NeuroRehabilitation - Volume 32, issue 3

Authors: Greenwald, Brian D. | Gurley, James M.

Article Type: Editorial

DOI: 10.3233/NRE-130865

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 433-435, 2013

Authors: Khan, Sarah | Chang, Richard

Article Type: Review Article

Abstract: Introduction: A sense of proper sensory processing of head motion and the coordination of visual and postural movements to maintain equilibrium is critical to everyday function. The vestibular system is an intricate organization that involves multiple levels of sensory processing to achieve this goal. Purpose: This chapter provides an overview of the anatomical structures and pathways of the vestibular system. Summary: The five major vestibular structures are located in the inner ear and include: the utricle, the saccule, and the lateral, superior, and posterior semicircular canals. Hair cells on the neuroepithelium of the peripheral vestibular organs …carry sensory impulses to primary processing centers in the brainstem and the cerebellum. These areas send input via ascending and descending projections to coordinate vital reflexes, such as the vestibuloocular reflex and the vestibulospinal reflex, which allow for the proper orientation of the eyes and body in response to head motion. Specific connections regarding higher level cortical vestibular structures are poorly understood. Conclusion: Vestibular centers in the brainstem, cerebellum, and cerebral cortex function to integrate sensory information from the peripheral vestibular organs, visual system, and proprioceptive system to allow for proper balance and orientation of the body in its environment. Show more

Keywords: Vestibular apparatus, kinocilium, stereocilia, utricle, saccule, semicircular ducts, macula, cupula, striola, vestibular, nuclear complex, vestibuloocular reflex, vestibular spinal reflex

DOI: 10.3233/NRE-130866

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 437-443, 2013

Authors: Chandrasekhar, Sujana S.

Article Type: Research Article

Abstract: Objectives: All degrees of traumatic brain injury (TBI) are associated with balance dysfunction and/or dizziness. The clinician assessing and managing patients with TBI should become familiar with vestibular and non-vestibular causes of dizziness and imbalance, and be able to perform screening tests to determine when referral to a vestibular specialist is warranted. This chapter outlines the clinical pathways to be followed in history-taking, physical examination, and assessment. Introduction: Dizziness, vertigo, balance dysfunction and gait ataxia can have their origin in the vestibular system, elsewhere, or be multifactorial. The complex anatomy and physiology of the balance canals, otolithic organs, …and vestibular nerves peripherally, and the vestibular nuclei centrally, as well as the neural connections between vestibular, oculomotor, and proprioceptive systems will be covered in clinically pertinent detail. Methods: A majority of diagnosis of dizziness/vertigo can be made after a proper history has been obtained. This can be challenging in all dizzy patients, and more so in the TBI patient in whom memory and recall may be impaired. The reader will learn how to use tools such as dizziness questionnaires as well as targeted history taking to elicit the information. Similarly, the addition of a programmatic, targeted physical examination of the dizzy patient will allow the clinician to fine-tune the diagnosis between peripheral and central causes. Results: Once history and examination have narrowed the diagnostic possibilities, appropriate testing – in the vestibular laboratory and radiologic testing – is indicated. The reader will learn when these tests should be considered, and what the findings will show. Treatment can then be targeted for maximal outcome. Conclusion: Managing TBI is challenging; the addition of dizziness or balance complaints in these individuals makes it even more so. This paper seeks to provide a useful roadmap clinical pathway for assessment of these patients with appropriate and timely referral for treatment. Show more

Keywords: Dizziness, balance disorders, vertigo, gait ataxia, TBI, vestibular dysfunction

DOI: 10.3233/NRE-130867

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 445-454, 2013

Authors: Smouha, Eric

Article Type: Research Article

Abstract: Objectives: To present a framework for the diagnosis and treatment of inner ear disorders, with an emphasis on problems common to neuro-rehabilitation. Introduction: Disorders of the inner ear can cause hearing loss, tinnitus, vertigo and imbalance. Hearing loss can be conductive, sensorineural, or mixed; conductive hearing loss arises from the ear canal or middle ear, while sensorineural hearing loss arises from the inner ear or auditory nerve. Vertigo is a hallucination of motion, and is the cardinal symptom of vestibular system disease. It should be differentiated from other causes of dizziness: gait imbalance, disequilibrium, lightheadedness (pre-syncope). Vertigo can …be caused by problems in the inner ear or central nervous system. Methods: The diagnosis of inner ear disorders begins with a targeted physical examination. The initial work-up of hearing loss is made by audiometry, and vertigo by electronystagmography (ENG). Supplemental tests and MRI are obtained when clinically indicated. Results: The clinical pattern and duration of vertigo are the most important clinical features in the diagnosis. Common inner ear causes of vertigo include: vestibular neuritis (sudden, unilateral vestibular loss), Meniere’s disease (episodic vertigo), benign paroxysmal positional vertigo (BPPV), and bilateral vestibular loss. Common central nervous system causes of vertigo include: post concussion syndrome, cervical vertigo, vestibular migraine, cerebrovascular disease, and acoustic neuroma. Conclusion: A basic knowledge of vestibular physiology, coupled with a understanding of common vestibular syndromes, will lead to correct diagnosis and treatment in most cases. Show more

Keywords: Acoustic neuroma, benign paroxysmal positional vertigo, dizziness, imbalance, inner ear, labyrinthitis, Meniere's disease, migraine, nystagmus, superior canal dehiscence syndrome, vertigo, vestibular neuritis, vestibulo-ocular reflex

DOI: 10.3233/NRE-130868

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 455-462, 2013

Authors: Lei-Rivera, Laura | Sutera, John | Galatioto, Jessica A. | Hujsak, Bryan D. | Gurley, James M.

Article Type: Research Article

Abstract: Introduction: Although a majority of patients following minor traumatic brain injury recover to their pre-morbid functional level, persistent activity and participation limitations can occur in the refractory patient. These long-term consequences of brain injury may only become apparent months to years after the injury. In order to quantify these long-term sequella, laboratory, clinical and functional outcome measures may not only identify needed areas of treatment, but may also assist in determining the impact of the treatment on the individuals function. Purpose: The aim of this manuscript is to review the clinical utility of vestibular laboratory testing and the …bedside vestibular examination in patients following mild traumatic brain injury. In addition, the validity and inter-observer reliability of functional outcome measures commonly used in individuals with mTBI will also be reviewed. Summary: Because of the diffuse pathology seen with mTBI, multiple tests are needed to determine the resultant impairment and their impact on the patient’s activity level and participation level. Laboratory test and bedside tests of vestibular impairment are reviewed. Functional outcome measures including the Dynamic Gait Index, the Functional Gait Assessment, the Balance Error Scoring System, and Dual Task Performance are reviewed for their appropriateness in quantifying the effect of mTBI at activity level and participation level of the individual. Conclusion: TBI rehabilitation services are increasingly exemplified by the needs of patients, rather than by the underlying pathology or diagnosis. Basing treatment decisions and treatment timing on laboratory, clinical, and functional testing can optimize the rehabilitation outcome. Show more

Keywords: Vestibular rehabilitation, traumatic brain injury, concussion, outcomes measures

DOI: 10.3233/NRE-130869

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 463-472, 2013

Authors: Gay, Robin K.

Article Type: Research Article

Abstract: Introduction: Problems with balance and dizziness are one of the most common complaints of individuals who have experienced a brain injury and are reported in up to 90% of cases. Despite the ubiquity of vestibular disturbance in this population, there remains a dearth of research on the interaction between physiological and cognitive systems responsible for maintaining balance. Purpose: The purpose of this article is to review studies on the interaction of physiological and cognitive processes required to maintain balance that may aide assessment and recovery of balance disturbance in patients with brain injury. Summary: This article …provides a review of research on the role of higher order cognitive processes in maintaining balance and rational for further inclusion of neurocognitive measures in the assessment of vestibular disturbance. Conclusion: Greater inclusion of neurocognitive measures in assessment of vestibular disturbance provides a method of assessment containing increased ecological validity compared to traditional assessments, better prepares patients for discharge, and may reduce the incidence of future injury. Show more

Keywords: Balance, dizziness, mild traumatic brain injury, concussion, sports injury, neurocognitive assessment, falls prevention, brain injury rehabilitation

DOI: 10.3233/NRE-130870

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 473-482, 2013

Authors: Cohen, Allen H.

Article Type: Research Article

Abstract: Introduction: This article discusses, in a clinically relevant format, the importance of including a neuro-optometrist as a member of the management team for patients with balance disorders. Purpose: To review the importance of vision and visual processing for maintaining a sense of balance and equilibrium and the role of the neuro-optometrist in the overall rehabilitation of patients with balance disorders Summary: Dizziness, balance problems and the sensation that the space world is moving (vertigo) are one of the most commonly reported problems in general medical practice. Persons with a central nervous system injury or other idiopathic …causes of visual processing problems or who have functional vision problems that are not adequately managed, often experience extreme difficulty with balance and movement, as well as with their perception of space. Consequently, the patient often experiences difficulty functioning in an environment with excessive visual stimulation such as a grocery store or shopping mall. Symptoms of disequilibrium, vestibular and balance problems are commonly a result of VOR disturbance secondary to an inner ear problem and an unstable binocularity. Conclusion: The combination of neuro-optomertic rehabilitative therapy and balance therapy will result in a is an effective treatment for reducing or resolving these symptoms. Show more

Keywords: Neuro-optometric rehabilitation therapy, vestibular ocular reflex, VOR, disequilibrium, visual-vestibular disorder, dorsal stream and ventral stream

DOI: 10.3233/NRE-130871

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 483-492, 2013

Authors: Shaikh, Aasef G. | Ghasia, Fatema F.

Article Type: Research Article

Abstract: Introduction: Foveation is the fundamental requirement for clear vision. Saccades rapidly shift the gaze to the interesting target while gaze holding ensures foveation of the desired object. Purpose: We will review the pertinent physiology of saccades and gaze holding and their pathophysiology leading to saccadic oscillations, slow saccades, saccadic dysmetria, and nystagmus. Summary: Motor commands for saccades are generated at multiple levels of the neuraxis. The frontal and parietal eye field send saccadic commands to the superior colliculus. Latter then projects to the brain-stem saccadic burst generator. The brain-stem burst generators guarantee optimum signal to ensure …rapid saccadic velocity, while the neural integrator, by mathematically integrating the saccadic pulse, facilitates stable gaze holding. Reciprocal innervations that ensure rapid saccadic velocity are prone to inherent instability leading to saccadic oscillations. In contrast, suboptimal function of the burst generators causes slow saccades. Impaired error correction, either at the cerebellum or the inferior olive, leads to impaired saccade adaptation and ultimately saccadic dysmetria and oculopalatal tremor. Impairment in the function of neural integrator causes nystagmus. Conclusion: Neurophysiology of saccades, gaze holding, and their deficits are well recognized. These principles can be implemented to define novel therapeutic and rehabilitation approaches. Show more

Keywords: Balance, vision, cerebellum, brainstem, nystagmus, vertigo

DOI: 10.3233/NRE-130872

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 493-505, 2013

Authors: Rine, Rose Marie | Wiener-Vacher, Sylvette

Article Type: Research Article

Abstract: Introduction: The effect of vestibular dysfunction since birth is more debilitating than that attained later in life, and unlike adults, children with vestibular dysfunction since or shortly after birth do not recover function without intervention. Purpose: The purpose of this report is to provide an overview of the etiology of vestibular dysfunction in children as well as the related impairments, and to describe testing methods and evidence based interventions to ameliorate the vestibular related impairments in children. Summary: In recent years, investigations have revealed that vestibular dysfunction is more common in children than previously thought, with …consequent impairments in motor development, balance and reading abilities. The dysfunction may be due to central or peripheral lesions, each with distinct presentation of symptoms and test results. Common etiologies and clinical presentation of vestibular dysfunction in children are reviewed; appropriate screening and diagnostic techniques and efficacious medical and rehabilitation interventions are presented. Conclusion: Despite advances in clinical and diagnostic testing of vestibular function in children and infants, testing of vestibular function is not typically done. Comprehensive testing of signs and symptoms is critical for diagnosis and implementation of appropriate interventions. Show more

Keywords: Pediatric vestibular deficits, pediatric vestibular rehabilitation, pediatric vestibular testing

DOI: 10.3233/NRE-130873

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 507-518, 2013

Authors: Gurley, James M. | Hujsak, Bryan D. | Kelly, Jennifer L.

Article Type: Research Article

Abstract: Introduction: Vertigo, dizziness, and imbalance are a symptom complex that is commonly found following concussion. Early metabolic changes following concussion may lead to worsening of the injury and symptoms in individuals not properly managed from the outset. When symptoms do not recover spontaneously, skilled vestibular rehabilitation can be an effective modality in an attempt to normalize the individual’s vestibular responses. Purpose: The purpose of this review is to appraise the current and accepted methods available to the skilled clinician in quantifying and treating vestibular dysfunction following concussion. Incidence and prognostic indicators will be reviewed along with common barriers …to recovery. Summary: Vestibular Rehabilitation following concussion utilizes similar tools and techniques employed when treating those solely with peripheral pathology. The clinician must not only have a solid understanding of when and why certain exercises are required, but also be willing to accept that less exercise may be indicated in this population. As injury to the system following mild traumatic brain injury can include both peripheral and central structures, the duration of therapy and the time to recovery may be prolonged. Co-morbidities including cognitive and behavioral issues, visual-perceptual dysfunction, metabolic dysfunction, and autonomic dysfunction may hamper the effectiveness of the traditional Vestibular Rehabilitation approach. As successful treatment does not occur in a vacuum, working closely with other disciplines well versed in treating these co-morbid issues will help the individual to obtain optimal recovery. Conclusion: Vestibular Rehabilitation is an effective modality for managing dizziness, vertigo, and imbalance following concussion. Careful consideration of the acuity of the injury, along with effective management of co-morbid conditions will optimize the result. Show more

Keywords: Vestibular rehabilitation, traumatic brain injury, concussion

DOI: 10.3233/NRE-130874

Citation: NeuroRehabilitation, vol. 32, no. 3, pp. 519-528, 2013