% ± 3.5%, and 20.4% ± 2.2%, respectively (p < 0.01). The GVS improved all 3 parameters in 91% of patients. The amplitude of the optimal stimulus was 456 ± 82 μA, and it improved the velocity, area, and RMS by 29.4% ± 4.9%, 45.6% ± 4.7%, and 22% ± 3.3%, respectively (p < 0.01)., Conclusions: Noisy GVS is effective in improving postural stability in healthy subjects as well as in patients with bilateral vestibular dysfunction., Classification of Evidence: This study provides Class IV evidence that in patients with bilateral vestibular dysfunction, an imperceptible level of noisy GVS may improve postural stability.

Introduction: Kinesitherapy is widely accepted management in patients with vertigo and imbalance, but there has been inadequate evidence that one form of therapy is superior to another., The Aim: of the study was to compare effectiveness of two kinesitherapy protocols in patients with the peripheral vestibular system disorders., Material and Methods: Fifty patients (mean age 46.0±13.1 year) with vertigo and balance instability lasting over 3 months with unilateral vestibular disorder, confirmed in Videnystagmography, were included in the study. Thirty patients underwent supervised and 20 patients home-based exercise programs. All of them were assessed three times at the baseline, after 4 weeks and 3 months, on vertigo intensity and frequency with the Vertigo Syndrome Scale (VSS), Vertigo Visual Analog Scale (VAS) and clinical unsteadiness with tests (Romberg, Amended Motor Club Assesment (AMCA), Eurofit test - standing on one leg., Results: In both groups the clinical tasks and the intensity of vertigo in VAS significantly decreased. The mean value of VSS (part physical and emotional)score significantly decreased only in supervised group at the end of 4 weeks and 3 months (p=ns). Recovery was more dynamic in supervised group than home-based exercises group, in AMCA test (3.9 vs. 1.3 s, p<0.05) in Eurofit tests eye open (14.1 vs. 0.9 s, p<0.05) and eye closed (3.5 vs. 1 s, p<0.05)., Conclusions: In patients with unilateral peripheral vestibular dysfunction supervised and home-based group kinesitherapy is an effective treatment method. In supervised group patients recovery has been faster., (Copyright © 2013 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z.o.o. All rights reserved.)

Background: Although significant progress has been achieved in developing sensory augmentation methods to improve standing balance, attempts to extend this research to locomotion have been quite limited in scope. The goal of this study was to characterize the effects of two real-time feedback displays on locomotor performance during four gait-based tasks ranging in difficulty., Methods: Seven subjects with vestibular deficits used a trunk-based vibrotactile feedback system that provided real-time feedback regarding their medial-lateral (M/L) trunk tilt when they exceeded a subject-specific predefined tilt threshold during slow and self-paced walking, walking along a narrow walkway, and walking on a foam surface. Two feedback display configurations were evaluated: the continuous display provided real-time continuous feedback of trunk tilt, and the gated display provided feedback for 200 ms during the period immediately following heel strike. The root-mean-square (RMS) trunk tilt and percentage of time below the tilt thresholds were calculated for all locomotor tasks., Results: Use of continuous feedback resulted in significant decreases in M/L trunk tilt and increases in percentage times below the tilt thresholds during narrow and foam trials. The gated display produced generally smaller changes., Conclusions: This preliminary study demonstrated that use of continuous vibrotactile feedback during challenging locomotor tasks allowed subjects with vestibular deficits to significantly decrease M/L RMS trunk tilt. Analysis of the results also showed that continuous feedback was superior.

Conclusions: Foam posturography reveals that idiopathic bilateral vestibulopathy (IBV) significantly affects postural stability. Instability was more severe in patients with damage to both of the vestibular nerve systems. Residual function in the spared vestibular nerve system might contribute to postural stability in IBV., Objective: Postural stability was assessed using foam posturography in patients with IBV according to whether the inferior, superior or both of the vestibular nerve systems were affected., Methods: Two-legged stance tasks were performed by patients with IBV (n = 29) in four conditions: eyes open with and without foam rubber, and eyes closed with and without foam rubber. We examined six variables: the velocity of movement of the center of pressure (COP), the envelopment area traced by the movement of the COP, Romberg's ratio of velocity and area, and the foam ratios of velocity and area., Results: The presence of IBV was significantly positively related to all the variables in adjusting for the subjects' gender and age (p < 0.001). Five of the 29 patients (17%) with IBV required assistance to prevent falling with eyes closed/foam rubber. Four of these five patients showed bilateral canal paresis in caloric testing and bilaterally no responses in cervical vestibular evoked myogenic potential testing.

Introduction: This article discusses, in a clinically relevant format, the importance of including a neuro-optometrist as a member of the management team for patients with balance disorders., Purpose: To review the importance of vision and visual processing for maintaining a sense of balance and equilibrium and the role of the neuro-optometrist in the overall rehabilitation of patients with balance disorders, Summary: Dizziness, balance problems and the sensation that the space world is moving (vertigo) are one of the most commonly reported problems in general medical practice. Persons with a central nervous system injury or other idiopathic causes of visual processing problems or who have functional vision problems that are not adequately managed, often experience extreme difficulty with balance and movement, as well as with their perception of space. Consequently, the patient often experiences difficulty functioning in an environment with excessive visual stimulation such as a grocery store or shopping mall. Symptoms of disequilibrium, vestibular and balance problems are commonly a result of VOR disturbance secondary to an inner ear problem and an unstable binocularity., Conclusion: The combination of neuro-optomertic rehabilitative therapy and balance therapy will result in a is an effective treatment for reducing or resolving these symptoms.

Background: There are several protocols designed to treat vestibular disorders that focus on habituation, substitution, adaptation, and compensation exercises. However, protocols that contemplate not only vestibular stimulation but also other components that are essential to the body balance control in older people are rare. This study aims to compare the effectiveness of two vestibular rehabilitation protocols (conventional versus multimodal) on the functional capacity and body balance control of older people with chronic dizziness due to vestibular disorders., Methods/design: A randomized, single-blind, controlled clinical trial with a 3 months follow-up period will be performed. The sample will be composed of older individuals with a clinical diagnosis of chronic dizziness resulting from vestibular disorders. The subjects will be evaluated at baseline, post-treatment and follow-up. Primary outcomes will be determined in accordance with the Dizziness Handicap Inventory (functional capacity) and the Dynamic Gait Index (body balance). Secondary outcomes include dizziness features, functional records, body balance control tests, and psychological information. The older individuals (minimum sample n = 68) will be randomized to either the conventional or multimodal Cawthorne&Cooksey protocols. The protocols will be performed during individual 50-minute sessions, twice a week, for 2 months (a total of 16 sessions). The outcomes of both protocols will be compared according to the intention-to-treat analysis., Discussion: Vestibular rehabilitation through the Cawthorne&Cooksey protocol has already proved to be effective. However, the addition of other components related to body balance control has been proposed to improve the rehabilitation of older people with chronic dizziness from vestibular disorders., Trial Registration: ACTRN12610000018011.

Objectives/hypothesis: To identify the predictive ability of vestibular function test results on motor performance among hearing-impaired children., Study Design: Cross-sectional study., Methods: Fifty-one typically developing children and 48 children with a unilateral (n = 9) or bilateral hearing impairment (n = 39) of more than 40 dB HL between 3 and 12 years were tested by the Movement Assessment Battery for Children-Second Edition (M ABC-2), clinical balance tests, posturography, rotatory chair testing, and vestibular evoked myogenic potential (VEMP). From the group of hearing-impaired children, 23 had cochlear implants., Results: Balance performance on M ABC-2, clinical balance tests, as well as the sway velocity assessed by posturography in bipedal stance on a cushion with eyes closed and in unilateral stance differed significantly between both groups. Presence of a VEMP response is an important clinical parameter because comparison of the motor performance among hearing-impaired children between those with present and absent VEMPs showed significant differences in balance performance. The three most important predictor variables on motor performance by bivariate regression analyses are the vestibular-ocular reflex (VOR) gain value of the rotatory chair test at 0.01 and 0.05 Hz frequency, as well as the VEMP asymmetry ratio. Multivariate regression analyses suggest that the VOR asymmetry value of the rotatory chair test at 0.05 Hz and the etiology of the hearing loss seem to have additional predictive value., Conclusions: Hearing-impaired children are at risk for balance deficits. A combination of rotatory chair testing and VEMP testing can predict the balance performance., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Unlabelled: Abnormal body balance and cognitive dysfunction may develop in elderly patients with chronic vestibular dysfunction., Aim: To evaluate the relationship between cognitive processing and body balance in elderly patients with chronic peripheral vestibular disease., Type of Study: Cross-sectional., Methods: Seventy-six patients (> 60 years) with chronic peripheral vestibular dysfunction and dizziness for more than three months were enrolled. The tests for investigating body balance were: the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Timed Up and Go Test (TUGT) Timed Up and Go Test modified (TUGTm); the Mini Mental State Examination (MMSE), Test Clock (RT,) and Verbal Fluency Test (VF) were applied for assessing cognition., Results: The mean age was 69.03 years (SD=6.21 years); most were female (82.9%). There was a significant negative correlation between the MMSE and the TUGT (ρ=-0.312; p=0.01), MMSE and TUGTm (ρ=-0.306; p=0.01), FV and TUGT (ρ=-0.346; p=0.01), and FV and TUGTm (ρ=-0.536; p=0.01); there was a significant positive correlation between the TR and BBS (ρ=0.343; p=0.01), TR and DGI (ρ=0.298; p=0.01), FV and BBS (ρ=0.299; p=0.01), and FV and DGI (ρ=0.306; p=0.01)., Conclusion: Elderly patients with chronic peripheral vestibular disease and worse performance in body balance tests have functional impairment in cognitive skills.

Background: Most HIV-seropositive subjects in western countries receive highly active antiretroviral therapy (HAART). Although many aspects of their health have been studied, little is known about their vestibular and balance function. The goals of this study were to determine the prevalences of vestibular and balance impairments among HIV-seropositive and comparable seronegative men and women and to determine if those groups differed., Methods: Standard screening tests of vestibular and balance function, including head thrusts, Dix-Hallpike maneuvers, and Romberg balance tests on compliant foam were performed during semiannual study visits of participants who were enrolled in the Baltimore and Washington, D. C. sites of the Multicenter AIDS Cohort Study and the Women's Interagency HIV Study., Results: No significant differences by HIV status were found on most tests, but HIV-seropositive subjects who were using HAART had a lower frequency of abnormal Dix-Hallpike nystagmus than HIV-seronegative subjects. A significant number of nonclassical Dix-Hallpike responses were found. Age was associated with Romberg scores on foam with eyes closed. Sex was not associated with any of the test scores., Conclusion: These findings suggest that HAART-treated HIV infection has no harmful association with vestibular function in community-dwelling, ambulatory men and women. The association with age was expected, but the lack of association with sex was unexpected. The presence of nonclassical Dix-Hallpike responses might be consistent with central nervous system lesions.

Here we summarize the recent progress made in the diagnosis and treatment of balance and gait disorders. Focusing on work published in the Journal of Neurology in 2010 and 2011, we have found evidence for the following clinically relevant statements: (1) the exclusion of stroke in acute vestibular syndromes is based on the bedside clinical findings; (2) the risk of developing secondary somatoform vertigo is predictable; it is especially high in patients with vestibular migraine; (3) postural imbalance and falls in Parkinson syndromes are related to dysfunction of the cholinergic midbrain thalamic axis; (4) aminopyridines improve a variety of cerebellar parameters including central nystagmus and gait variability.

Unlabelled: Vestibular disorders are common among the elderly, mainly resulting in dizziness and imbalance--symptoms which can impact daily routine activities., Aim: To study the correlation between body balance and functional capacity and a comparison of risk of falls, actual falls and the functional capacity of the elderly with chronic vestibular dysfunctions., Materials and Methods: A cross-sectional, clinical and experimental study with 50 senior citizens--60 to 86 years, with chronic peripheral vestibular dysfunction. These participants underwent body balance assessment by the Dynamic Gait Index (DGI) and functional capacity assessment by the Functional Independence Measure (FIM). The data was tested using the Spearman correlation and comparison tests, Mann-Whitney and Kruskal-Wallis, being α=5% (0.05)., Results: There was a significant correlation between the total DGI score and all FIM scores, especially the total score (r=0.447; p<0.001) and loss of functional capacity in elderly patients with the highest risk of falling (p<0.001)., Conclusion: There is a positive correlation between body balance and functional capacity in elderly patients with peripheral vestibular disorders, that is: the better the balance, the better the individual's functional capacity. In addition, a worse functional capacity increases the individual's risk of falling.

This is a review of the normal methods for vestibular examination, both clinical and instrumental, to evaluate the vestibular system. Emphasis is given to the examination sequence and objectives in each method., (Copyright © 2010 Elsevier España, S.L. All rights reserved.)

The purpose of this study was to investigate the effect of anxiety on the postural stability of a variety of dizzy patients during upright standing. To address this issue, 54 patients complaining of dizziness were enrolled in this study. The degree of anxiety in patients was evaluated on the basis of a routine vestibular examination together with their dizziness handicap inventory (DHI) scores as well as the hospital anxiety and depression scale (HADS). The patients were divided into 3 groups. If there was no vestibular dysfunction, they were defined as psychogenic (PSY) (N=16). The remaining subjects were further divided on the basis of their HADS score. If the score of A (anxiety) was less than 5, they are defined as organic (ORG) (N=25), and the rest were defined as a combination of psychogenic and organic (PSY+ORG) (N=13). Posturographic measurements were performed in a quiet and stable standing position on a force platform, as one of the vestibular examinations. The total length, the area of body sway, and the ratio of maximum perturbation of antero-posterior axis (A/P ratio) were registered. Spectrum analyses of the left-right axis and antero-posterior axis were also performed by using the fast Fourier transform (FFT) method of body sway. We found a significant correlation between anxiety and postural instability in the antero-posterior axis in all subjects as a group and in either group PSY or PSY+ORG. However, no significant correlation was found in group ORG. Using power spectrum analysis (FFT), we identified 3 frequency components of postural sway: group A (0.02-0.21Hz), group B (0.22-2.01Hz), and group C (2.01-10Hz). Statistical significance of the data was examined by ANOVA. Group C reflected somatosensory inputs, and group A reflected vestibular inputs. The power of group C decreased in the high anxiety group, whereas the power of group A increased in the high anxiety group. These phenomena disappeared in the eyes-closed condition. Our study shows that the effect of visual input on vestibular and somatosensory input is affected by anxiety. In conclusion, our results indicate that anxiety affects the postural perturbation in the antero-posterior axis and that anxiety possibly affects the interactions of visual inputs with vestibular and somatosensory inputs in the maintenance of postural balance in patients complaining of dizziness., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: Determine the prevalence of vestibular and balance disorders in children, rate of complaints of imbalance, and odds ratio of related diagnoses., Patients and Methods: Retrospective review of pediatric health system during a 4-year period for International Classification of Diseases, 9th Revision, codes related to balance disorders. Identified records were searched for chief complaints related to balance and for codes of related otologic and neuro-otologic diagnoses., Results: A total of 561,151 distinct patient encounters were found. Unspecified dizziness was diagnosed in 2,283 patients (0.4%). Also, 22% presented with balance complaints. Peripheral disorders were diagnosed in 159, and central disturbances were diagnosed in 109 (prevalence < 0.0002%). Cumulative prevalence of diagnoses related to balance was 0.45% (2,546/561,151). Of all patients, 5,793 (1.03%) had chief complaint related to balance, and 2,076 (35.84%) were also diagnosed with vestibular disorder. Moreover, 38% with peripheral disturbances and 21% with central disturbances had balance complaints. Odds ratio of syncope was 21× higher than the general pediatric population in patients with unspecified dizziness, and sensorineural hearing loss was 43 times higher in those with peripheral vestibular disorders. In patients with central disorders headache was 16× higher (p < 0.05)., Conclusion: The prevalence of balance disorders in children is low. Children diagnosed with these disorders typically do not present with chief complaint related to balance. Significant associations exist between sensorineural hearing loss, syncope, and headache in children diagnosed with balance disorders.

Unlabelled: Posturography is a useful new tool to study the influence of vestibular diseases on balance., Aim: to compare the results from the Balance Rehabilitation Unit (BRU) static posturography in elderly patients with Benign Paroxysmal Positional Vertigo (BPPV), before and after Epley's maneuver., Materials and Methods: a prospective study of 20 elderly patients with a diagnosis of BPPV. The patients underwent static posturography and the limit of stability (LE) and ellipse area were measured. We also applied the Dizziness Handicap Inventory (DHI) questionnaire to study treatment effectiveness., Results: 80% were females, with a mean age of 68.15 years. After the maneuver, the LE increased significantly (p=0.001). The elliptical area of somatosensory, visual and vestibular conflicts (2,7,8,9 situations) in BRU and the DHI scores decreased significantly (p<0.05) after treatment., Conclusion: the study suggests that elderly patients with BPPV may present static postural control impairment and that the maneuver is effective for the remission of symptoms, to increase in the stability and improvement in postural control in situations of visual, somatosensory and vestibular conflicts.

Purpose: During locomotion, head perturbations, consisting of rotations and translations (linear movements), occur with predominant frequencies of 0.5-5.0 Hz. The vestibular reflexes act at short latency to safeguard clear vision and stable posture during locomotion. Much is known about the angular vestibulo-ocular reflex (aVOR) in response to head rotations, which depend on the semicircular canals of the vestibular labyrinth. However, the means to test reliably the linear or translational vestibulo-ocular reflex (tVOR), which depends on the otolithic organs, has only become available more recently., Methods: We used a moving platform to translate normal human subjects vertically at frequencies similar to those occurring during locomotion, under ambient illumination., Results: Our findings suggested that, whereas aVOR is concerned with stabilizing images of visual targets on the retina to optimize visual acuity, tVOR seems best suited to minimize retinal image motion between objects lying in different depth planes, in order to optimize motion parallax information. We then asked whether the tVOR functioned abnormally in patients with two neurological disorders that often cause falls: progressive supranuclear palsy (PSP) and cerebellar ataxia. We found that patients with PSP cannot adjust tVOR responses appropriately during viewing of near objects, nor converge their eyes. Vestibular-evoked myogenic potentials (VEMPs), an otolith-spinal reflex, are also impaired in PSP patients. Patients with cerebellar ataxia also lack the ability to adjust tVOR for near viewing, even though they may be able to converge., Conclusions: Taken together, our studies suggest that abnormal otolithic vestibular reflexes contribute to postural instability in PSP and cerebellar ataxia, and deserve further investigation.

Background: A subgroup of individuals with vestibular dysfunction and visual motion hypersensitivity (VMH) become dizzy and imbalanced in response to movement of the visual environment. The purpose of this study was to investigate ocular fixational stability during gaze on a target, with and without visual background movement. Binocular vision functions were also examined as possible contributory factors to the dizziness and imbalance., Methods: Twenty-four individuals with VMH, 20 with vestibular disorders without VMH and 20 healthy subjects were tested. Assignment to the experimental group was by symptoms of VMH. Outcome measures included electro-oculogram recordings of horizontal fixation and blink. Four clinical binocular vision functions were also tested. The Dizziness Handicap Inventory was used to assess the level of dizziness., Conclusion: Subjects with VMH made significantly more refixational eye movements and had higher levels of dizziness than those in the other 2 diagnostic groups. There were abnormalities of binocular function in both the VMH and vestibular dysfunction groups compared with the control group. Individuals with VMH were unable to maintain stable gaze and inhibit eye movements to background motion. The large number of subjects with diagnosis of fluctuating vestibular function in the VMH group compared with the vestibular dysfunction group may indicate that VMH is a maladaptation of the system.

Purpose: To evaluate the incidence of coexistent peripheral vestibular dysfunction and cardiovascular autonomic dysfunction in patients undergoing evaluation for dizziness exacerbated by postural changes., Materials and Methods: Retrospective case review of 56 sequential patients seen from 2003 to 2006 at a tertiary center for a primary complaint of dizziness who underwent both passive tilt table testing for evaluation of neurocardiogenic etiology and quantitative vestibular testing. The vestibular test battery consisted of alternating bithermal caloric testing; computerized sinusoidal vertical axis rotation (at frequencies 0.01-0.64) with infrared videonystagmography; and oculomotor and positional testing including bilateral Dix-Hallpike, head center supine, and 30-degree supine head turns right and left., Results: Eight of the 56 subjects had caloric weakness. Forty-five subjects (80%) had abnormal tilt table test findings. The incidence of coexistent neurocardiogenic and vestibular test abnormalities was 10.7%. There was no significant association between abnormal tilt table test result and caloric weakness (Fisher exact test; P = .64). The degree of compensation seen on vestibule-ocular reflex gain testing did not affect tilt table findings (chi2; P = .872)., Conclusions: There is no difference in the rate of postural orthostatic intolerance in subjects with evidence of caloric weakness compared with those with normal caloric function.

Background and Aims: We undertook this study to assess the influence of diabetic peripheral neuropathy on self-reported disability and postural control during quiet stance of patients with peripheral vestibular disease, before and after a standardized program of vestibular rehabilitation (Cawthorne & Cooksey exercises)., Methods: Twenty patients with peripheral vestibular disease participated in the study (mean age 56+/-7.8 years), 10 with and 10 without peripheral neuropathy (age matched). The Dizziness Handicap Inventory and static posturography (eyes open/closed and firm/soft surface) were evaluated prior to rehabilitation and at week 7 of follow-up., Results: Compared to patients without neuropathy, patients with neuropathy had more time elapsed since the diabetes was diagnosed, higher glycemia and HbAc level and higher composite scores on the Dizziness Handicap Inventory, but similar results on static posturography. After rehabilitation, although scores on the Dizziness Handicap Inventory decreased in the two groups, the difference between them persisted. In patients with neuropathy, static posturography showed improvement of postural control only with the eyes closed and soft surface, whereas in patients without neuropathy the postural control improved during all sensory conditions (eyes open/closed and firm/soft surface)., Conclusions: In diabetic patients with peripheral vestibular disease, peripheral neuropathy contributes to self-reported disability and may interfere with complete balance recovery.