Head-Movement-Emphasized Rehabilitation in Bilateral Vestibulopathy.

Nadine Lehnen,Cornelia Schlick,Maria Heuberger,Erich Schneider,Alexander G Knorr,Silvy Kellerer,Cecilia Ramaioli,Klaus Jahn

doi:10.3389/fneur.2018.00562

Abstract

Objective: Although there is evidence that vestibular rehabilitation is useful for treating chronic bilateral vestibular hypofunction (BVH), the mechanisms for improvement, and the reasons why only some patients improve are still unclear. Clinical rehabilitation results and evidence fromeye-head control in vestibular deficiency suggest that headmovement is a crucial element of vestibular rehabilitation. In this study, we assess the effects of a specifically designed head-movement-based rehabilitation program on dynamic vision, and explore underlying mechanisms.Methods: Two adult patients (patients 1 and 2) with chronic BVH underwent two 4-week interventions: (1) head-movement-emphasized rehabilitation (HME) with exercises based on active head movements, and (2) eye-movement-only rehabilitation (EMO), a control intervention with sham exercises without head movement. In a double-blind crossover design, the patients were randomized to first undergo EMO (patient 1) and–after a 4-week washout–HME, and vice-versa (patient 2). Before each intervention and after a 4-week follow-up patients’ dynamic vision, vestibulo-ocular reflex (VOR) gain, as well as re-fixation saccade behavior during passive headmotion were assessed with the head impulse testing device–functional test (HITD-FT).Results: HME, not EMO, markedly improved perception with dynamic vision during passive head motion (HITD-FT score) increasing from 0 to 60% (patient 1) and 75% (patient 2). There was a combination of enhanced VOR, as well as improved saccadic compensation.Conclusion: Head movement seems to be an important element of rehabilitation for BVH. It improves dynamic vision with a combined VOR and compensatory saccade enhancement.

Highlights

Bilateral vestibular hypofunction (BVH) significantly affects quality of life [1]
There was no clinical manifestation of cerebellar syndrome, Abbreviations: BVH, bilateral vestibular hypofunction; eye-movement-only rehabilitation (EMO), eye-movementonly rehabilitation; HITD-FT, head impulse testing device—functional test; headmovement-emphasized rehabilitation (HME), head-movement-emphasized rehabilitation; MDC, minimal detectable change; VOR, vestibulo-ocular reflex
Vestibular rehabilitation based solely on head movement exercises (HME) improved dynamic vision, with HITD-FT scores increasing from 0% before HME to 60% and 75% afterwards (Figure 2)

Summary

Introduction

Bilateral vestibular hypofunction (BVH) significantly affects quality of life [1]. Patients suffer from symptoms like oscillopsia with head movement and postural instability, leading to difficulties with activities of daily living like driving and a 31fold increased risk of falls with considerate morbidity [1]. Due to ototoxic aminoglycosides, Menière’s disease or meningitis [2], BVH has an unfavorable prognosis with no improvement of peripheral vestibular function over several years in more than 80% of patients [3]. At variance with its clinical importance, and compared to most other vestibular disorders (including unilateral vestibular dysfunction), prospective therapeutic clinical trials in patients with BVH are sparse [4, 5]. While it is consensus that vestibular rehabilitation is beneficial [(6–9), for review see [5], for clinical practice guideline see [4]], the mechanisms for improvement, their relative importance and the reasons why only some patients improve are still unclear [6,7,8,9,10]

Methods

Results

Conclusion