Chronic Vestibular Dysfunction Research Articles

Development of a new clinical tool to evaluate the balance abilities of children with bilateral vestibular loss: The Geneva Balance Test.

Vestibular deficits are considered rare in children, but the lack of systematic screening leads to underdiagnosis. It has been demonstrated that chronic vestibular dysfunction impacts the normal psychomotor development of children. Early identification is needed to allow for clinical management, ensuring better global development. For this purpose, our research group has developed the Geneva Balance Test (GBT), aiming to objectively quantify the balance capacity of children over a broad age range, to screen for bilateral vestibulopathy (BV), and to quantify the improvement of balance abilities in children. To determine the capacity of the GBT to quantify the balance capacity of children with BV, we conducted an observational prospective study with three populations: 11 children with BV, and two age-matched control groups composed of (1) 15 healthy subjects without the vestibular or auditory disorder (HS) and (2) 11 pediatric cochlear implant recipients (CIs) without vestibular disorders. Results of the three populations have been compared in three different age sub- groups (3-5, 6-9, and ≥10 years), and with results of a short, modified version of the Bruininks-Oseretsky test of Motor proficiency Ed. 2 (mBOT-2). Statistical analyses demonstrated significant differences in the scores of the GBT between children aged 3-5, 6-9, and ≥10 years with BV and in both control populations (HS and CI). BV scores reflected poorer balance capacities at all ages. Children in the youngest CI sub-group (3-5 years) showed intermediate GBT scores but reached HS scores at 6-9 years, reflecting an improvement in their balance capacities. All the results of the GBT were significantly correlated with mBOT-2 results, although only a few BV completed the entire mBOT-2. In this study, the GBT allowed quantifying balance deficits in children with BV. The BOT-2 test is not validated for children <4.5 years of age, and the GBT seems to be better tolerated in all populations than the mBOT-2. Furthermore, mBOT-2 results saturated, reaching maximum values by 6-9 years whereas the GBT did not, suggesting that the GBT could be a useful tool for monitoring the development of balance capacities with age and could be used in the follow-up of children with severe vestibular disorders.

153 AN EVALUATION OF OLDER PERSONS WITH VESTIBULAR DYSFUNCTION AS IDENTIFIED DURING COMPREHENSIVE GERIATRIC ASSESSMENT

Abstract Background Vestibular dysfunction accounts for 25% of dizziness complaints. In 30-50% of these cases, dizziness is attributed to Benign Paroxysmal Positional Vertigo (BPPV). Thirty percent of people will experience vestibular dysfunction in their lifetime, with likelihood increasing with age. Individuals with vestibular dysfunction are eight times more likely to experience a fall. Vestibular assessment and rehabilitation services can be difficult to access. Methods A Plan, Do, Study, Act (PDSA) cycle was undertaken. All referrals to the Older Persons’ Services Clinics from November 2021 to May 2022 were triaged by an Integrated Care Team for the Older Person and scheduled for Comprehensive Geriatric Assessment (CGA). In the course of CGA, patients who reported symptoms suggestive of vestibular dysfunction received assessment by a Physiotherapist with vestibular expertise. Results were entered on an Excel spreadsheet and analysed using descriptive statistics. Results Six patients (4 female, 2 male) received vestibular assessment and treatment. Mean age was 75 years (SD: 11) with median Clinical Frailty Score of 4 (vulnerable). Reported symptoms were dizziness (n=3) and spinning (n=3). Sixteen percent (n=1) reported a fall and 66% (n=4) reported fear of falling. All patients had symptom duration of &amp;gt;2 years. Following vestibular assessment, the following diagnoses were made; right posterior canal BPPV, (n=2), vestibular migraine (n=2), right horizontal canal canalithiasis BPPV, with secondary diagnosis of persistent postural-perceptual dizziness (n=1) and left peripheral vestibular hypofunction due to vestibular neuronitis (n=1). The mean number of Physiotherapy visits per person was 4. Three patients reported full resolution of symptoms. The remaining 3 reported an improvement in symptoms and confidence to self-manage. Conclusion This small cohort of older persons with chronic vestibular dysfunction benefited from vestibular diagnosis and intervention. The next step of the process is to include specific vestibular screening questions into CGA. This will enable Integrated Care Team members to screen more specifically for vestibular dysfunction.

Testosterone treatment restores vestibular function by enhancing neuronal survival in an experimental closed-head repetitive mild traumatic brain injury model

Repetitive mild traumatic brain injury (rmTBI) results in a myriad of symptoms, including vestibular impairment. The mechanisms underlying vestibular dysfunction in rmTBI patients remain poorly understood. Concomitantly, acute hypogonadism occurs following TBI and can persist chronically in many patients. Using a repetitive mild closed-head animal model of TBI, the role of testosterone on vestibular function was tested. Male Long Evans Hooded rats were randomly divided into sham or rmTBI groups. Significant vestibular deficits were observed both acutely and chronically in the rmTBI groups. Systemic testosterone was administered after the development of chronic vestibular dysfunction. rmTBI animals given testosterone showed improved vestibular function that was sustained for 175 days post-rmTBI. Significant vestibular neuronal cell loss was, however, observed in the rmTBI animals compared to Sham animals at 175 days post-rmTBI and testosterone treatment significantly improved vestibular neuronal survival. Taken together, these data demonstrate a critical restorative role of testosterone in vestibular function following rmTBI. This study has important clinical implications because it identifies testosterone treatment as a viable therapeutic strategy for the long-term recovery of vestibular function following TBI.

The Navigation Ability Test (NAT 2.0): From Football Player Performance to Balance Rehabilitation in Chronic Unilateral Vestibular Loss.

Aim of the Study: in humans, spatial orientation consists of the ability to move around the environment through memorized and pre-programmed movements, according to the afferent sensory information of the body and environmental analysis of the Central Nervous System (CNS). The purpose of this study is to analyze the abilities of professional athletes, such as footballers, to use mental navigation systems, cognitive maps, and memorized motor patterns in order to obtain better physical performance and to obtain useful information for training both non-sports subjects and vestibular patients for rehabilitation purposes. Materials and Methods: all the motor performances of sportsmen, healthy non-sporting subjects, or vestibular patients are based on the acquisition of visual–spatial and training information. In this study, we analyzed the visual–spatial performance of 60 trained sportsmen (professional footballers), 60 healthy non-sports subjects, and 48 patients affected by chronic unilateral vestibular loss by means of the Navigation Ability Test 2.0. A score based on the number of targets correctly reached in the various tests quantifies the degree of performance of the subjects. Results: NAT 2.0 scores progressively improve from vestibular subjects to healthy non-sporting subjects to footballers. NAT 2.0 scores improve in all three subject groups as the number of tasks performed in all patient groups increases, regardless of gender and age. Conclusions: the analysis of performance data through NAT 2.0 in athletes (footballers) opens new perspectives for rehabilitation purposes, regardless of age, sex, and training conditions, both in healthy non-sporting subjects to improve their sporting potential and in patients affected by chronic vestibular dysfunction, in order to optimize their motor skills and prevent falls.

Vestibular rehabilitation therapy in combination with transcranial direct current stimulation (tDCS) for treatment of chronic vestibular dysfunction in the elderly: a double-blind randomized controlled trial

IntroductionDizziness and imbalance are common dysfunctions in the elderly. Vestibular rehabilitation therapy is an effective method to alleviate chronic dizziness in patients with vestibular dysfunction. Transcranial direct current stimulation has reportedly improved balance function in patients with vestibular dysfunction. ObjectiveThis study was conducted to investigate the therapeutic efficacy of vestibular rehabilitation combined with transcranial direct current stimulation in elderly patients with vestibular dysfunction. MethodsIn a double-blinded randomized controlled trial, 36 elderly patients with chronic vestibular dysfunction were randomly assigned to either vestibular rehabilitation and transcranial direct current stimulation (n = 18) or vestibular rehabilitation alone (n = 18) group. The transcranial stimulation protocol consisted of multisession bifrontal electrical stimulation of the dorsolateral prefrontal cortex (2 mA intensity and 20 min duration), followed by rehabilitation exercises. The vestibular rehabilitation protocol consisted of habituation and adaptation exercises combined with gait exercises during a three week period. The primary outcome of this study was the dizziness handicap inventory score, and the secondary outcomes were activities-specific balance confidence and Beck anxiety inventory scores. ResultsFor the dizziness handicap score, the repeated-measures analysis of variance showed a significant main effect of “time”, “stimulation” and stimulation × time interaction effect. There was a significant reduction in the overall dizziness handicap score with “time” for both the groups, which was more pronounced in the vestibular rehabilitation and electrical stimulation group. In terms of activities-specific balance confidence change scores, we found a significant main effect of “time” and “stimulation” main factors, but this effect for stimulation × time interaction was not significant. For the Beck anxiety score, we observed a significant main effect of “time”, but no evidence for the main effect of the “stimulation” factor. ConclusionBifrontal transcranial direct current stimulation in combination with vestibular rehabilitation therapy is a promising approach to improve chronic vestibular symptoms in the elderly.

Evaluation of the effectiveness of immersive virtual reality-based exercise system for vestibular rehabilitation

Objective:To evaluate the efficacy of virtual reality technology assisted vestibular rehabilitation training（VRT） in treating chronic vestibular dysfunction patients. Method:Ninety-eight vestibular dysfunction patients were assigned into the experimental group（n=73） and the control group（n=25） using mechanical sampling. The experimental group received immersive virtual reality assisted VRT treatment, while the control group received conventional VRT treatment. Chinese vertigo symptom scale（VSS-C） was used to measure vertigo symptoms before treatment and 12 weeks post-treatment. Balance feedback instrument was used to measure the center of pressure（COP）, maximum oscillation length（MOL） and COP envelope area（EA） which smaller numbers indicating better balance functions. Analysis of variance and Fisher's exact test were performed using SPSS 20.0 software to compare mean values and frequencies, respectively. Result:①Before treatment as baseline, there were no statistically significant differences in the total score of VSS-C scale, balance correlation and anxiety correlation score between the two groups. Total score and balance related score of experimental group were significantly different between before and after treatment（P<0.01）, while no statistically significant difference in anxiety related scores. After treatment, there were statistically significant differences in total VSS-C score（P<0.01） and balance correlation score（P<0.05） between the two groups, while no statistically significant difference in anxiety correlation score. ②After 12 weeks of treatment, there were statistically significant differences between MOL and EA in open-eye state（P<0.01）, but no statistically significant difference in close-eye state between two groups. Conclusion:The introduction of VR technology by VRT can provide interesting interactions for patients in training and encourage patients to actively participate in various repetitive rehabilitation exercises that are boring, achieving good effect. The effect of VR on subjective balance rehabilitation without visual impairment is better than that of conventional.

Rebalancing the Vestibular System by Unidirectional Rotations in Patients With Chronic Vestibular Dysfunction.

Introduction: Vestibular dysfunction is a common disorder that results in debilitating symptoms. Even after full compensation, the vestibulo-ocular reflex (VOR) could be further improved by using rehabilitation exercises and visual-vestibular adaptation. We hypothesized that in patients with asymmetric vestibular function, the system could be rebalanced by unidirectional rotations toward the weaker side (i.e., a pure vestibular stimulation).Methods: Sixteen subjects (5 female and 11 male, 43.2 ± 17.0 years old) with chronic vestibular dysfunction that was non-responsive to other types of medical treatment were recruited for the study (ClinicalTrials.gov Identifier: NCT01080430). Subjects had VOR asymmetry quantified by an abnormal directional preponderance (DP) with rotation test and no previous history of central vestibular problems or fluctuating peripheral vestibular disorders. They participated either in the short-term study (one session) or the long-term study (7 visits over 5 weeks). Rehabilitation consisted of five trapezoid unidirectional rotations (peak velocity of 320°/s) toward the weaker side. Care was taken to slowly stop the rotation in order to avoid stimulation in the opposite direction during deceleration. To study the short-term effect, VOR responses were measured before and 10, 40, and 70 min after a single unidirectional rotational rehabilitation session. For long-term effects, the VOR gain was measured before and 70min after rehabilitation in each session.Results: We observed a significant decrease in VOR asymmetry even 10 min after one rehabilitation session (short-term study). With consecutive rehabilitation sessions in the long-term study, DP further decreased to reach normal values during the first 2 sessions and only one subjects required further rehabilitation after week 4. This change in DP was due to an increase in responses during rotations toward the weaker side and a decrease in VOR responses during rotations in the other direction.Conclusion: Our results show that unidirectional rotation can reduce the VOR imbalance and asymmetry in patients with previously compensated vestibular dysfunction and could be used as an effective supervised method for vestibular rehabilitation even in patients with longstanding vestibular dysfunction.

Short-term memory impairment in vestibular patients can arise independently of psychiatric impairment, fatigue, and sleeplessness.

Vestibular dysfunction is associated with visual short-term memory impairment; however, it remains unclear if this impairment arises as a direct result of the vestibular dysfunction or is a consequence of comorbid changes in mood, affect, fatigue, and/or sleep. To this end, we assessed the concurrence and interdependence of these comorbidities in 101 individuals recruited from a tertiary balance clinic with a neuro-otological diagnosis. Over fifty per cent of the sample showed reduced visuospatial short-term memory, 60% and 37% exceeded cut-off on the Beck Anxiety and Depression Inventories, respectively, 70% exceeded cut-off on the Fatigue Severity Scale, 44% reported daytime sleepiness on the Epworth Sleepiness Scale, and 78% scored above cut-off on the Pittsburgh Sleep Quality Index. The high concurrence of these symptoms gives reason to infer the existence of a vestibular cognitive affective syndrome. Structural equationmodelling indicated that the significant statistical association between general unassisted posture (a marker of chronic vestibular dysfunction and strong predictor of falls risk) and short-term memory was not mediated by mood and wakefulness. Instead, the memory impairment related more directly to vestibular dysfunction. From a rehabilitation perspective, the implication is that if the vestibular disorder is treated successfully then the memory problem will likewise improve.

Patients with chronic dizziness following traumatic head injury typically have multiple diagnoses involving combined peripheral and central vestibular dysfunction

ObjectiveWe hypothesised that chronic vestibular symptoms (CVS) of imbalance and dizziness post-traumatic head injury (THI) may relate to: (i) the occurrence of multiple simultaneous vestibular diagnoses including both peripheral and central vestibular dysfunction in individual patients increasing the chance of missed diagnoses and suboptimal treatment; (ii) an impaired response to vestibular rehabilitation since the central mechanisms that mediate rehabilitation related brain plasticity may themselves be disrupted. MethodsWe report the results of a retrospective analysis of both the comprehensive clinical and vestibular laboratory testing of 20 consecutive THI patients with prominent and persisting vestibular symptoms still present at least 6months post THI. ResultsIndividual THI patients typically had multiple vestibular diagnoses and unique to this group of vestibular patients, often displayed both peripheral and central vestibular dysfunction. Despite expert neuro-otological management, at two years 20% of patients still had persisting vestibular symptoms. ConclusionIn summary, chronic vestibular dysfunction in THI could relate to: (i) the presence of multiple vestibular diagnoses, increasing the risk of ‘missed’ vestibular diagnoses leading to persisting symptoms; (ii) the impact of brain trauma which may impair brain plasticity mediated repair mechanisms. Apart from alerting physicians to the potential for multiple vestibular diagnoses in THI, future work to identify the specific deficits in brain function mediating poor recovery from post-THI vestibular dysfunction could provide the rationale for developing new therapy for head injury patients whose vestibular symptoms are resistant to treatment.

Establishment and reliability test of a "Vertigo Council Diagnosis Questionnaire" for patients with chronic vestibular dysfunction: preliminary study.

This study aims to establish a "Vertigo Council Diagnosis Questionnaire" for patients with chronic vestibular dysfunction and show the reliability of this questionnaire. A "Vertigo Council Diagnosis Questionnaire" consisting of 10 questions was prepared by 15 specialist physicians and analyzed for reliability using the "translation-back-translation" method. When all the items of our questionnaire were evaluated, the content validity ratio ranged from 0.6 to 0.87, and the content validity index was 0.676. The conformity ratio between the real diagnosis and the diagnosis based on the questionnaire was 63.19%, and the kappa was 0.441 (moderate). No significant difference was found between the first and second responses to any of the questions (p>0.05). There was no significant difference between question conformity (conformity between the first and second responses) and diagnostic conformity (conformity between the real diagnosis and the diagnosis based on the questionnaire) (p>0.05) in any of the questions. No relationship was found between diagnostic conformity and sociodemographic data (age, sex, education, occupation) (p>0.05). Our study results suggest that, in Turkish patients, diagnosis of vertigo should be based on face-to-face interviews, and clinical and laboratory evaluations rather than a questionnaire.

Cognitive processing and body balance in elderly subjects with vestibular dysfunction

Abnormal body balance and cognitive dysfunction may develop in elderly patients with chronic vestibular dysfunction. AimTo evaluate the relationship between cognitive processing and body balance in elderly patients with chronic peripheral vestibular disease. Type of Study: Cross-sectional. MethodsSeventy-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. ResultsThe 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). ConclusionElderly patients with chronic peripheral vestibular disease and worse performance in body balance tests have functional impairment in cognitive skills.

Dizziness handicap inventory - em um grupo de pacientes submetidos a reabilitação vestibular personalizada

OBJETIVO: investigar o impacto da Reabilitação Vestibular personalizada e comparar os aspectos físicos, emocionais e funcionais pré e pós a aplicação do Dizziness Handicap Inventory. MÉTODOS: participaram 10 pacientes, com sintomas decorrentes de distúrbios do sistema vestibular e hipótese diagnóstica de disfunção vestibular crônica. Estes foram avaliados quanto aos aspectos físicos, emocionais e funcionais por meio do Dizziness Handicap Inventory pré e pós reabilitação vestibular personalizada. RESULTADOS: no Dizziness Handicap Inventory pré foi verificado que o aspecto físico foi o mais pontuado, seguido pelo emocional e funcional. A reabilitação vestibular foi eficaz, uma vez que houve diminuição nas queixas de qualidade de vida, e melhores resultados em todos os aspectos avaliados no Dizziness Handicap Inventory pós, apenas um paciente obteve melhora somente dos aspectos emocionais e funcionais, além de piora dos aspectos físicos. CONCLUSÃO: o Dizziness Handicap Inventory brasileiro aplicado pré e pós reabilitação vestibular personalizada mostrou-se como um teste eficaz para acompanhar pacientes submetidos a reabilitação vestibular, capaz de mostrar a melhora significante nos sintomas da vertigem crônica, além do impacto negativo na qualidade de vida dos pacientes deste estudo.

The clinical manifestations and neurophysiological features of long-lasting paroxysmal vertigo:theanalysis of the original observations

The objective of the present study was to elucidate specific features of etiology and pathophysiology of recurring chronic vestibular dysfunction. It included 90 patients with this pathology of whom 24 (26.6%) presented with vascular compression of the vestibulocochlear nerve diagnosed by means of high-field MRI. This method revealed the high frequency of positionally-dependent vestibular dysfunction associated with neurovascular interactions. Analysis of the state of vestibular dysfunction during the attack-free periods demonstrated the signs of latent vestibular dysfunction in 20 (83.3%) patients. The results of the study provide additional information on the prevalence of vascular compression of the vestibulocochlear nerve in the patients presenting with recurrent chronic dizziness; moreover, they make it possible to evaluate the state of vestibular function and develop the new diagnostic criteria for vestibular paroxismia.

Interactive 3-dimensional virtual reality rehabilitation for patients with chronic imbalance and vestibular dysfunction

BACKGROUND: Chronic imbalance is common in patients with vestibular dysfunction. Vestibular rehabilitation is effective in improving upright balance control. Vestibular rehabilitation exercises, su...

Three‐Dimensional, Virtual Reality Vestibular Rehabilitation for Ménière's Disease‐Induced Chronic Imbalance Problem

Objectives: Patients with Ménière’s disease (MD) may suffer from chronic imbalance problem that cannot be cured by surgery or medication. For these patients, vestibular rehabilitation is another treatment option. Three-dimensional (3D), virtual reality (VR) technology may be applied to facilitate rehabilitation exercise. In this study we report outcomes of 3D, VR rehabilitation for patients with MD-related chronic vestibular dysfunction. Methods: A VR-based rehabilitation system was developed. The system consists of the Kinect Xbox for full-body interaction, 3D-ready projector with shutter-glasses for stereo imaging, Wii Fit pressure pad (for tracing the center of gravity sway and statokinesigrams [SKG], in cm2), and Unity game engine for leveled-difficulty design. The modified Cawthorne-Cooksey exercises (MCCE) was adapted into this system; the MCCE scores were compared following intervention. 50 MD patients with chronic balance were recruited for this prospective, longitudinal, uncontrolled clinical study. Patients followed the instructions of MCCE to complete at least 6 sessions of vestibular rehabilitation within a 4-week period. Results: All patients experienced improvement of balance function performing daily activities and were overall positive about the training protocol. After intervention, the fast components of postural sway and SKG ( P &lt; 0.05) were reduced. The MCCE scores significantly improved (66.6 to 74.6, P &lt; 0.05). We found age (Î2 = -0.52, P &lt; 0.05) and number of training sessions (Î2 = 2.53X, P &lt; 0.05) were significant predictors for clinical improvement. Conclusions: Vestibular rehabilitation can assist MD patients who cannot benefit from medication and surgery. The data support the applicability of 3D, VR technology in the field of vestibular rehabilitation.

Vestibular Rehabilitation Outcomes in the Elderly with Chronic Vestibular Dysfunction

BackgroundChronic vestibular dysfunction is a frustrating problem in the elderly and can have a tremendous impact on their life, but only a few studies are available. Vestibular rehabilitation therapy (VRT) is an important therapeutic option for the neuro-otologist in treating patients with significant balance deficits.ObjectivesThe purpose of this study was to assess the effect of vestibular rehabilitation on dizziness in elderly patients with chronic vestibular dysfunction.Materials and MethodsA total of 33 patients older than 60 years with chronic vestibular dysfunction were studied. Clinical and objective vestibular tests including videonystagmography (VNG) and dizziness handicap inventory (DHI) were carried out at their first visit, 2 weeks, and 8 weeks post-VRT. The VRT exercises were performed according to Cawthorne and Cooksey protocols.ResultsOculomotor assessments were within normal limits in all patients. Nineteen patients (57.57%) showed abnormal canal paralysis on caloric testing which at follow-up sessions; CP values were decreased remarkably after VRT exercises. We found a significant improvement between pre-VRT and post-VRT total DHI scores (P < 0.001). This improvement was most prominent in functional subscore.ConclusionsOur study demonstrated that VRT is an effective therapeutic method for elderly patients with chronic vestibular dysfunction.

Chronic Vestibular Dysfunction as an Unappreciated Cause of Chronic Nausea and Vomiting

In patients with chronic nausea and/or vomiting, gastroparesis is frequently diagnosed, often on the basis of abnormal gastric emptying scintigraphy (GES). When typical treatments fail, patients may be referred to a referral center. This retrospective study evaluated the diagnoses made in patients referred for chronic nausea and vomiting and appraised the GES utilized to assess these patients. Records of outpatients referred for chronic nausea and vomiting over a 3-year period were analyzed for previous evaluation and treatment, subsequent investigation, and response to treatment. Of 248 patients referred for chronic nausea and vomiting, 156 (63%) were referred with a suspected diagnosis of gastroparesis. Of 102 GES available for review, 95 were done with nonstandardized methods. Repeat standardized testing was normal in 27 of 36 patients (75%). Only 28 patients (11%) had confirmed gastroparesis. The most common specific diagnosis in the entire group was chronic vestibular dysfunction (CVD, 64 patients, 26%) made by abnormal modified Fukuda stepping test, nystagmus, or abnormal Romberg test. CVD patients did not typically report a history of an inner-ear disorder or vertigo. Eighty-nine percent of CVD patients were given trials of antivertiginous medications; of the 39 followed for a median of 5 months, improvement occurred in two thirds. Diagnosis of gastroparesis should not be based on a nonstandardized GES. In our referred patients, gastroparesis was infrequent, while CVD was much more likely. Treatment for CVD may mitigate the nausea and vomiting.

Chronic Vestibular Dysfunction: An Unappreciated Cause of Chronic Nausea and Vomiting: ACG /AstraZeneca Fellow Award

Purpose: Patients with chronic nausea and/or vomiting who are not found to have structural lesions of the stomach are frequently diagnosed as having gastroparesis. This impression may be strengthened by an abnormal gastric emptying scan. When standard treatments fail, these patients may be referred to a center for advanced therapy. We reviewed the records of patients referred to our center for chronic nausea and vomiting over a three year period to learn about their subsequent diagnosis and management. Methods: Consecutive outpatients referred for chronic nausea and vomiting from January 2008—December 2010 were identified from billing records. Medical records were reviewed to characterize evaluation and treatment before referral, subsequent investigation, and response to treatment. Results: Of 248 patients referred for chronic nausea and vomiting during this interval, 156 (62.9%) were referred with a diagnosis of gastroparesis. 95 of these patients had abnormal non-standardized gastric emptying tests [duration <4 hours, atypical test meal, concurrent symptoms, confounding medications]; repeat testing using the international standard protocol was done in 36 patients and was normal in 27 (75.0%). Only 28 patients from the initial cohort (11.3%) had a final diagnosis of gastroparesis. Other diagnoses included cyclical vomiting syndrome (8.8%), rumination syndrome (1.2%), postsurgical syndromes (2.0%), medication-induced vomiting (1.2%), GERD (2.4%), and unspecified or other (47.3%). The most common specific diagnosis in this cohort was chronic vestibular dysfunction (CVD, 64 patients, 25.8%). This diagnosis was made on the basis of an abnormal modified Fukuda stepping test (>90° rotation within 60 seconds while marching in place with eyes closed and ears occluded), presence of nystagmus, or abnormal Romberg test. 43 (67.2%) of these patients had been referred for “gastroparesis.” Most had had an abnormal nonstandard gastric emptying scan; when a standardized test was repeated, it was normal in 8 of 9. As compared to patients ultimately diagnosed with other conditions, CVD patients more often presented with nausea alone. Diabetes was present in similar proportions in CVD and non-CVD patients (20% vs 27.2%, p=0.27). Vertigo was reported by only 6 (9.4%). 57 of 64 CVD patients were given trials of anti-vertiginous medications; of the 39 followed for a median of 5 months, improvement occurred in two-thirds. Conclusion: Diagnosis of gastroparesis should not be based on a non-standardized gastric emptying test. Gastroparesis was an unlikely diagnosis in our cohort. Chronic vestibular dysfunction was a much more likely diagnosis. Treatment for this condition may mitigate nausea and vomiting.

Cultured vestibular ganglion neurons demonstrate latent HSV1 reactivation

Vestibular neuritis is a common cause of both acute and chronic vestibular dysfunction. Multiple pathologies have been hypothesized to be the causative agent of vestibular neuritis; however, whether herpes simplex type I (HSV1) reactivation occurs within the vestibular ganglion has not been demonstrated previously by experimental evidence. We developed an in vitro system to study HSV1 infection of vestibular ganglion neurons (VGNs) using a cell culture model system. basic science study. Lytic infection of cultured rat VGNs was observed following low viral multiplicity of infection (MOI). Inclusion of acyclovir suppressed lytic replication and allowed latency to be established. Upon removal of acyclovir, latent infection was confirmed with reverse-transcription polymerase chain reaction and by RNA fluorescent in situ hybridization for the latency-associated transcript (LAT). A total of 29% cells in latently infected cultures were LAT positive. The lytic ICP27 transcript was not detected by reverse-transcription polymerase chain reaction (RT-PCR). Reactivation of HSV1 occurred at a high frequency in latently infected cultures following treatment with trichostatin A (TSA), a histone deactylase inhibitor. VGNs can be both lytically and latently infected with HSV1. Furthermore, latently infected VGNs can be induced to reactivate using TSA. This demonstrates that reactivation of latent HSV1 infection in the vestibular ganglion can occur in a cell culture model, and suggests that reactivation of HSV1 infection a plausible etiologic mechanism of vestibular neuritis.

Platform Tilt Perturbation as an Intervention for People With Chronic Vestibular Dysfunction

Training to improve responses to perturbations may be beneficial for individuals with unilateral vestibular dysfunction. We evaluated the effects of an incrementally increasing surface tilt perturbation intervention for individuals with chronic vestibular pathology on gait, activities of daily living, and dizziness. Participants (n = 29) were randomly assigned to 1 of 3 groups. The first group received random surface tilt perturbations of increasing angles and speed, half of the trials with vision-occluding goggles, 3 times weekly for 3 weeks (P group). The second group received tilt perturbation intervention (as above) plus a home program of vestibular rehabilitation exercises (P+EX group). The third group performed only the vestibular rehabilitation exercises (EX group). Outcome measures included temporospatial gait measures, Dynamic Gait Index (DGI), Dizziness Handicap Inventory (DHI), Patient Specific Functional Scale (PSFS), and a Perceived Outcomes Scale (POS). The P and P+EX groups showed greater improvement on the PSFS and the POS compared to the EX group. DGI scores indicated decreased fall risk in 8 of 9 individuals who participated in P or P+EX training and who initially scored below the 19-point cutoff score. Both the P and P+EX groups showed significant within-group changes on some gait characteristics, DGI, DHI, PSFS, and POS measures. The EX group showed within-group change only on the DHI. Surface tilt perturbation training appears to be more effective for improving abilities at the activities and participation levels than vestibular exercises alone. In addition, tilt perturbation training reduced fall risk as measured by the DGI.