A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care

BACKGROUND: 'Vestibular rehabilitation' (VR) is an increasingly popular treatment option for patients with persistent dizziness. Previous clinical trials have only evaluated the effects of specialist therapy programmes in small, selective, or uncontrolled patient samples. AIM: To determine the benefits of VR compared with standard medical care, using a brief intervention for dizzy patients in primary care. METHOD: Adults consulting their general practitioner (GP) with dizziness or vertigo were randomly assigned to treatment or control groups. Patients in both groups received the same evaluation at baseline, six-week follow-up, and six-month follow-up, comprising examination of nystagmus, postural control, and movement-provoked dizziness, and a questionnaire assessment of subjective status, symptoms, handicap, anxiety, and depression. At baseline and six weeks later, the treatment group also received an individualized 30-minute therapy session, in which they were taught head, eye, and body exercises designed to promote vestibular compensation and enhance skill and confidence in balance. RESULTS: The treatment group (n = 67) improved on all measures, whereas the control group (n = 76) showed no improvement, resulting in a significant difference between the two groups on physical indices of balance and subjective indices of symptoms and distress. Odds ratios for improvement in treated patients relative to untreated patients were 3.1:1 at six weeks (95% CI = 1.4-6.8) and 3.8:1 at six months (95% CI = 1.6-8.7). CONCLUSION: VR is a simple, inexpensive, and beneficial treatment, and may be an appropriate first stage of management for many dizzy patients in primary care.     

Support for the possible locus on chromosome 4p16 for bipolar affective disorder

Since the majority of people with dizziness in the community are never referred for specialist testing and treatment, the purpose of this study was to investigate whether it was desirable and feasible to provide vestibular rehabilitation for this patient population. Demand for therapy was assessed by a survey of 9198 working age people randomly sampled from six general practices. One in 10 respondents reported current, handicapping dizziness, but fewer than 2% of those with dizziness severe enough to merit treatment proved suitable and willing to attend hospital for testing and rehabilitation. Nevertheless, vestibular rehabilitation was clearly beneficial for the 16 patients who completed the therapy programme, as their scores on measures of symptoms, disability, handicap and postural stability improved significantly post-therapy to near-normal levels. We conclude that there is a need for provision of vestibular rehabilitation in primary care for patients with dizziness in the community.     

Otolaryngologic management of dizziness in the older patient

Studies report that dizziness is the most common presenting symptom in older patients who seek primary care. To understand the causes of dizziness, which is one of the major risk factors in causing falls in the older population, basic anatomy and physiology are reviewed in this article. Age-specific histopathologic changes occur in the labyrinth of the inner ear. To display evidence of the patient's symptoms, evaluation must include a comprehensive history, neurotologic examination, and diagnostic testing. There are common disorders associated with dizziness; thus, management depends on the cause. Once a diagnosis is secured, treatment is instituted based on sound medical principles.     

Functional outcome of vestibular rehabilitation in patients with abnormal sensory-organization testing

A goal of vestibular rehabilitation is to improve the functional status of patients with balance disorders. Despite the focus of vestibular rehabilitation on function, few objective data describe the outcome of vestibular rehabilitation in terms of balance function. In this prospective observational study, we tested a well-defined patient cohort (n = 67) with abnormal pretreatment sensory-organization testing who were undergoing vestibular rehabilitation. Patient outcomes were determined by using objective and subjective measures of function before and after rehabilitation. Overall, 60% of patients showed objective improvement of balance function; 25% of patients improved to normal. Analysis of success and failure of vestibular rehabilitation is important as an aid to appropriate patient counseling and efficient use of rehabilitation resources.     

A task for assessing vertigo elicited by repetitive head movements

OBJECTIVE: We developed a simple, inexpensive test for assessing vertigo in persons with peripheral vestibular disorders. METHOD: The test was administered to 16 asymptomatic adults and 16 patients with chronic vertigo caused by peripheral vestibular disorders. Participants sat in a chair and as rapidly as possible transferred 25 beanbags one at a time from a basket placed on the floor to a basket held .91 m up in the air. The task was timed, and the participants rated the level of vertigo elicited on a 10-point scale. RESULTS: Patients took significantly more time to perform the task and reported significantly greater levels of vertigo than did the asymptomatic adults. Test scores did not differ significantly across test sessions or raters. CONCLUSION: Performance on this task reliably differentiated patients with vestibular disorders from asymptomatic adults. The test is inexpensive, takes less than 1 min to perform, and has minimal technical requirements, making it suitable for a variety of facilities and levels of staff expertise.     

Hearing loss secondary to lumbar puncture

Hearing complaints have been described in patients after lumbar puncture, although other symptoms like headache, nausea, and dizziness can easily obscure hearing disorders. Reduced cerebrospinal fluid pressure after lumbar puncture may explain the origin of this vestibulocochlear dysfunction. Two cases of hearing loss and tinnitus that appeared hours after otherwise uncomplicated diagnostic spinal puncture are reported. The pure tone audiogram showed a 40-50 dB bilateral sensorial hearing loss in the lower frequencies. Hearing recovered and tinnitus disappeared entirely within 7-10 days. Since permanent hearing loss has been reported after diagnostic or therapeutic lumbar puncture, we should be aware of the possibility of this adverse effect.     

One-year outcome for patients with a chief complaint of dizziness

OBJECTIVE. To determine the one-year outcome for patients with a chief complaint of dizziness that had persisted at least two weeks. DESIGN: Prospective cohort study. SETTING: Federal teaching hospital. PATIENTS: 100 dizzy patients and 25 control subjects. MEASUREMENTS: The primary outcome was dizziness status (improved or not improved); the secondary outcomes were morbidity and health care utilization. RESULTS: The dizziness resolved for 18 patients, whereas the status improved for 37, stayed the same for 32, and worsened for 11, with two patients lost to follow-up. Thus, 55% of patients whose dizziness had not resolved two weeks after their initial visits improved over the subsequent 12 months. Logistic regression revealed four independent predictors of persistent dizziness at one-year follow-up: dizziness due to psychiatric causes, dysequilibrium, vertigo other than benign positional vertigo, vestibular neuronitis, or migraine (odds ratio, 6.3; 95% CI, 2.1-18.6); daily dizziness (odds ratio, 6.4; 95% CI, 2.0-21.0); dizziness worse with walking (odds ratio, 3.0; 95% CI, 1.1-9.0); and patient had initially feared a serious illness (odds ratio, 0.25; 95% CI, 0.10-0.74). These four factors could be used to classify patients as having either a high (82%), medium (47%), or low (0%) likelihood of improvement at one-year follow-up. One patient died from heart failure, and none developed a serious disease for which dizziness had been a harbinger. Dizziness was not associated with an increased number of clinic visits. CONCLUSIONS: Among patients with a chief complaint of dizziness who are still symptomatic at two-week follow-up, more than half improve within a year. Clinical factors identify patients at higher risk for persistent dizziness.     

Low levels of beta hexosaminidase A in healthy individuals with apparent deficiency of this enzyme

The common denominator of the different meanings of dizziness is a disturbance of spatio-postural orientation, which indicates an imminent danger of fall. H?henschwindel (fear of hights) with grasping and holding in the primate is instinctive behavior caused by a visual cliff or sudden dizziness. Because of the many possible meanings of dizziness, the case history is important for differential diagnosis. Vertiginous and non-vertiginous dizziness, black out and unsteady gait without vertigo should be distinguished. In addition, the duration and time course of the attack, releasing mechanisms and accompanying symptoms of dizziness should be explored. In recurrent dizziness without hearing loss, vestibular, vascular, cardial and epileptic disorders should be considered as well as intoxication, cerebral tumor, cerebellar hemangioblastoma, multiple sclerosis, neurosis and psychosis. Epileptic dizziness occurs not only in the prodromal stage of grand mal attacks and in temporal lobe epilepsy, but also in petit mal absences of short duration (less than 5 s) in which the blurring of consciousness is not apparent; absences of short duration are easily overlooked in childhood. Besides the objective history obtained from the patient's relatives, EEG-recording when falling asleep in the morning after one night of sleep deprivation are the best means for the diagnosis of epilepsia. Spontaneous nystagmus after complete exclusion of visual fixation is a physiological phenomenon. For differential diagnosis between physiological and pathological spontaneous nystagmus, Frenzel's spectacles in the dark room are indispensable. The distinction of spontaneous nystagmus in the narrower sense, gaze nystagmus and fixation nystagmus is discussed. The diagnostic importance of the direction of nystagmus is mentioned. Jerking nystagmus may be congenital. Pendular nystagmus may be acquired. Therefore, additional criteria for the differential diagnosis between congenital and acquired nystagmus are necessary.     

Polyamines increase in the brain stem and cerebellum following labyrinthectomy

The goal of this investigation was to test the hypothesis that unilateral damage to the vestibular end-organ (labyrinthectomy) stimulates polyamine synthesis in central vestibular neural structures that mediate the process of behavioral recovery (vestibular compensation). Pharmacological studies have shown that compensation can be altered by alpha-difluoromethylornithine (DFMO), a specific inhibitor of polyamine synthesis. Because polyamines are important in regeneration, development and modulation of N-methyl-D-aspartate (NMDA) excitatory amino acid receptors, which mediate vestibular synaptic plasticity, we investigated changes in polyamines in specific central vestibular structures after unilateral labyrinthectomy. The supernatant fraction of brain tissue homogenates was reacted with dansyl chloride. Dansylated polyamine derivatives were quantified in the vestibular nuclei, cerebellum, and inferior olive in both the control and the unilaterally labyrinthectomized guinea pig by high-performance liquid chromatography-fluorometric detection. No left-right differences in putrescine, spermidine, or spermine were detected in any brain parenchyma of controls. Polyamine imbalance, characterized by increased spermidine in the ipsilateral medial and lateral vestibular nuclei, was noted 12 and 24 h after unilateral labyrinthectomy (UL). In contrast, spermidine, spermine, and putrescine were elevated bilaterally in the cerebellum and inferior olive after UL. These biochemical changes may represent neuronal modifications to establish a balance between the vestibular nuclei after unilateral labyrinthectomy. Elucidation of the role of polyamines in central vestibular function and in vestibular compensation offers promise for the development of novel therapeutic strategies for treatment of vestibular disorders.     

Occupation and visual/vestibular interaction in vestibular rehabilitation

Otolaryngologists often prescribe head movement exercise programs for patients with vestibular disorders, although the effectiveness of these programs and the critical features of the exercises are poorly understood. Because many patients who dislike exercising do not follow through with their exercises, alternatives to the traditional repetitive exercises would be useful. Subjects diagnosed with vestibular disorders were treated for 6 weeks with either an outpatient exercise program that incorporated interesting, purposeful activities or a simple home program of head movements, comparable with the exercises otolaryngologists often give their patients when they do not refer to rehabilitation. Both treatments incorporated repetitive head movements in all planes in space, graduated in size and speed. Subjects were all tested before and after treatment with standard measures of vestibulo-ocular reflex and balance, level of vertigo, gross motor skills, and self-care independence. Subjects in both groups improved significantly on the functional measures, with slightly greater improvements in the occupational therapy group. The results were maintained 3 months after the cessation of intervention. These data suggest that graded purposeful activities are a useful alternative for treating this patient population and that the essential factor in any exercise program is the use of repetitive head movements.     

Sleep disorders: diagnosis and treatment

Disturbed or inadequate sleep is a frequent complaint with a great impact on daily functions and an often chronic course requiring adequate treatment. To choose an appropriate therapy it is necessary to develop a useful, reliable, valid and specific diagnostic procedure. Primary care physicians can recognize and treat most sleep disorders. For special diagnostic cases sleep centers are recommended. Sleep disorders may be managed by adequate pharmacological as well as nonpharmacological treatment. Besides specific pharmacological means, education in sleep/wake physiology and hygiene and several psychotherapeutic strategies may be valuable.     

Bilateral vestibulopathy revisited

Bilateral vestibular failure (BVF) is an often undetected disorder of the peripheral labyrinths or the eighth nerves. Key symptoms are oscillopsia during locomotion or head movements and unsteadiness, particularly in the dark. Diagnosis is made by a bedside test for defective vestibulo-ocular reflex and the absence of nystagmic reaction to both caloric and rotatory pendular testing. Most frequent etiologies include ototoxicity, cerebellar degeneration, meningitis, neuropathies, sequential vestibular neuritis, autoimmune disorders, tumors, and miscellaneous otological diseases. Idiopathic BVF is found in more than twenty percent of the patients. Recovery is possible but mostly incomplete. Somatosensory and visual input largely substitute the vestibular deficit for spatial orientation, postural balance and ocular motor control.     

Permanent cardiac pacing in elderly patients with recurrent falls, dizziness and syncope, and a hypersensitive cardioinhibitory reflex

The study was designed to assess the outcome of treatment with permanent dual-chamber pacing of elderly patients with falls, dizziness and syncope associated with the demonstration of a hypersensitive cardioinhibitory reflex. Questionnaires were sent to patients (and their general practitioners) who had been referred to a regional pacing centre with recurrent falls, dizziness or syncope diagnosed as likely to be secondary to cardioinhibitory carotid sinus syndrome or predominantly cardioinhibitory vasovagal syndrome. After pacemaker insertion, 84% of patients had no further syncope over a mean follow-up period of 10 (range 1.5 to 30) months. Minor symptoms persisted in only 40% of all patients. Symptoms were unchanged in 22%. It was concluded that permanent dual-chamber pacing is an effective treatment for elderly patients with recurrent falls, dizziness and syncope in whom a hypersensitive cardioinhibitory reflex is found. Good results were obtained in this group with a simple diagnostic work-up.     

Peroxidative and glutathione status in uterus and placenta after normal and pathological pregnancy

The content and amount of the allergologic diagnostic measures differs more and more in comparison to the causal treatment and consulting of the patient during care. The tasks of quality assurance may include the development of criteria for evaluated diagnostic measures and the resulting treatment concepts with respect to an interdisciplinary approach. The cooperation with patient groups should be integrated in such a concept. The basic allergologic care, the interaction with allergologic centers, the supervision and coordination with facilities of in-patient care have to be newly defined in the frame of a structural discussion.     

Psychiatric diagnosis among referred patients in Ghana

Ninety six patients were referred between January and December 1988, to the psychiatric out-patient clinic at the Korle Bu Teaching Hospital in Accra. The majority (62.8%), were referred from the physician clinics, 14.9% from the surgical and allied surgical clinics. Fewer percentages were referred from the other departments. Nearly half of those referred were found to be suffering from mood (affective) and neurotic and stress related disorders; 13.2% from schizophrenia, schizotypal and delusional disorders. Approximately nine per cent of the referrals, all male students aged between 14 and 21 were diagnosed as suffering from mental and behavioural disorders due to the use of psychoactive substances, mainly cannabis and alcohol. Five and a half per cent of those referred were found to have no psychiatric illness. About 21.3% of the patients required immediate transfer to the Accra Psychiatric Hospital for treatment while 66.3% required out-patient psychiatric and/or psychological treatment within the teaching hospital, and 5.6% were treated in the general wards of the teaching hospital. Nearly seven per cent were referred back to the referring clinicians with advice on further management and investigation, with collaboration of the psychiatrist. The setting up of a psychiatric department as an integral part of the Korle Bu Teaching Hospital is strongly advocated.     

Extending the functional cerebral systems theory of emotion to the vestibular modality: A systematic and integrative approach.

Throughout history, vestibular and emotional dysregulation have often manifested together in clinical settings, with little consideration that they may have a common basis. Regarding vestibular mechanisms, the role of brainstem and cerebellar structures has been emphasized in the neurological literature, whereas emotion processing in the cerebral hemispheres has been the focus in psychology. A conceptual model is proposed that links research in the 2 disparate fields by means of a functional cerebral systems framework. The claim is that frontal regions exert regulatory control over posterior systems for sensation and autonomic functions in a dense, interconnected network. Impairment at levels within the system is expected to influence vestibular and cognitive processes depending on the extent of frontal regulatory capacity. M. Kinsbourne's (1980) shared cerebral space model specifies the conditions under which dysfunction of the vestibular modality will influence higher cognitive levels. A position on laterality and associative relations within the right hemisphere is proposed to explain links among dizziness, nausea, and negative emotion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of the dizzy patient

This discussion has focused primarily on the history and physical examination of the patient with dizziness which, in fact, are the two most important elements in the evaluation process. To perform the examination expeditiously and completely, a broad differential diagnosis of dizziness must be kept in mind. The clinician should also keep in mind two basic objectives: first, to identify serious pathology (e.g., central nervous system lesion, brainstem ischemia, cardiac arrhythmia); and second, to recognize diseases that can be specifically treated, such as an endocrine abnormality, middle ear infection, Meniere's disease, or a drug reaction. Reassurance and/or vestibular rehabilitation are the mainstays of therapy for the patients not falling into the above two categories.     

Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin

OBJECTIVE: To assess postural performance in patients with dizziness of suspected cervical origin in whom extracervical causes had been excluded, and to assess the effects of physiotherapy on postural performance and subjective complaints of neck pain and dizziness. DESIGN: Prospective, randomized, controlled trial. SETTING: Primary care centers and a tertiary referral center. PATIENTS AND SUBJECTS: Of 65 referrals, 43 patients were excluded because extracervical etiology was suspected. Of the remaining 22 patients, 17 completed the study (15 women, 2 men, x age 37 yr, range 26-49). The controls were 17 healthy subjects (15 women, 2 men, x age 36 yr, range 25-55). INTERVENTION: Physiotherapy based on analysis of symptoms and findings, and aimed to reduce cervical discomfort. Patients were randomized either to receive immediate physiotherapy (n = 9), or to wait 2 months, undergo repeat measurements, and then receive physiotherapy (n = 8). MAIN OUTCOME MEASURES: Posturography, measuring velocity and variance of vibration-induced body sway and variance of galvanically induced body sway. Subjective intensity of neck pain (Visual Analog Scale ratings, 0-100), intensity and frequency of dizziness (subjective score 0-4). RESULTS: The patients manifested significantly poorer postural performance than did healthy subjects (.05 > p > .0001). Physiotherapy significantly reduced neck pain and intensity and the frequency of dizziness (p < .01), and significantly improved postural performance (.05 > p > .0007). CONCLUSIONS: Patients with dizziness of suspected cervical origin are characterized by impaired postural performance. Physiotherapy reduces neck pain and dizziness and improves postural performance. Neck disorders should be considered when assessing patients complaining of dizziness, but alternative diagnoses are common.     

Passive sustained turning of the head induces asymmetric gain of the vestibulo-ocular reflex in healthy subjects

In order to test the hypothesis of an interaction between neck proprioception and the vestibulo-ocular reflex (VOR), we rotated 16 healthy subjects both facing forward and with their heads passively turned 70 degrees to either side. We found that gain tended to be lower when the subjects were rotated with their heads turned opposite to the direction of rotation compared to when they were rotated in the same direction, but facing forward. Although our findings were not statistically significant, they suggest that there is a measurable interaction between neck proprioception and the VOR in subjects with normal vestibular function. Asymmetric neck muscle proprioceptive signals seem to give rise to asymmetric functioning of the VOR, which, at least in part, could be the pathogenesis of cervical dizziness. If so, this could lead to misinterpretation of vestibular assessments in patients with neck pain who also complain of dizziness.     

Cervical vertigo--reality or fiction?

Neck afferents not only assist the coordination of eye, head, and body, but they also affect spatial orientation and control of posture. This implies that stimulation of, or lesions in, these structures can produce cervical vertigo. In fact, unilateral local anesthesia of the upper dorsal cervical roots induces ataxia and nystagmus in animals, and ataxia without nystagmus in humans. If cervical vertigo exists outside these experimental conditions, it is obviously characterized by ataxia and unsteadiness of gait, and not by a clear rotational or linear vertigo. Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin. To date, however, the syndrome remains only a theoretical possibility awaiting a reliable clinical test to demonstrate its independent existence.