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Additional file 1. The distribution of diagnoses in the study sample, according to the ICD-11 system.

Forced vital capacity (FVC) is an essential respiratory measurement for assessment and monitoring of patients with Amyotrophic Lateral Sclerosis (ALS). Our clinic rapidly implemented remote assessment of FVC after COVID-19 related restrictions on respiratory testing were imposed, using mini-spirometers and video consultation. We sought to evaluate the patient's experiences of performing remote respiratory assessments to guide future development and optimisation of the service. Twenty-five patients completed surveys. The mean age was 65.2 years and average time from diagnosis was 17.04 (2���99) months. Seventy-two percent (n = 18) required help from a caregiver to perform the tests. Ninety-two percent (n = 23) of patients reported that overall, they were satisfied and were happy to continue with remote respiratory assessment. Reducing the number of clinic visits for review and assessment was valued by 92% (n = 23) and reducing the risk associated with COVID-19 was valued by 96% (n = 24). The highest frequency reported as acceptable for performing the remote breathing assessments was monthly (60%, n = 15), followed by every second month (28%, n = 7). Remote respiratory testing is viewed positively by patients. These technologies used in combination with video-consultations and other novel forms of remote monitoring implemented in response to the COVID-19 crisis will continue to be valuable tools for clinical care in future. However, further evaluation of the validity of remote respiratory assessment is required.

Vestibular rehabilitation is an evidence based treatment for peripheral unilateral vestibular hypofunction (UVH). It is effective in improving physical function (balance, gait and dynamic visual acuity) and in reducing symptoms of dizziness, but precise effects on gait are less well known. The increasing prevalence of technology worldwide has produced opportunities for professionals in the area of vestibular rehabilitation. One technology, virtual reality, has potential but evidence relating to its effectiveness is lacking. The thesis contains four studies related to two main objectives. The first objective was to investigate the effectiveness of an off-the-shelf virtual reality system, the Nintendo Wii Fit Plus™ (NWFP™) compared to conventional vestibular rehabilitation. In preparing to investigate effectiveness, study one quantified the usability and safety of the NWFP™ and found that patients with vestibular disease enjoyed balance exercises on the NWFP™ and perceived that it was beneficial. Subsequently, study two compared the effectiveness of the NWFP™ to conventional vestibular rehabilitation. A parallel group, randomised controlled trial allocated n=71 patients with UVH to six weeks of NWFP™ based vestibular rehabilitation or six weeks of conventional vestibular rehabilitation. Intention to treat analysis indicated that the NWFP™ was not superior in improving the primary outcome of gait speed or secondary outcomes of balance, dynamic visual acuity, other gait parameters, dizziness, anxiety or depression. However, significantly more enjoyment was reported by the NWFP™ group, in addition to less difficulty with, and less tiredness after exercising. Concurrently with the RCT, study three investigated the second objective, to compare the gait of healthy controls and UVH patients using computerised three dimensional gait analysis. Evidence was found that the primary impairment in UVH gait was reduced speed, and control In the medio-lateral direction. Study four investigated the reliability of computerised dynamic visual acuity testing and found that although DVA was more impaired in UVH patients when compared to healthy controls, reliability co-efficients were low. In conclusion this thesis presents novel findings on the effectiveness of virtual reality in vestibular rehabilitation and on the factors contributing to gait impairment in UVH.