Rx for hand pieces: preventive maintenance key to long life

Patients with hemispheric lesions frequently suffer from equilibrium impairment that may be prolonged and may interfere with rehabilitation. In an effort to clarify whether this phenomenon is related to vestibular dysfunction, we examined the relationship of the horizontal vestibulo-ocular reflex (VOR) with stability in 15 patients with unilateral hemispheric stroke. The study included electro-oculographic recording of the VOR while the patients were rotated in a vestibular chair. Stability was scored in accordance with the patients' ability to maintain equilibrium in six graded positions. The findings demonstrated relationship between VOR gain (eye/head displacement) and equilibrium. It is suggested that the "loss of balance" after stroke may be related to an impairment of the corticovestibular modulation of the vestibular function.     

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.     

Aphysiologic performance on dynamic posturography

The remarkable ability of the body to maintain balance is the result of central nervous system integration of sophisticated inputs from the vestibular, visual, and somatosensory systems. Strategies by patients with balance dysfunction are aphysiologic when their performance is relatively better on more difficult conditions of sensory conflict than on easier ones. Twenty-two aphysiologic patterns on computerized dynamic posturography were compared with age-matched normal and vestibular patterns. The aphysiologic group performed significantly better than the patients in the vestibular dysfunction group on the most difficult subtests of computerized dynamic posturography, conditions 5 and 6, yet significantly poorer on the easier subtests, conditions 1 through 4. In addition, patients in the aphysiologic group tended to show greater intertrial variability compared with patients in both normal and vestibular system dysfunction groups. A stepwise linear discriminant analysis was used to determine a set of conditions that had significant value in discriminating between the three patient groups. Case studies are presented to further illustrate the clinical usefulness of computerized dynamic posturography testing in the evaluation of patients suspected of having a functional component to their on-feet balance problems.     

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.     

Genotypic heterogeneity and phenotypic variation among patients with type 2 Gaucher''s disease

Electrophysiological examination of the function of perceptive organs, like eye or cochlea, works up more and more interest in scientists to look for an objective method of vestibular end organ investigation. In many papers authors attempt to estimate the efficiency of vestibular organs after using angular or linear acceleration as stimulus, which required special and expensive apparatus. Papers that described vestibular evoked myogenic potentials (VEMPs) seem to be very promising. In this study an attempt was taken to obtain VEMPs with own modification of stimulus and response register. Preliminary examinations in 14 healthy volunteers were performed. Two subjects with sensorineural deafness on one side and symmetric, normal excitability of vestibular organs and 4 with bilateral hearing loss and unilateral weakness of vestibular excitability were examined. There were also 6 patients with only weakness of vestibular excitability. On the basis of practical observations, there is a possibility that evoked potentials were a result of stimulation of vestibular part of the inner ear--sacculus. The method of the study is objective, simple, secure and comfortable for patients.     

Light touch contact as a balance aid

Canes and crutches are commonly used mobility aids, and most studies of their use have focused on issues equating support with the resulting decrease in force required of the affected limb. Clinicians, however, often observe patients with poor balance control using light touch of surrounding objects and surfaces to stabilize themselves while standing and walking. A series of studies have shown that sensory input to the hand and arm through contact cues at the fingertip or through a cane can reduce postural sway in individuals who have no impairments and in patients without a functioning vestibular system, even when contact force levels are inadequate to provide physical support of the body. This article summarizes these results, which have implications for design considerations of rehabilitation aids. Mobility devices or rehabilitation aids that provide feedback about applied force or enhance existing resolution of applied force changes across the skin surface may lead to new rehabilitation techniques.     

Middle ear pressure and dysfunction of the labyrinth: is there a relationship?

Relationships between middle ear pressure and non-infection-related cochleovestibular dysfunction have been suggested by several authors. According to some data, vertiginous attacks can be prevented by the insertion of a ventilation tube in patients suffering from Meniere's syndrome. The aim of our study was to investigate if the incidence of eustachian tube malfunction and pathologic middle ear pressure is frequent, and if routine implantation of ventilation tubes is reasonable in ears with dysfunctions of the labyrinth, including clinical Meniere's syndrome. So, we determined in our pressure chamber all active and passive parameters of eustachian tube function in 40 patients suffering from Meniere's syndrome, sudden sensory hearing impairment (SSHI), or vestibular neuronitis. Our results disclosed no nonrandom incidence of impaired tubal function among our patients compared to healthy control subjects. Pressure equalization was sufficient in most patients suffering from clinical Meniere's syndrome, and only one patient with vestibular neuronitis presented with a patulous tube. Our results show that impairment of vestibular or cochlear function is not regularly accompanied by eustachian tube dysfunction. Furthermore, no patient reported symptoms while pressure variation was performed. We conclude that variation of middle ear pressure does not usually play a role in the genesis of Meniere's syndrome, vestibular neuronitis, or SSHI. Thus, from our data, we cannot recommend routine implantation of tympanic ventilation tubes in patients suffering from Meniere's syndrome, vestibular neuronitis, or sudden hearing loss.     

Vestibular schwannoma management in the next century: a radiosurgical perspective

PURPOSE: To discuss how the evolution of vestibular schwannoma radiosurgery, changes in health care delivery, and patient accessibility to medical information will affect the management of vestibular schwannomas in the future. CONCEPT: In comparison with microsurgical resection of vestibular schwannomas, radiosurgery has a lower morbidity rate, a similar risk of requiring further surgery, and higher patient satisfaction. As this information becomes more widely available to patients and third-party payors, radiosurgery may replace surgical resection as the preferred management strategy for patients with small to medium sized vestibular schwannomas in the United States. RATIONALE: It is estimated that 2500 patients are diagnosed with vestibular schwannomas each year in the United States. Assuming that 80% undergo surgery, 2000 operations are performed annually for newly diagnosed vestibular schwannomas. Data available since 1987 regarding the number of cases for which gamma knife radiosurgery was performed were used to predict the number of patients who will undergo vestibular schwannoma radiosurgery in the future. If the current trend continues, an equal number of patients will undergo surgical resection and radiosurgery to treat their vestibular schwannomas (approximately 1000/yr) sometime between 2005 and 2010. Moreover, it is predicted that by 2020, two-thirds of the patients who are newly diagnosed with vestibular schwannomas will undergo radiosurgery, with surgical resection being reserved for patients with large tumors associated with symptomatic brain stem compression. DISCUSSION: Early data regarding vestibular schwannoma radiosurgery predicted an exponential growth curve. Although it is premature to assume that the current trend will continue, it is likely that an ever increasing percentage of patients will undergo radiosurgery as accessibility to this alternative increases, and more data are published regarding long-term tumor growth control rates. If the mathematical model proves to be accurate, then stereotactic radiosurgery will replace surgical resection as the preferred management strategy for the majority of patients with vestibular schwannomas.     

Predicting return to work. A long-term follow-up study of railroad workers after low back injuries

STUDY DESIGN: Evaluation of the long-term outcomes of 178 railroad employees with low back injury who had completed a multidisciplinary rehabilitation program. OBJECTIVES: To study two major areas: 1) outcomes of the rehabilitation program in terms of the patient's improvement in function and rate of return to work and 2) factors that predict long-term retention at work, both at the railroad and elsewhere. SUMMARY OF BACKGROUND DATA: Several studies have been published examining rehabilitation outcomes of individuals covered under workers' compensation law, but few exist that have examined railroad workers covered by the Federal Employers Liability Act, and few studies exist with follow-up periods longer than 3 years. METHODS: Physical/medical, self-reported, and employment/financial data were collected on each patient from medical and employment records. Follow-up data regarding employment status were obtained either from the employer or from the patient by telephone interview. RESULTS: On average, the patients improved in all objective and subjective measures after rehabilitation. Improvements in these measures were not predictive of return to work. At follow-up examination, 89% of the contacted patients were employed--61% still at the rail-road. The employment factors of lost work days and length of employment and the financial factor of wage rate were the most predictive of long-term work status. CONCLUSIONS: The multidisciplinary program in the current study was found to improve patient physical functioning and reduce pain. However, success in these measures was not predictive of long-term work status, suggesting that other factors have an impact on work status. Clinicians must be aware that employment and financial factors may have a strong influence on return-to-work outcomes.     

Identification and characterization of two thrombin-activatable fibrinolysis inhibitor isoforms

OBJECT: The indications, operative findings, and outcomes of vestibular schwannoma microsurgery are controversial when it is performed after stereotactic radiosurgery. To address these issues, the authors reviewed the experience at two academic medical centers. METHODS: During a 10-year interval, 452 patients with unilateral vestibular schwannomas underwent gamma knife radiosurgery. Thirteen patients (2.9%) underwent delayed microsurgery at a median of 27 months (range 7-72 months) after they had undergone radiosurgery. Six of the 13 patients had undergone one or more microsurgical procedures before they underwent radiosurgery. The indications for surgery were tumor enlargement with stable symptoms in five patients, tumor enlargement with new or increased symptoms in five patients, and increased symptoms without evidence of tumor growth in three patients. Gross-total resection was achieved in seven patients and near-gross-total resection in four patients. The surgery was described as more difficult than that typically performed for schwannoma in eight patients, no different in four patients, and easier in one patient. At the last follow-up evaluation, three patients had normal or near-normal facial function, three patients had moderate facial dysfunction, and seven had facial palsies. Three patients were incapable of caring for themselves, and one patient died of progression of a malignant triton tumor. CONCLUSIONS: Failed radiosurgery in cases of vestibular schwannoma was rare. No clear relationship was demonstrated between the use of radiosurgery and the subsequent ease or difficulty of delayed microsurgery. Because some patients have temporary enlargement of their tumor after radiosurgery, the need for surgical resection after radiosurgery should be reviewed with the neurosurgeon who performed the radiosurgery and should be delayed until sustained tumor growth is confirmed. A subtotal tumor resection should be considered for patients who require surgical resection of their tumor after vestibular schwannoma radiosurgery.     

Postural motor programming in paraplegic patients during rehabilitation

One of the basic aims in the rehabilitation of thoracic spinal cord injured (SCI) patients concerns the regaining of sitting posture control. This implies the development of new postural strategies requiring the adjustment of motor programming processes. The aim of this study was to investigate the time course of postural reorganization during active, clinical rehabilitation of thoracic SCI patients with different SCI levels. Thus changes in motor programming in sitting balance control were investigated in two groups of complete low or high thoracic SCI patients. At several stages during the rehabilitation process an experiment was held in which sitting posture was perturbed systematically using submaximal reaching movements over four reaching distances. This bimanual reaching task was presented as a visual precue choice reaction time (RT) task in which reaching distance (i.e. grade of postural perturbation) was precued. Results indicated that in both high and low thoracic SCI patients RTs in movements involving postural perturbation became shorter during the course of the rehabilitation period. However, low thoracic SCI patients were generally slower in the programming of balance perturbing movements than high thoracic SCI patients, a phenomenon that did not change over time. Furthermore, initial differences in RTs as a function of grade of postural perturbation disappeared in both groups in the course of the rehabilitation phase. Precue benefit, equally large for both groups, did not change as a function of rehabilitation time. It is concluded that the observed phenomena signify the gradual development of new central postural control processes in both SCI groups during rehabilitation. Low thoracic SCI patients, having more residual sensorimotor functions, seem to adopt more complex strategies in maintaining and restoring sitting balance that take longer to specify and to programme. High thoracic SCI patients seem to rely on simpler strategies using more passive postural support.     

The vestibular & balance center: tools for diagnosing the dizzy patient

Without access to adequate diagnostic facilities, management of vestibular and balance disorders can be a frustrating process for both clinicians and patients. Expert clinical staff and state-of-the-art tools for the evaluation of balance disorders and dizziness are available within the vestibular and balance center. These centers can provide referring physicians and their patients with access to diagnostic expertise and facilities not practical within a general practice environment. Providing detailed evaluative reports, balance centers can help the referring physician define directions for surgical and medical treatment and assist in the management and rehabilitative treatment of acute and chronic dizziness and balance dysfunction.     

Endolymphatic sac obliteration for large vestibular aqueduct syndrome

The objective of this study was to investigate the effects of endolymphatic sac obliteration for stabilization of progressive hearing loss in patients with the large vestibular aqueduct syndrome. This was a retrospective case review conducted at a private neurootologic office in a metropolitan area. Seven ears in six patients were subjected to surgery for obliteration of the endolymphatic sac in an effort to stabilize progressive hearing loss associated with the large vestibular aqueduct syndrome. The study population was composed of four boys and two girls 4-17 years of age. The large vestibular aqueduct was unilateral in two patients and bilateral in four patients. All seven ears demonstrated progressive sensorineural hearing loss preoperatively. Surgical tissue obliteration was performed via a transmastoid approach in seven ears. The main outcome measure was comparison of pre- and postoperative hearing levels and stability. Magnetic resonance imaging also was performed in all cases at least 6 months postoperatively to determine patency of the endolymphatic sac and vestibular aqueduct. Six of seven ears maintained stable hearing during the follow-up period, which ranged from 6 months to 6 years (mean 3.2 years). One patient showed continued progression of hearing loss postoperatively. All seven ears demonstrated continued obliteration on postoperative imaging studies. Surgical obliteration of the endolymphatic sac may stabilize hearing in patients with the large vestibular aqueduct syndrome and progressive hearing loss. These results support the theory of pressure or fluid reflux into the labyrinth as a cause of progressive hearing loss in these patients.     

Posturography does not test vestibulospinal function

The clinical usefulness of posturography is unknown, despite its costing more than +500 per test in some areas of the United States, including Boston. We cross-sectionally and prospectively studied blinded vestibulo-ocular and vestibulospinal tests from 29 stable patients with chronic vestibular hypofunction; 22 patients were affected bilaterally (BVH), and 7 were affected unilaterally (UVH). Vestibulo-ocular function was assessed by electronystagmographic caloric stimulation and sinusoidal vertical axis rotation gains at 0.05 Hz. Vestibulospinal function was assessed by moving-platform and visualsurround posturography sensory organization tests (SOTs), paced and free gait in a gait laboratory, and clinical tests of timed gait and standing. Posturography SOT moving-platform tests 4 through 6, designed to assess vestibular function, correlated significantly (r < or = 0.72, P > or = 0.01) with vestibulo-ocular tests in 5 of 6 comparisons among BVH patients. Posturography SOT results, however, correlated poorly with other vestibulospinal measures: correlations were statistically significant for only 7 of 18 comparisons with clinical balance and gait function (r < or = 0.69, P > or = 0.01) and with 2 of 12 comparisons for gait laboratory dynamic stability measures (r < or = 0.55, P > or = 0.01) among the BVH patients. When both the platform and visual surround moved (SOT 6), however, correlations were statistically significant with static standing clinical measures (r = 0.51 to 0.69, P < 0.01) and with whole-body maximum moment arm during paced gait (r = 0.55, P < 0.01). Posturography scores for the UVH patients did not significantly correlate with any vestibulo-ocular or other vestibulospinal measures. These data indicate that among patients with BVH posturography SOT scores relate at best modestly with accepted measure of vestibulo-ocular function, less well with clinical measures of balance control, and poorly with dynamic gait-performance measures. We conclude that posturography SOT does not assess vestibulospinal function.     

Age-associated differences in sensori-motor function and balance in community dwelling women

Tests of visual, vestibular, sensori-motor and balance function were administered to 550 women, aged between 20 and 99 years at a Balance and Gait Laboratory. All of the sensory, motor and balance system measures showed significant age-associated differences. Multiple regression analyses revealed that the measures of lower limb sensation were the consistent sensori-motor factors contributing to balance under normal conditions (standing on a firm surface with eyes open or closed). Under more challenging conditions (standing on foam with eyes open) vision, strength and reaction time played significant roles, whilst when standing on foam with eyes closed, vestibular function also made a significant contribution. Analysis of percentage increases in sway under conditions where visual and peripheral sensation systems were removed or diminished, compared with sway under optimal conditions, indicated that up until age 65 there was an increased reliance on vision for balance control. Beyond this age, the contribution made by vision declined, so that in the oldest age-groups reduced vision was less able to supplement peripheral input, resulting in increased sway areas. Peripheral sensation however was the most important sensory system in the maintenance of static postural stability at all ages.     

Presentation and treatment of stapes dislocation and subluxation (author's transl)]

The symptomatology, especially vestibular, and the surgical findings in traumatic dislocation of the stapes into the oval window are described in 2 patients, one of whom seen 1 3/4 h after the accident and the other after 12 days. The main indication for exploratory tympanotomy was change of the spontaneous nystagmus from an irritative to a paretic type. Special attention should be given to positional nystagmus, which increases on turning onto the affected side, the mechanism for which is apparently similar to the positional vertigo of labyrinthine fistulae. Hearing was preserved in both patients. In one patient, vestibular function recovered considerably whilst in the other, there remained considerable impaired function.     

Gain and delay of human vestibulo-ocular reflexes to oscillation and steps of the head by a reactive torque helmet. I. Normal subjects

Vestibulo-ocular reflexes (VOR) were evaluated with a reactive torque helmet that imposed high-frequency oscillation (2-20 Hz) or step displacements of the head in the horizontal plane. The present paper describes the results in patients with vestibular deficiencies (labyrinthine defective; LD); experimental and analytical techniques and results for normal subjects were described in Part 1 of this paper. The patient groups included: total unilateral LD (related to acoustic neuroma; n = 40); severe (clinically total) bilateral LD (n = 7); bilateral hyporeflexia (n = 14); unilateral hyporeflexia (n = 11); and patients with LD phenomena that had subsided (n = 3). Helmet-induced head steps provided the most specific information. Characteristically, gain was lowered in one direction or both directions after unilateral or bilateral vestibular lesions, respectively; in general, the magnitude of the gain reduction correlated well with the degree of complaints and disability. Surprisingly, delay was systematically prolonged (up to several tens of milliseconds) in all groups of subjects with manifest vestibular pathology. These results suggest that the determination of delay, in addition to gain of the VOR, is feasible and important in the evaluation of vestibular function. The results of head oscillation generally supported the results for steps, but were somewhat less specific. The responses to manually generated head steps roughly agreed with those to helmet-induced steps, but because of the non-uniform acceleration they allowed a less exact analysis of VOR function.     

Primary diffusely infiltrative adenocarcinoma of the colon and rectum

In this study, patient opinion on oral rehabilitation by means of Br?nemark implants was investigated. All patients were referred to a periodontal clinic for implant installation and treated by one and the same operator. Prosthetic restorations were performed by dentists, who had no previous experience with prostheses on implants, but had completed a postgraduate training course. Patient opinion was obtained through questionnaires, pertaining to satisfaction and oral function. A comparison was made between pre-implant situation, short-term (< 4 months) and long-term functioning (3 years) with the implant-restorative rehabilitation. In total, 61 patients participated in the study; 23 received a full lower arch bridge and 18 a full upper arch bridge, while 20 patients got partial bridges. Of 298 installed implants, 7 failed at abutment connection (2.3%) and 1 during the 3-year follow-up interval (0.3%). The study results indicated that a great majority of patients were very satisfied with the treatment. Comfort with eating, aesthetics, phonetics and overall satisfaction improved significantly and nearly all patients said that they would undergo the treatment again or recommend it to others. Patients experienced their implants as "natural" teeth. The conclusion is that rehabilitation ad modum Br?nemark, even in the hands of non-specialized dentists, can be of high quality, improving oral function and satisfying the needs and demands of patients.     

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.     

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.