The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study.

Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorientating visual stimuli (e.g. supermarkets). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. Virtual reality (VR), which immerses patients in realistic, visually challenging environments, has also been suggested as an adjunct to VR to improve VV symptoms. This pilot study compared the responses of sixteen patients with unilateral peripheral vestibular disorder randomly allocated to a VR regime incorporating exposure to a static (Group S) or dynamic (Group D) VR environment. Participants practiced vestibular exercises, twice weekly for four weeks, inside a static (Group S) or dynamic (Group D) virtual crowded square environment, presented in an immersive projection theatre (IPT), and received a vestibular exercise program to practice on days not attending clinic. A third Group D1 completed both the static and dynamic VR training. Treatment response was assessed with the Dynamic Gait Index and questionnaires concerning symptom triggers and psychological state. At final assessment, significant betweengroup differences were noted between Groups D (p = 0.001) and D1 (p = 0.03) compared to Group S for VV symptoms with the former two showing a significant 59.2% and 25.8% improvement respectively compared to 1.6% for the latter. Depression scores improved only for Group S (p = 0.01) while a trend towards significance was noted for Group D regarding anxiety scores (p = 0.07). Conclusion: Exposure to dynamic VR environments should be considered as a useful adjunct to vestibular rehabilitation programs for patients with peripheral vestibular disorders and VV symptoms.

The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study

Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorientating visual stimuli (e.g. supermarkets). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. Virtual reality (VR), which immerses patients in realistic, visually challenging environments, has also been suggested as an adjunct to VR to improve VV symptoms. This pilot study compared the responses of sixteen patients with unilateral peripheral vestibular disorder randomly allocated to a VR regime incorporating exposure to a static (Group S) or dynamic (Group D) VR environment. Participants practiced vestibular exercises, twice weekly for four weeks, inside a static (Group S) or dynamic (Group D) virtual crowded square environment, presented in an immersive projection theatre (IPT), and received a vestibular exercise program to practice on days not attending clinic. A third Group D1 completed both the static and dynamic VR training. Treatment response was assessed with the Dynamic Gait Index and questionnaires concerning symptom triggers and psychological state. At final assessment, significant betweengroup differences were noted between Groups D (p = 0.001) and D1 (p = 0.03) compared to Group S for VV symptoms with the former two showing a significant 59.2% and 25.8% improvement respectively compared to 1.6% for the latter. Depression scores improved only for Group S (p = 0.01) while a trend towards significance was noted for Group D regarding anxiety scores (p = 0.07). Conclusion: Exposure to dynamic VR environments should be considered as a useful adjunct to vestibular rehabilitation programs for patients with peripheral vestibular disorders and VV symptoms.

Comparison of Computerized Dynamic Posturography (CDP) results with subjective visual vertical (SVV) test in patients with and without vestibular dysfunction: effects of horizontal headshaking

The goal of the study was to identify what effect headshaking in the horizontal plane has on Computerized Dynamic Posturography results in normals and patients with unilateral vestibular dysfunction. Additionally, the results were compared to results of the dynamic subjective visual vertical test.

Comparative study of the Gaze Stabilization Test (GST) and the Dynamic Visual Acuity Test (DVAT) for detecting patients with unilateral vestibular dysfunction

This paper compares the use of two diagnostic tests, Gaze Stabilization Test (GST) and the Dynamic Visual Acuity Test (DVAT) to detect unilateral vestibular dysfunction.

A new method to analyze the subjective visual vertical in patients with bilateral vestibular dysfunction

OBJECTIVE: The aim of this study was to assess the subjective visual vertical in patients with bilateral vestibular dysfunction and to propose a new method to analyze subjective visual vertical data in these patients. METHODS: Static subjective visual vertical tests were performed in 40 subjects split into two groups. Group A consisted of 20 healthy volunteers, and Group B consisted of 20 patients with bilateral vestibular dysfunction. Each patient performed six measurements of the subjective visual vertical test, and the mean values were calculated and analyzed. RESULTS: Analyses of the numerical values of subjective visual vertical deviations (the conventional method of analysis) showed that the mean deviation was 0.326 +/- 1.13 degrees in Group A and 0.301 +/- 1.87 degrees in Group B. However, by analyzing the absolute values of the subjective visual vertical (the new method of analysis proposed), the mean deviation became 1.35 +/- 0.48 degrees in Group A and 2.152 +/- 0.93 degrees in Group B. The difference in subjective visual vertical deviations between groups was statistically significant (p < 0.05) only when the absolute values and the range of deviations were considered. CONCLUSION: An analysis of the absolute values of the subjective visual vertical more accurately reflected the visual vertical misperception in patients with bilateral vestibular dysfunction.

Effects of physiotherapy on balance and unilateral vestibular hypofunction in vertiginous elderly

Background: We aimed to analyze the effect of a physical therapy protocol on unilateral vestibular hypofunction and overall balance in elderly with vertigo. Methods: The study included nine subjects, four male subjects (68.5 ± 11.09 years old) and five females (72.4 ± 7.09 years old). It was used the performance-oriented Mobility Assessment (POMA), to evaluate the balance and the Unterberger – Fukuda test for analysis of unilateral vestibular dysfunction through rotations and displacements of the body. We developed and applied a structured physical therapy protocol, consisting of group exercises. Results: It was observed that after the protocol, all participants improved balance (33.9 ± 5.1 vs. 47.3 ± 7.6, p < 0.0001) and displacement (111.1 ± 38.0 vs. 53.3 ± 34.6, p = 0.0001). However, it was not found significant differences for rotation. Conclusion: The proposed protocol has contributed to an improvement in balance and vestibular dysfunction of the aged.

Static postural balance study in patients with vestibular disorders using a three dimensional eletromagnetic sensor system

The vestibular-ocular reflex assessment is important, but not enough. Tridimensional electromagnetic sensor systems represent a new method to assess posturography. Aim: To assess body sway in healthy subjects who had positive Dix Hallpike and Epley maneuvers and with other vestibular dysfunctions by means of a three-dimensional system. Study design: Prospective. Materials and Methods: We had 23 healthy women, 15 with peripheral vestibular dysfunction found upon caloric test and 10 with positive Epley and Dix Hallpike maneuvers. All tests performed in the following positions: open and closed eyes on stable and unstable surfaces. Results: With the Eyes Open and on a stable surface, p < 0.01 between the control group and the one with peripheral vestibular dysfunction in all variables, except the a-p maximum, full speed and mediolateral trajectory velocity, which had a p < 0.01 between the group with vestibular dysfunction and controls in all positions. The group with positive Epley and Dix Hallpike maneuvers had p < 0.01 at full speed and in its components in the x and y in positions with open and eyes closed on an unstable surface. Conclusion: The tridimensional electromagnetic sensors system was able to generate reliable information about body sway in the study volunteers.

Diagnostic value of vestibulo-ocular reflex parameters in the detection and characterization of labyrinthine lesions.

OBJECTIVE: To evaluate the power of various parameters of the vestibulo-ocular reflex (VOR) in detecting unilateral peripheral vestibular dysfunction and in characterizing certain inner ear pathologies. STUDY DESIGN: Prospective study of consecutive ambulatory patients presenting with acute onset of peripheral vertigo and spontaneous nystagmus. SETTING: Tertiary referral center. PATIENTS: Seventy-four patients (40 females, 34 males) and 22 normal subjects (11 females, 11 males) were included in the study. Patients were classified in three main diagnoses: vestibular neuritis: 40; viral labyrinthitis: 22; Meniere's disease: 12. METHODS: The VOR function was evaluated by standard caloric and impulse rotary tests (velocity step). A mathematical model of vestibular function was used to characterize the VOR response to rotational stimulation. The diagnostic value of the different VOR parameters was assessed by uni- and multivariable logistic regression. RESULTS: In univariable analysis, caloric asymmetry emerged as the most powerful VOR parameter in identifying unilateral vestibular deficit, with a boundary limit set at 20%. In multivariable analysis, the combination of caloric asymmetry and rotational time constant asymmetry significantly improved the discriminatory power over caloric alone (p&lt;0.0001) and produced a detection score with a correct classification of 92.4%. In discriminating labyrinthine diseases, different combinations of the VOR parameters were obtained for each diagnosis (p&lt;0.003) supporting that the VOR characteristics differ between the three inner ear disorders. However, the clinical usefulness of these characteristics in separating the pathologies was limited. CONCLUSION: We propose a powerful logistic model combining the indices of caloric and time constant asymmetries to detect a peripheral vestibular loss, with an accuracy of 92.4%. Based on vestibular data only, the discrimination between the different inner ear diseases is statistically possible, which supports different pathophysiologic changes in labyrinthine pathologies.

Visual vertigo: an observational case series of eleven patients.

BACKGROUND: Dizziness is a common symptom which is frequently due to either peripheral or central vestibular dysfunction. However, some patients may lack typical signs suggesting a vestibular or cerebellar lesion and they mostly complain of vertigo or posture imbalance induced by visual stimulation. The symptoms immediately improve either on cessation of the visual input or upon closure of the eyes. Such a presentation is typical of visual vertigo. PATIENTS AND METHODS: From 1993 to 2003, 242 patients were examined for either "vertigo" or "dizziness". The diagnosis of visual vertigo was based on both history and clinical examination and was present in 11 patients. RESULTS: Visual vertigo was diagnosed in 11/242 patients (4.5 %). Age range was 31 - 77 years (mean 47 years) with a sex ratio of 8 females for 3 males. Neuro-ophthalmological examination was normal in all cases. CONCLUSIONS: Visual vertigo is not a rare condition but the disease is underdiagnosed. The symptoms result from a mismatch between vestibular, proprioceptive and visual inputs. Neuro-ophthalmological, neurological and neuro-otological examination are often normal or not relevant and the diagnosis is largely based on history. It is important to recognize this entity because the symptoms might improve if the patients are treated with psycho-motor rehabilitation.

Intoxicação por metronidazol em cão - relato de caso

Metronidazole is a nitronidazolic antibiotic used in veterinary medicine to the treatment of a variety of diseases. The cause of metronidazole neurotoxicity has not been determined. We report the case of a dog, female, Teckel, five-year-old, with a history of dorsiflexion of the tail, ataxia, muscle stiffness, recumbency, vertical nystagmus, apathy and anorexia, which was being medicated for seven days with metronidazole in a dose higher than the maximum recommended, and the neurological signs began after this period. Neurological signs were consistent with central vestibular dysfunction caused by metronidazole, such as ataxia and vertical nystagmus. In addition to the neurological changes, the clinical signs of anorexia and apathy are consistent with the administration of excessive doses of the medicine. The diagnosis of metronidazole-induced toxicosis is based on the history of normal to increased doses, clinical signs and resolution after discontinuation of the drug. In general, the prognosis is good after drug withdrawal and early diagnosis. Some dogs may die and others may recover completely. The neurotoxicosis has disappeared after the suspension of the medicine and supportive treatment. Veterinarians must be aware of potential complications associated with the use of this medicine, as well as limit their chronic use or high doses for the most severe cases, and diagnose the problem as quickly as possible to institute an early treatment.

Postural Control in Older Patients with Benign Paroxysmal Positional Vertigo

Objective. To evaluate the effectiveness of a canalith-repositioning procedure in postural control of older patients with idiopathic benign paroxysmal positional vertigo (BPPV). Study Design. Prospective clinical trial. Setting. A tertiary referral center. Methods. A 9-month follow-up survey with a prospective design was conducted among 33 older patients with BPPV. Patients underwent static posturography (Balance Rehabilitation Unit [BRU]) and were administered the Dizziness Handicap Inventory (DHI) before and after the maneuver. After the treatment, they were compared with 33 healthy older subjects. The posturography parameters were the limit of stability (LOS), the center of body-pressure area (COP), and the velocity of oscillation (VOS) under conditions of visual, somatosensory, and visual-vestibular conflict. Results. One canalith-repositioning procedure relieved most patients' complaints (54.5%), and 100% were relieved with 1 to 3 maneuvers. Total DHI score and all subscales improved after treatment (P < .01). The LOS values pretreatment (mean [SD] 134.27 [55.32] cm(2)) and posttreatment (181.03 [47.79] cm(2)) were significantly different (P < .01). Comparative analysis of COP values showed a relevant statistical difference in 8 of 10 postmaneuver conditions (P < .01). The postmaneuver VOS showed a significant difference under 7 conflict conditions. There were no differences between the healthy older subjects and treated patients for all VOS values under all conditions and for COP values under 9 conditions. Conclusion. The canalith-repositioning procedure promotes remission of symptoms, an increase in LOS, and improvement in postural control under conditions of somatosensory and visual conflict and visual-vestibular interaction.

Space and Motion Perception and Discomfort in Air Travel

RAMOS RT, MATTOS DA, REBOUCAS ITS, RANVAUD RD. Space and motion perception and discomfort in air travel. Aviat Space Environ Med 2012; 83:1162-6. Introduction: The perception of comfort during air trips is determined by several factors. External factors like cabin design and environmental parameters (temperature, humidity, air pressure, noise, and vibration) interact with individual characteristics (anxiety traits, fear of flying, and personality) from arrival at the airport to landing at the destination. In this study, we investigated the influence of space and motion discomfort (SMD), fear of heights, and anxiety on comfort perception during all phases of air travel. Methods: We evaluated 51 frequent air travelers through a modified version of the Flight Anxiety Situations Questionnaire (FAS), in which new items were added and where the subjects were asked to report their level of discomfort or anxiety (not fear) for each phase of air travel (Chronbach's alpha = 0.974). Correlations were investigated among these scales: State-Trait Anxiety Inventory (STAB, Cohen's Acrophobia Questionnaire, and the Situational Characteristics Questionnaire (SitQ, designed to estimate SMD levels). Results: Scores of SitQ correlated with discomfort in situations involving space and movement perception (Pearson's rho = 0.311), while discomfort was associated with cognitive mechanisms related to scores in the anxiety scales (Pearson's rho = 0.375). Anxiety traits were important determinants of comfort perception before and after flight, while the influence of SMD was more significant during the time spent in the aircraft cabin. Discussion: SMD seems to be an important modulator of comfort perception in air travel. Its influence on physical well being and probably on cognitive performance, with possible effects on flight safety, deserves further investigation.

Development of a genotyping microarray for Usher syndrome

BACKGROUND: Usher syndrome, a combination of retinitis pigmentosa (RP) and sensorineural hearing loss with or without vestibular dysfunction, displays a high degree of clinical and genetic heterogeneity. Three clinical subtypes can be distinguished, based on the age of onset and severity of the hearing impairment, and the presence or absence of vestibular abnormalities. Thus far, eight genes have been implicated in the syndrome, together comprising 347 protein-coding exons. METHODS: To improve DNA diagnostics for patients with Usher syndrome, we developed a genotyping microarray based on the arrayed primer extension (APEX) method. Allele-specific oligonucleotides corresponding to all 298 Usher syndrome-associated sequence variants known to date, 76 of which are novel, were arrayed. RESULTS: Approximately half of these variants were validated using original patient DNAs, which yielded an accuracy of >98%. The efficiency of the Usher genotyping microarray was tested using DNAs from 370 unrelated European and American patients with Usher syndrome. Sequence variants were identified in 64/140 (46%) patients with Usher syndrome type I, 45/189 (24%) patients with Usher syndrome type II, 6/21 (29%) patients with Usher syndrome type III and 6/20 (30%) patients with atypical Usher syndrome. The chip also identified two novel sequence variants, c.400C>T (p.R134X) in PCDH15 and c.1606T>C (p.C536S) in USH2A. CONCLUSION: The Usher genotyping microarray is a versatile and affordable screening tool for Usher syndrome. Its efficiency will improve with the addition of novel sequence variants with minimal extra costs, making it a very useful first-pass screening tool.

Human myosin VIIA responsible for the Usher 1B syndrome: a predicted membrane-associated motor protein expressed in developing sensory epithelia.

The gene encoding human myosin VIIA is responsible for Usher syndrome type III (USH1B), a disease which associates profound congenital sensorineural deafness, vestibular dysfunction, and retinitis pigmentosa. The reconstituted cDNA sequence presented here predicts a 2215 amino acid protein with a typical unconventional myosin structure. This protein is expected to dimerize into a two-headed molecule. The C terminus of its tail shares homology with the membrane-binding domain of the band 4.1 protein superfamily. The gene consists of 48 coding exons. It encodes several alternatively spliced forms. In situ hybridization analysis in human embryos demonstrates that the myosin VIIA gene is expressed in the pigment epithelium and the photoreceptor cells of the retina, thus indicating that both cell types may be involved in the USH1B retinal degenerative process. In addition, the gene is expressed in the human embryonic cochlear and vestibular neuroepithelia. We suggest that deafness and vestibular dysfunction in USH1B patients result from a defect in the morphogenesis of the inner ear sensory cell stereocilia.

Expression in cochlea and retina of myosin VIIa, the gene product defective in Usher syndrome type 1B.

Myosin VIIa is a newly identified member of the myosin superfamily of actin-based motors. Recently, the myosin VIIa gene was identified as the gene defective in shaker-1, a recessive deafness in mice [Gibson, F., Walsh, J., Mburu, P., Varela, A., Brown, K.A., Antonio, M., Beisel, K.W., Steel, K.P. & Brown, S.D.M. (1995) Nature (London) 374, 62-64], and in human Usher syndrome type 1B, an inherited disease characterized by congenital deafness, vestibular dysfunction, and retinitis pigmentosa [Weil, D., Blanchard, S., Kaplan, J., Guilford, P., Gibson, F., Walsh, J., Mburu, P., Varela, A., Levilliers, J., Weston, M.D., Kelley, P.M., Kimberling, W.J., Wagenaar, M., Levi-Acobas, F., Larget-Piet, D., Munnich, A., Steel, K.P., Brown, S.D.M. & Petit, C. (1995) Nature (London) 374, 60-61]. To understand the normal function of myosin VIIa and how it could cause these disease phenotypes when defective, we generated antibodies specific to the tail portion of this unconventional myosin. We found that myosin VIIa was expressed in cochlea, retina, testis, lung, and kidney. In cochlea, myosin VIIa expression was restricted to the inner and outer hair cells, where it was found in the apical stereocilia as well as the cytoplasm. In the eye, myosin VIIa was expressed by the retinal pigmented epithelial cells, where it was enriched within the apical actin-rich domain of this cell type. The cell-specific localization of myosin VIIa suggests that the blindness and deafness associated with Usher syndrome is due to lack of proper myosin VIIa function within the cochlear hair cells and the retinal pigmented epithelial cells.