Search

Purpose Vestibular rehabilitation (VR) using posturography systems has proved useful in improving balance among elderly patients with postural instability. However, its high cost hinders its use. The objective of this study is to assess whether two different protocols of VR with posturography, one of them longer (ten sessions) and the other shorter (five sessions), show significant differences in the improvement of balance among old patients with instability. Patients and methods This is a prospective, experimental, single-center (Department of Otorhinolaryngology of a tertiary referral hospital), randomized (into balanced patient blocks) study with two parallel arms, in 40 people over 65 years of age, with instability and at a high risk of falling. The percentage of the average balance (composite) in the sensory organization test (SOT) of the CDP (main outcome measure), other CDP scores, time and steps in the "timed up and go" test, scores of Dizziness Handicap Inventory (DHI), short Falls Efficacy Scale - International (short FES-I), and Vertiguard were compared before and 3 weeks after VR between both intervention groups. Results The two treatment groups (20 patients per group) were comparable in age, sex, and pre-VR balance evaluation. In both groups, we observed a significant improvement in global balance (composite) after VR (49±11.34 vs 57±13.48, p=0.007, in the group undergoing 10 sessions; 51±12.55 vs 60±12.99, p=0.002, 5 sessions). In both groups, we also observed improvements in other posturographic parameters (in the SOT and limits of stability) but not in the timed up and go scores or in the questionnaires. Comparison of the improvement level achieved in both groups revealed no significant differences between them. Conclusion The protocols of vestibular rehabilitation by posturography of 5 sessions in elderly patients with postural instability are as effective as those of 10 sessions for improving balance among elderly patients with postural instability. Trial registration ClinicalTrials.gov identifier: NCT03034655. Registered on 25 January 2017.

Essential tremor (ET) is a neurological disorder characterized primarily by action tremor. Balance impairments in ET patients were formerly considered to be uncommon and simply age-related. However quantitative assessment with posturography has revealed impairments in control of both static and dynamic balance.The aim of the present study is to assess postural stability with different posturographic techniques in ET patients.A prospective cross-sectional study conducted in two University Hospitals. Eleven patients diagnosed with essential tremor and twelve healthy controls were included. Balance assessment were performed with: sensory organization test (SOT) and limits of stability (LOS) of the computer dynamic posturography (CDP), results of free-field body sway analysis with mobile posturography (Vertiguard®), modified timed up and go test (TUG), Dizziness handicap inventory (DHI) and activities-specific balance confidence scale (ABC).Patients with ET showed poorer scores in the SOT than controls for composite balance and somatosensory input. They also performed worse in LOS tests and Vertiguard® device indicated a higher risk of falling. There were no differences in the modified TUG. The mean score of DHI was 15.64 and 85.16 for ABC.Posturography assessment (CDP and Vertiguard®) is more accurate in showing balance impairment in ET patients than clinical evaluation (modified TUG). Balance impairment involves deteriorated processing of somatosensory input which could be explained by cerebellar dysfunction. Balance deficits could be included into future diagnostic criteria.

This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.

Our previous study has shown that vestibular rehabilitation (VR) is an effective technique to reduce falls in elderly patients. It would be interesting to establish patients’ clinical characteristics in which vestibular rehabilitation is expected to be more effective. Evaluate factors that could modify rehabilitation outcomes in elderly patients with previous falls. Fifty-seven patients randomized to one of the intervention group (computerized dynamic posturography—CDP—training, optokinetic stimulus or exercise at home) and with previous falls were analyzed. Patients were assessed with objective outcome measures (sensorial organization test and limits of stability—LOS—of CDP, modified timed up and go test—TUG—and number of falls) and with subjective outcome measures (dizziness handicap inventory and Short falls efficacy scale-international—Short FES-I) during a 12-month follow-up period. In the logistic regression model, a worse score in the maximum excursion (MXM), and a shorter time in the TUG significantly associated with a reduction > 50% of falls. Also, association with a higher score in the Short FES-I was close to a statistical significance. There was no statistical significance association with other covariables. In patients with reduced limits of stability, VR seems to be more effective and they should be encouraged to perform it. But on the other hand, patients with longer time in the TUG show worse outcomes and may benefit more with gait training. VR in elderly people with previous falls is effective regardless of their age and gender.

Vestibular rehabilitation (VR), specifically, VR with dynamic computerized posturography (CDP) has proven to be useful to improve balance and reduce the risk of falling in old patients. Its major handicap is probably its cost, which has hindered its generalisation. One solution to reduce this cost is performing VR with mobile posturography systems, which allow assessment of stability at the center of body mass in daily-life conditions. Also, rehabilitation with vibrotactile neurofeedback training could be used in dynamic tasks. To assess whether two different protocols of vestibular rehabilitation (using CDP and the Vertiguard system) show significant differences in the improvement of balance among older persons with imbalance A clinical trial comparing VR with CDP exercises and VR with mobile posturography (Vertiguard) exercises, was designed. The participants were people over 65 years, with imbalance. The composite (average balance) in the sensory organization test (SOT) of the CDP was the main outcome measure; it was compared before and 3 weeks after VR, and between both intervention groups. 40 patients were included in the study (19 in the CDP-VR group and 21 in the Vertiguard-VR group). Average balance was significantly improved in both intervention groups (51% pre-VR vs 60% post-VR, p = 0.002, CDP-VR group; 49% pre-VR vs 57% post-VR, p = 0.008, Vertiguard-VR group); no significant differences in this improvement were found comparing both groups (p = 0.580). VR using mobile posturography is useful to improve stability in old people with instability, showing similar improvement rates to those of VR using CDP. NCT03034655 www.clinicaltrials.gov Registered on 25 January 2017.

Purpose Vestibular rehabilitation (VR) using posturography systems has proved useful in improving balance among elderly patients with postural instability. However, its high cost hinders its use. The objective of this study is to assess whether two different protocols of VR with posturography, one of them longer (ten sessions) and the other shorter (five sessions), show significant differences in the improvement of balance among old patients with instability. Patients and Methods This is a prospective, experimental, single-center (Department of Otorhinolaryngology of a tertiary referral hospital), randomized (into balanced patient blocks) study with two parallel arms, in 40 people over 65 years of age, with instability and at a high risk of falling. The percentage of the average balance (composite) in the sensory organization test (SOT) of the CDP (main outcome measure), other CDP scores, time and steps in the “timed up and go” test, scores of Dizziness Handicap Inventory (DHI), short Falls Efficacy Scale – International (short FES-I), and Vertiguard were compared before and 3 weeks after VR between both intervention groups. Results The two treatment groups (20 patients per group) were comparable in age, sex, and pre-VR balance evaluation. In both groups, we observed a significant improvement in global balance (composite) after VR (49±11.34 vs 57±13.48, p=0.007, in the group undergoing 10 sessions; 51±12.55 vs 60±12.99, p=0.002, 5 sessions). In both groups, we also observed improvements in other posturographic parameters (in the SOT and limits of stability) but not in the timed up and go scores or in the questionnaires. Comparison of the improvement level achieved in both groups revealed no significant differences between them. Conclusion The protocols of vestibular rehabilitation by posturography of 5 sessions in elderly patients with postural instability are as effective as those of 10 sessions for improving balance among elderly patients with postural instability. Trial Registration ClinicalTrials.gov identifier: NCT03034655. Registered on 25 January 2017.

Computerized posturography is the gold standard for balance assessment. Because of the great cost and dimensions of commercial equipments, low-cost and portable devices have been developed and validated, such as RombergLab, a software in open source term which works connected with a low-cost force platform. The objective of this study was to obtain normative posturography data using this software.A multicentric prospective and descriptive study, with 350 healthy participants, was designed. Static postural stability (measured using the modified clinical test of sensory interaction on balance) was evaluated using the software connected to the force platform. Using the confidence ellipse area (CEA) in each condition, global equilibrium score (GES) was calculated and adjusted for significant variable factors using cluster analysis.Mean (SD) GES was 0.72 (0.22). Age (p 0.01), height (p 0.01) and recruitment center (p 0.05) were found as influence factors for GES. Cluster analysis obtained 16 groups stratified by age and height. GES decreases with age and height (p 0.005). No significant interaction of age nor height was found with GES in these clusters (p 0.05). After correction for height and age, GES was no longer influenced by the recruitment center (p 0.05).With the introduction of the global equilibrium score values of the present study into the software, we consider RombergLab v1.3 a reference posturography tool for healthy individuals. Further studies are needed for validating it as a suitable instrumented test for screening between healthy and pathologic subjects and its reliability over time for the follow-up of patients.

Epidemiological studies have found a higher prevalence of allergic symptoms and positive prick tests in patients with Meniere's disease (MD); however the effect of allergenic extracts in MD has not been established. Thus, this study aims to determine the effect of Aspergillus and Penicillium stimulation in cytokine release and gene expression profile in MD. Patients with MD showed higher basal levels of IL-1 beta, IL-1RA, IL-6 and TNF-alpha when compared to healthy controls. We observed that IL-1 beta levels had a bimodal distribution suggesting two different subgroups of patients, with low and high basal levels of cytokines. Gene expression profile in peripheral blood mononuclear cells (PBMC) showed significant differences in patients with high and low basal levels of IL-1 beta. We found that both mold extracts triggered a significant release of TNF-alpha in MD patients, which were not found in controls. Moreover, after mold stimulation, MD patients showed a different gene expression profile in PBMC, according to the basal levels of IL-1 beta. The results indicate that a subset of MD patients have higher basal levels of proinflammatory cytokines and the exposure to Aspergillus and Penicillium extracts may trigger additional TNF-alpha release and contribute to exacerbate inflammation., This work was supported by Grants from Meniere's Society, UK and PI13/1242 Grant from ISCIII by FEDER Funds from the EU. Lidia Frejo was a PhD student oft he Biomedicine Program at the University of Granada. The authors would like to thank all patients and healthy controls participating in this study. We also would like to thank the Supercomputing and Bioinnovation Center (SCBI) from University of Malaga for the sharing of their resources (IPA (R)).

Although it is commonly recognized that dietary restrictions may improve the clinical course of Menière's disease, their effectiveness has not been definitely demonstrated. The aim of this study was to examine whether caffeine consumption could be involved in Menière's disease.Cross-sectional, observational, case-control study, comparing caffeine consumption (intake of coffee, tea, kola-type beverages, energy drinks, and chocolate-containing beverages or foods) between patients with Menière's disease (group A) and patients affected by vertigo with other origins (group B) and/or control subjects (group C).180 subjects (72 in group A, 72 in group B, and 36 in group C). Caffeine intake was categorized in four levels: very low (0-25 mg/day), low (26-100 mg/day), moderate (101-300 mg/day), and high (≥301 mg/day). Very low and low intake were considered light consumption, and moderate and high intake, heavy consumption.Mean daily caffeine intake was 175.8 mg. Menière's disease patients showed a daily caffeine intake (222 mg) greater than those not affected by this disease (145 mg). Excluding in group B migraine patients, differences in caffeine intake are significant among the three groups (P = 0.021). There were significantly more heavy-consumers in group A than in other two groups jointed (P = 0.024; OR = 1.301, IC95% (1.015;1.668)). In group A, the age at onset of symptoms in caffeine consumers (49.7 years) was lower than in non-consumers (55.9 years).It should be recommended to reduce caffeine intake in those population groups with higher risk of Menière's disease (e.g. subjects with family members suffering from this disease).

Balance becomes more precarious with age, and even without pathological disorders, the physiological decline in balance that occurs with age is a factor that also favors falls. So the aim of the present study is to assess the short-term effectiveness of three different methods of vestibular rehabilitation, compared to a control group, in improving balance in elderly patients with postural instability. 139 elderly patients with high risk of falls were included and randomized to one of the following study arms: computer dynamic posturography (CDP) training, optokinetic stimulus, exercises at home, or control group. Patients were assessed with objective and subjective outcome measures. The individuals that trained using CDP improved significantly more than the control group on the average balance score (p

Objective:To determine whether demographic characteristics or balance examination findings can predict the adherence of older people with instability to a vestibular rehabilitation programme.Methods:A prospective case–control study was conducted of 120 patients aged 65 years or more (mean age, 77.3 ± 6.33 years). Two groups were classified according to patients’ adherence with the follow-up post-rehabilitation protocol. Analysed variables included: age, sex, body mass index, Timed Up and Go test findings, computerised dynamic posturography, Dizziness Handicap Inventory scores and Short Falls Efficacy Scale – International questionnaire results, number of falls, and type of vestibular rehabilitation.Results:Two groups were established: adherents (99 individuals) and non-adherents (21 individuals). There were differences between the groups regarding: sex (female-to-male ratio of 4.8:1 in adherents and 1.63:1 in non-adherents), age (higher in non-adherents) and voluntary movement posturographic test results (non-adherents had poorer scores).Conclusion:The patients most likely to abandon a vestibular rehabilitation programme are very elderly males with low scores for centre of gravity balancing and limits of stability.

Classical posturography techniques have been recently enhanced by the use of different motion tracking devices, but for technical reasons they are not used to track directly the body spatial position of a subject. To describe and clinically evaluate a wireless inertial measurement unit-based mobile system to track body position changes. The developed system used a calculus transformation method using the acceleration data corrected by Kalman and Butterworth filters to output position data. A prospective non-randomized clinical study involving 15 healthy subjects was performed to evaluate the agreement between the confidence ellipse areas synchronously measured by the new developed system and a classical posturography system while performing a modified clinical test of sensory interaction in balance. The overall intra-class correlation index was 0.93 (CI 0.89, 0.96). Grouped by conditions, under conditions 1–4, Pearson’s correlation was 0.604, 0.78, 0.882, and 0.81, respectively. The developed wireless inertial measurement unit-based posturography system was valid for tracking the sway variances in normal subjects under habitual clinical testing conditions. Further studies are needed to validate this system on patients and also under other posture conditions.

This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.

Background Accidental falls, especially for the elderly, are a major health issue. Balance disorders are one of their main causes. Vestibular rehabilitation (VR) has proven to be useful in improving balance of elderly patients with instability. Its major handicap is probably its cost, which has prevented its generalisation. So, we have designed a clinical trial with posturographic VR, to assess the optimum number of sessions necessary for a substantial improvement and to compare computerised dynamic posturography (CDP) (visual feedback) and mobile posturography (vibrotactile feedback). Methods Design: randomized controlled trial. It is an experimental study, single-center, open, randomized (balanced blocks of patients) in four branches in parallel, in 220 elderly patients with high risk of falls; follow-up period: twelve months. Setting: Department of Otorhinolaryngology of a tertiary referral hospital. Participants: people over 65 years, fulfilling two or more of the following requirements: a) at least one fall in the last twelve months. b) take at least 16 s or require some support in perform the “timed up and go” test. c) a percentage of average balance in the sensory organization test (SOT) of the CDP 60%. Intervention: Four differents protocols of vestibular rehabilitation (randomization of the patients). Main outcome measure: The percentage of average balance in the SOT-CDP. Secondary measures: time and supports in the “timed up and go” test, scores of the CDP and Vertiguard, and rate of falls. Discussion Posturographic VR has been proven to be useful for improving balance and reducing the number of falls among the aged. However, its elevated cost has limited its use. It is possible to implement two strategies that improve the cost-benefit of posturography. The first involves optimising the number of rehabilitation sessions; the second is based on the use of cheaper posturography systems. Trial registration ClinicalTrials.gov identifier: NCT03034655. Registered on 25 January 2017.

Fear of falling (FOF) is a common problem among the elderly. The purpose of this study is to evaluate whether there is a correlation between FOF, estimated via the short FES-I test, and objective evaluation of balance in a group of elderly patients with age-related instability. The balance of 139 subjects of more than 65 years of age is evaluated by the timed up and go test and the computerised dynamic posturography (CDP). Different groups of elderly patients were established according to the number of falls in the previous 12 months, and the correlation with short FES-I test scores was evaluated. Based on the results, ROC curves were calculated. The short FES-I test presents a good capacity to distinguish between subjects with ≤ 3 falls/year and subjects with ≥ 4 falls/year (AUC 0.719, 95%CI 0.627-0.810). A test score of 14.5 is the best cut-off point (74% sensitivity, 51% specificity). Using this cut-off point, the study sample comprises two groups: subjects with test scores of 7-14 vs 15-28, with the first group obtaining best results with statistical significance (Student's t-test and the Mann-Whitney test) in most of the balance tests. The short FES-I is an excellent instrument that measures FOF in the elderly, and it is correlated with their number of falls both in real life and on the CDP. It is simple and fast, and so can be considered an extraordinary screening test relative to real risk of falls in the elderly.

Objectives: Dietary changes are useful in the management of Meniere’s disease; regarding alcohol, many clinicians recommend to avoid or reduce its consumption. However, there are no researches aime...

Our previous study had shown the effectiveness of vestibular rehabilitation (VR) in improving balance in elderly patients, assessed immediately afterwards. The main goal of the present study is to consider whether this improvement in balance assessment turns out in a reduction of the number of falls. 139 elderly patients with high risk of falls were included and randomized to one of the following study arms: computerized dynamic posturography (CDP) training, optokinetic stimulus, exercises at home or control group. Patients were assessed with objective outcome measures (sensorial organization test and limits of stability of CDP, number of falls and number of hospital admissions due to falls) and subjective outcome measures (dizziness handicap inventory and short falls efficacy scale-international) during a 12-month follow-up period. Average number of falls significantly declined from 10.96 (before VR) to 3.03 (12-month follow-up) in the intervention group (p

The aim of the study is to assess whether obesity affects balance in elderly patients with postural instability. It is a case–control study, with cases defined by BMI ≥30 kg/m2, and developed in a third level university hospital. We included 135 patients aged 65 years old or more who presented postural instability. Balance assessment was through the sensory organisation test (SOT), limits of stability (LOS) and rhythmic weight shift (RWS) of computerised dynamic posturography (CDP) and the modified timed up-and-go (TUG) test. The patients also completed the Dizziness Handicap Inventory and short Falls Efficacy Scale-International questionnaire. Patients with obesity took longer to perform the modified TUG and required more steps. Also these patients had poorer scores in the subjective tests. In the CDP there were no significant differences in the SOT nor the LOS, and only there was a statistical significant difference in the anterior-posterior directional control of the RWS. Obese patients have a higher risk of fallings compared to non-obese patients. In essence, our results indicate that obesity interferes in the balance of elderly patients with postural instability, putting them at a greater risk of fallings, performing worse dynamic tasks and feeling more disabled. Although continued education on training balance may be useful in older population, since the obese group shows more rate of fallers, rehabilitation programmes focus on dynamic tasks in these patients could be useful to reduce their fall risk and improve their quality of life.

To assess whether a subjective questionnaire that measures the disability caused by balance disorders in daily life activities is correlated to objective assessment of balance in elderly patients with age-related instability. We included 37 subjects aged 65 years or more who presented balance disorders induced solely by age. Balance assessment was through the sensory organisation test and limits of stability of computerised dynamic posturography, the SwayStar system and the modified timed up and go test. The patients also completed the dizziness handicap inventory (DHI) questionnaire. The SwayStar balance control index (BCI) was most significantly correlated to the DHI score and the score of its different scales. When we divided the patients into subgroups according to DHI score, we only found statistically significant differences in the BCI and number of falls. In our population of elderly patients with instability, there is practically no correlation between the DHI and the static balance assessment. However, there is greater correlation with the BCI, which could show that dynamic balance is perceived as more disabling for these patients. In this case, when designing a rehabilitation protocol we should focus more on dynamic activities such as gait.

Introduction Parkinson’ disease (PD) is one of the most prevalent neurodegenerative diseases, and more than half of patients with PD experience falls. Research for clinically useful risk factors predicting falls has yielded inconsistent findings so far. Hence the aim of the study is to validate two different posturography techniques and one modified-timed up and go test (TUG) in discriminating fallers and non-fallers among PD patients. Methods 32 patients diagnosed with idiopathic PD were assessed with: Dizziness handicap inventory, Activities-specific balance confidence scale, modified-TUG, sensorial organization test (SOT) and limits of stability (LOS) of computer dynamic posturography, results of free-field body sway analysis with Vertiguard device and number of falls. Results Fallers had longer time to perform modified-TUG and required more steps. On average, fallers performed SOT and LOS significantly worse and Vertiguard device indicated a higher risk of falling. Based on the area under the curve of receiver operating characteristics analyses, the overall accuracy of directional control of LOS and steps in modified-TUG are close to 0.9 (high accuracy). Also assessment with Vertiguard device is more efficient in identifying fallers than the parameters of SOT. Discussion Our results indicate that LOS, mobile posturography (Vertiguard), vestibular input of SOT and number of steps taken in modified-TUG are very useful to identify fallers in PD patients.

Objective: Mobility is crucial to maintain a sufficient quality of life. Posturography should be therefore focused on the investigation of daily-life activities (‘‘mobile posturography’’). Nowadays, postural control is often estimated by stance tasks on a force plate under different sensorimotor conditions. This technique applies an indirect approximation of the center of body mass and is not related to tasks required for mobility. An alternative approach would be the direct measurement of body sway during daily-life conditions close to the center of body mass. The present study was aimed at investigating normal age-dependent postural control strategies by analyzing the body sway of male and female subjects in daily-life tasks. Furthermore, the results were compared with data of age- and sex-matched vestibular disorders to determine the sensitivity of the ‘‘mobile posturography’’. Study Design: Prospective study. Patients: The patient group included 76 subjects, and the control group comprised a total of 246 healthy volunteers. Trunk sway measures were performed using the Vertiguard-D device. With the device fixed by a belt at the hip (center of body mass), the subjects had to undergo 14 daily-life tasks under different sensorimotor conditions. Ankle sway was determined during the sensory organization test (SOT) on the BalanceMaster force plate in all patients by estimating the center of body mass from center of pressure changes within the plantar area. Results: A nonlinear relationship between age and body sway was observed in majority of all the conditions. Furthermore, large sex-related differences in body sway were observed. The sensitivity of the mobile posturography was higher than determined during the SOT-force plate measurements or reported in literature before for state-of-the-art platform posturography. Conclusion: The present results indicate that the method introduced here can quantify postural deficits in a broad range and in an inhomogenous sample of patients. Key Words: Body swayV Mobile posturographyVSensitivity. Otol Neurotol 34:282Y291, 2013.

A prospective study of patients diagnosed with ‘single-canal' benign paroxysmal positional vertigo (BPPV) was performed. Demographic, etiological and prognostic differences between patients with posterior, horizontal and superior canal BPPV were studied. A total of 614 patients diagnosed in a period of 11 years and with a follow-up period of at least 1 year were included in the study. The posterior semicircular canal was affected in 543 casas (88.4%), the horizontal in 39 (6.4%) and the superior canal in 32 (5.2%). Final status at the end of the follow-up period was better in posterior canal BPPV (95% cure) than in horizontal or superior canal BPPV (87% cure in both cases). This may be explained by two facts: a poorer initial response to repositioning maneuvers in anterior canal BPPV than in BPPV involving the other two canals, and a poorer response to maneuvers in recurrences of horizontal canal BPPV.

Objective Impaired balance in patients with Parkinson's disease (PD) leads to loss of balance and frequent falls. Computerized dynamic posturography allows the assessment of stance tasks whereas mobile posturography analyzes the balance in free-field conditions, where falls among PD patients commonly occur (e.g. sitting down or standing up). The aim of the present study is to assess postural stability in PD patients with both techniques. Study design Prospective study. Setting University Hospitals, ambulatory care (outpatient clinic). Patients Thirty-three patients diagnosed with idiopathic PD. Intervention Balance assessment. Main outcome measures Dizziness handicap inventory (DHI), activities-specific balance confidence scale (ABC), composite score of sensory organization test (SOT), results of free-field body sway analysis (standard balance deficit test (SBDT)), or geriatric SBDT. Results PD patients showed a significantly higher sway in the roll direction in almost all of the SBDT conditions. Also, pathological sway compared with normative values was more prominent in complex tasks. There is a significant correlation between the different objective variables of the postural study (SOT and SBDT) and the ABC, but not with the DHI. Finally, the percentage of PD patients with a pathological score in SOT-composite score was 54.5% whereas in SBDT-composite score it was significantly higher (93.9%). Conclusion Mobile posturography is more accurate in depicting the reality of balance impairment in PD patients than platform posturography. Also, ABC relates better than DHI to the significant psychological consequences of balance impairments. An increased lateral trunk sway seems to be a key factor of postural instability in PD patients.

There was a difference in average score of the sensory organization test (SOT) of the case group (elderly instability) compared to the control group (healthy subjects). Cases had worse scores on the limits of stability (LOS) than controls, but were only able to confirm statistically significant differences in the movement velocity.To study the LOS of elderly patients with instability vs healthy subjects of the same age to try to explain the increased risk of falls in elderly patients with instability.Fifty individuals ≥65 years, 30 cases (at least one of the next inclusion criteria: ≥1 fall in the last 12 months,15 s or some support in the timed up and go test, composite68 in SOT, ≥1 fall during production of the SOT) compared to 20 controls. Postural study: SOT and LOS, Smart Equitest Neurocomt-Student test (p 0.05).Mean value of overall balance: patients with instability =56% vs controls =77.1% (p 0.001). Movement velocity: cases =2243°/s vs controls =2860°/s (p = 0.029). The reaction time (cases =1217 s vs controls =1.077 s), excursion (56.95% vs 59.35%) and directional control (56.95% vs 59.35%) differences were not statistically significant.

Objectives:To analyze the equilibriometric differences between 2 populations of elderly patients (young elderly and very elderly) with instability induced solely by age.Methods:Cross-sectional study, with 2 study groups classified according to patient age (cut-points in twenty-fifth and seventy-fifth percentiles of the age of the sample). Population: 64 patients aged 65 years or more. Two groups of 32 subjects were established: group A (people 65 years of age or older but less than 72.6, twenty-fifth percentile) and group B (patients 82.5 years, seventh-fifth percentile, or older). Main analyzed variables: timed up-and-go test, sensory organization test of the computerized dynamic posturography, Dizziness Handicap Inventory (DHI), and Short Falls Efficacy Scale-International (FES-I) questionnaires. Student’s t test or the Mann-Whitney test were used.Results:The older patients obtain poorer scores in the equilibriometric tests but not in all of them. In the sensory organization test, the older patients make poorer use of visual and vestibular information; they also require more time and steps for the timed up-and-go. With regards to the questionnaires, fear of falling is greater (higher Short FES-I scores) but not subjective perception of disability (DHI scores without differences).Conclusions:There is a need to establish aged subgroups of elderly patients with instability, adapting therapeutic strategies.

Although it is uncommon for benign paroxysmal positional vertigo (BPPV) to affect more than one canal simultaneously, it is not exceptional. We attempt to determine whether these patients present differences relative to “single-canal” cases. A prospective study was done in patients with BPPV, divided into three groups: single-canal BPPV, multi-canal BPPV in one ear and multi-canal BPPV in both ears. Diagnosis was by Dix and Hallpike, supine roll and cephalic hyperextension tests. Treatment was according to the affected canals, by Semont, Epley, Lempert and Yacovino manoeuvres. Aetiology, sex, age, response to treatment, recurrence and final status in each of the three groups was evaluated. Five hundred and eighty-three patients were diagnosed with BPPV: 537 single-canal (92 %) and 46 multi-canal (8 %); of the latter, 36 bilateral and 10 unilateral cases. Basic differences between groups were: greater percentage of idiopathic cases in single-canal (p < 0.0001, Chi-square), greater percentage of post-traumatic cases in bilateral multi-canals (p = 0.006, Chi-square) and prior history of BPPV was more common in unilateral multi-canal (p = 0.006, Chi-square). No differences between groups in response to treatment, recurrence and final status were detected. There are aetiological differences between patients with single-canal BPPV, unilateral multi-canal BPPV and bilateral multi-canal BPPV. Response to therapeutic manoeuvres, however, shows that over 90 % of the patients in all the groups are cured.

Resumen Introduccion La Comision de Otoneurologia de la SEORL-PCF publico en 2008 una clasificacion de los vertigos perifericos, basada en criterios clinicos. El objetivo de este estudio es validar esta clasificacion mediante el analisis de la concordancia diagnostica entre multiples evaluadores. Metodos Participaron 7 evaluadores con experiencia clinica en el diagnostico de afeccion vestibular, pertenecientes a 6 centros diferentes. Uno de ellos selecciono las historias clinicas de 50 pacientes consecutivos que consultaron por alteraciones del equilibrio (24 varones y 26 mujeres; edad media: 53,5 anos). Estas historias, suprimidos los datos que permitiesen identificar a los pacientes, el diagnostico establecido y el tratamiento pautado, fueron remitidas a los otros 6 investigadores. Cada uno de ellos establecio un diagnostico, intentando ajustarlo a los epigrafes de la clasificacion. Resultados De los 50 pacientes, existio una coincidencia sustancial en el diagnostico (4 o mas evaluadores alcanzaron el mismo) en 31 (26 con diagnostico positivo y 5 negativo: no podia ser incluido en ningun epigrafe). El indice kappa, que mide el nivel de concordancia entre tres o mas observadores, fue de 0,4198 (lo que indica un grado de acuerdo moderado). La unanimidad solo se alcanzo en 7 pacientes (4 VPPB, dos enfermedades de Meniere y un vertigo asociado a migrana). Conclusiones La actual clasificacion, con los criterios que incluye, solo permite etiquetar con un consenso aceptable al 62% de los pacientes. Se propone una modificacion de la clasificacion, incluyendo el epigrafe de VPPB probable, y revisando los de vertigo-migrana y vertigo asociado a migrana.

Resumen Introduccion El objetivo del presente estudio es conocer la prevalencia del vertigo posicional paroxistico benigno (VPPB) en los pacientes diagnosticados de hydrops endolinfatico (HE) y analizar ademas si la asociacion es un factor de mal pronostico para nuestros enfermos. Material y metodos Realizamos un estudio retrospectivo en nuestro Servicio de los pacientes diagnosticados de enfermedad de Meniere definitiva segun los criterios de la Academia Americana de Otorrinolaringologia y de VPPB por medio de las maniobras de provocacion. Resultados La prevalencia de VPPB en nuestros enfermos con HE es del 5,1%. El indice de curacion con las maniobras de recolocacion es del 90,9%; sin embargo, con la primera maniobra solo fue del 63,36%. Las recidivas se presentaron hasta en un 22,22%. Encontramos menor tasa de exitos con la primera maniobra en relacion con el resto de los enfermos con VPPB sin que padecieran HE. Esta diferencia fue estadisticamente significativa (p=0,042). Discusion No encontramos que en estos pacientes exista un menor indice de curacion con las maniobras de recolocacion ni una mayor tasa de recidivas. Sin embargo, nuestra primera maniobra del protocolo tiene un exito menor que en el resto de los enfermos.

In patients with Parkinson's disease (PD), balance impairment involves considerable morbi-mortality from the numerous falls that may result. In an earlier postural study, we detected that a deteriorated processing of vestibular input is implicated. The aim of the present study is to assess the effectiveness of vestibular rehabilitation in improving overall stability in patients with PD.Out of an initial group of 45 patients with PD, we chose those presenting a high risk of falls, based on their score on the timed up and go test (TUG). Rehabilitation was performed on 10 patients using computerised dynamic posturography (CDP). Improvement was assessed using the dizziness handicap inventory (DHI), the TUG and the CDP.We found statistically significant improvement in the sensorial organisation test (SOT) and the limits of stability and rhythmic weight shift tests measured by the CDP, the DHI and the TUG. These improvements continue to be statistically significant 1 year post-treatment.Vestibular rehabilitation in PD has shown to be effective in improving the activities of daily life, gait velocity and balance, as well as in reducing the risk of falls. Moreover, these benefits persist over time.

Introduction The aim of this study was to determine the prevalence of benign paroxysmal positional vertigo (BPPV) in patients diagnosed with endolymphatic hydrops (EH) and to analyze whether this association is a factor for poor prognosis in these patients. Material and methods A retrospective study was carried out at our department among the patients definitively diagnosed as having Meniere's disease according to the criteria of the American Academy of Otolaryngology and BPPV by the usual triggering manoeuvres. Results The prevalence of BPPV in our patients with EH was 5.1%. The rate of cure with the repositioning manoeuvres is 90.9%, however success with the first manoeuvre was only 63.36%. Recurrences occurred in up to 22.22%. We found a lower success rate with the first manoeuvre in relation to the rest of the patients with BPPV without EH. This difference is statistically significant ( P Discussion We did not find that these patients had a lower rate of cure with the repositioning manoeuvres or a higher rate of recurrence. But in our protocol the first manoeuvre had a lower success rate than in the rest of the patients.

OBJECTIVE: The aim of this study is to determine whether clinical and instrumental examination of balance can predict the risk of falls in elderly patients with instability. METHODS: Study design: It is a case control study, with cases defined by falls in the last year, developed in a third level university hospital. PATIENTS: Seventy patients aged 65 years or more who met at least one of the following inclusion criteria: (a) at least one fall in the last year; (b) spend more than 15s during the timed up and go test (TUG); (c) a score of less than 68% average balance in the sensory organisation test (SOT) of the computerised dynamic posturography (CDP); or (d) at least one fall in the CDP-SOT. Intervention: TUG test, CDP-SOT, CDP centre of gravity balancing (CG) and limits of stability (LOS), Dizziness Handicap Inventory (DHI) test and short FES-I test. Main outcome measures: Number of steps and time (TUG), average balance and use of sensorial information (CDP-SOT), speed and directional control (CDP-CG and LOS), DHI score and short FES-I score. RESULTS: Comparing subjects without falls (non-fallers) vs subjects with at least one fall (fallers) in the last year, fallers obtain worse scores than non-fallers in condition 2 (p=0.043) and use of somatosensory information (p=0.039). Comparing subjects with five falls or less (non-multiple-fallers) vs subjects with more than five falls (multiple-fallers), multiple-fallers obtain worse scores than non-multiple-fallers in overall balance (p=0.023), condition 6 (p=0.036), directional control (swaying (p=0.006) and LOS (p=0.023)) and short FES-I score (p=0.007). CONCLUSION: The three most useful parameters for identifying unstable elderly patients at particularly high risk of repeated falls are mean balance in the CDP SOT, directional control of CDP LOS and short FES-I score. Language: en

Resumen Las tecnicas endoscopicas nasales permiten el tratamiento de diversos procesos patologicos de la base del craneo, entre las cuales se incluyen las fistulas de liquido cefalorraquideo (LCR). Estos abordajes tienen una elevada tasa de exitos y reducen el tiempo quirurgico y la morbilidad. Sin embargo, cuando se localizan en la pared lateral del esfenoides la cirugia es mas compleja. En el caso presentado la fistula parece relacionarse con la persistencia del canal de Sternberg. Ademas como factores predisponentes asociados encontramos la extensa neumatizacion unilateral del seno asi como una hipertension intracraneal benigna. El cierre de la fistula se realizo endoscopicamente mediante un abordaje transetmoidal y transpterigoideo para una correcta visualizacion de la pared lateral del esfenoides. Tras 5 anos de seguimiento la paciente no ha vuelto a presentar mas episodios de rinolicuorrea.

Evaluate the effectiveness of vestibular rehabilitation (VR) to improve the balance in older people, assessed immediately afterwards. (a) To verify the maintenance of improvement of the balance achieved in the medium term (6–12 months). (b) To consider whether this improvement results in a reduction in the number of falls. (c) To compare among themselves the effectiveness of three different methods of VR in improving balance and to explore whether there are differences to achieve a reduction in the number of falls. Design: Experimental study, single-centre, open, randomised (balanced blocks of patients) in four branches in parallel, in 220 elderly patients (over 64 years) with high risk of falls and a follow-up period of 12 months. Setting: Department of Otolaryngology of the University Hospital of Santiago. Participants: People over 64 years, fulfilling one of the following requirements: (a) At least one fall in the last year. (b) Take at least 16 s or require some support in perform the test “timed up and go”. (c) A percentage of average balance in the sensory organisation test (SOT) in the dynamic posturography (CDP)

Vestibular rehabilitation is effective and safe in patients with instability. However, there is insufficient evidence for distinguishing between efficacies of different dosage of therapies. Therefore, the aim of the present study was to verify whether there were differences between two computerised dynamic posturography (CDP) therapies of different numbers of sessions, in order to establish the optimal strategy. We conducted a prospective, comparative study of two different dosage of CDP therapy (a 5-session group and another of 10-session group) in patients with instability due to chronic unilateral peripheral vestibular disorder. We used balanced block randomisation to include 13 patients in each group. Improvement was assessed using the Dizziness Handicap Inventory and the CDP with the sensorial organisation test (SOT) and limits of stability (LOS). We found a statistically significant improvement in both groups in composite score, visual and vestibular input (SOT); and in reaction time, distance and directional control (LOS). If we compare the groups regarding these improvements, we found that 10-session group showed a greater benefit in distance covered and directional control of LOS. Since significant improvement is obtained with only five sessions, we believe this to be the optimal number of treatment sessions for most patients with chronic unilateral peripheral vestibular disorder. Nevertheless, those patients with more reduced limits of stability, and consequently greater likelihood of falling as a result of their diminished base of support, are candidates for rehabilitation protocols with a greater number of sessions.

El adenocarcinoma de laringe es un tipo de tumor muy infrecuente, que supone solo un 0,35-0,5 % de las neoplasias laringeas malignas. Se caracteriza por su elevada agresividad y por su tendencia a producir metastasis en los ganglios linfaticos regionales y a distancia. Presentamos el caso de un varon de 64 anos de edad con un adenocarcinoma de laringe con metastasis ganglionares en el momento del diagnostico. Fue tratado con una combinacion de cirugia y radioterapia postoperatoria. Siete meses despues presento recidiva regional.

Laryngeal adenocarcinomas are extremely unusual (only 0.35 %-0.5 % of all laryngeal malignancies). It usually behaves as a highly malignant tumour, with tendency for local lymph node and distant organ metastases. We report a case of a 64-year-old man with an adenocarcinoma of the larynx with cervical lymph node involvement at the moment of the diagnosis. The patient was treated with surgery (total laryngectomy and cervical lymph node dissection) and post-operative radiotherapy. Seven months later, the patient had a local recurrence.

Objectives:To evaluate the efficacy of the Santiago treatment protocol for benign paroxysmal positional vertigo of the posterior semicircular canal, to analyse recurrence and to establish prognostic factors.Material and methods:Four hundred and twelve patients with unilateral benign paroxysmal positional vertigo of the posterior semicircular canal were treated with the Semont manoeuvre and, if symptoms did not resolve, successive application of three Epley manoeuvres plus Brandt–Daroff exercises.Results:Symptoms resolved in 404 patients (98.1 per cent); a single Semont manoeuvre was sufficient in 334 (81.2 per cent). Aetiology had no impact on resolution of symptoms or number of manoeuvres required. The estimated likelihood of recurrence was 14 per cent in the first year and 27 per cent after 10 years. The only factor indicating a worse prognosis was recurrence.Conclusion:In unilateral benign paroxysmal positional vertigo of the posterior semicircular canal, the above treatment protocol cured 98 per cent of patients. More than half of recurrences occurred in the first year. None of the analysed factors increased the likelihood of recurrence.

The aim of this study was to assess effectiveness of balance training with a vibrotactile neurofeedback system in improving overall stability in patients with Parkinson's disease (PD). Ten patients diagnosed with idiopathic PD were included. Individualization of the rehabilitation program started with a body sway analysis of stance and gait tasks (Standard Balance Deficit Test, SBDT) by using the diagnostic tool of the applied device (Vertiguard®-RT). Those tasks with the poorest outcome as related to age- and gender-related controls were included in the training program (not more than six tasks). Improvement of postural stability was assessed by performing SBDT, Sensory Organization Test (SOT) of Computerized Dynamic Posturography (CDP), Dizziness Handicap Inventory (DHI), activity-specific balance confidence scale and recording the number of falls over the past three months. Furthermore, scores of SOT and DHI of 10 PD patients previously trained in an earlier study (by using CDP) were compared with results of those in the present study. After neurofeedback training (NFT), there was a statistically significant improvement in body sway (calculated over all training tasks), number of falls, and scores of SOT, DHI and ABC. In comparison with CDP-training, a statistically significant higher increase of SOT score was observed for patients after NFT with the Vertiguard-RT device compared to CDP training. Our results showed that a free-field vibrotactile NFT with Vertiguard®-RT device can improve balance in PD patients in everyday life conditions very effectively, which might led in turn to a reduction of falls.

Introduction In 2008, the Otoneurology committee of the SEORL-PCF published a classification of peripheral vertigo, based on clinical criteria. The objective of this study was to validate this classification through analysing the diagnostic agreement among several medical assessors. Methods Seven medical assessors, all with clinical experience, from 6 different hospitals, participated in the study. One of them selected the clinical histories of 50 consecutive patients who had consulted as a result of balance disorders (24 men and 26 women) with an average age of 53.5 years. These clinical histories – without any information that would identify the patient, the diagnosis established and the treatment – were sent to another 6 assessors. Each of these investigators established their own diagnosis, trying to adjust it to the epigraphs of the classification. Results Of the 50 patients, there was substantial agreement in the diagnosis (4 or more evaluators indicated the same one) in 31 cases (26 with a positive diagnosis and 5 with a negative one, which could not be included in any epigraph). The kappa index, which measures the level of accordance between 2 or more assessors, was 0.4198 (moderate level of agreement). Unanimity was achieved in only 7 cases (4 BPPV, 2 Meniere's disease and 1 vertigo associated with migraine). Conclusions The current classification, with the included criteria it includes, allows labelling with an acceptable consensus to only 62% of the patients. Therefore, a modification in the classification is proposed in relation with the probable BPPV epigraph, as well as a revision of the entries for vertigo-migraine and vertigo associated with migraine.

To establish success- or failure-predicting factors in Semont maneuver in the treatment of benign paroxysmal positional vertigo.Prospective study.Referral center, institutional practice, ambulatory care (outpatient clinic).A consecutive sample of 135 patients diagnosed with unilateral benign paroxysmal positional vertigo of posterior semicircular canal for 3 years (September 2007 to August 2010).Semont maneuver.Duration of the latency period and nystagmus status with the Dix-Hallpike test. Presence or absence of orthotropic nystagmus in the second position of the Semont maneuver. Effectiveness of the Semont maneuver (cure versus no cure).The Semont maneuver is effective in 73% of the patients. Orthotropic nystagmus was present in 67% of the cases and absent in 33%; when we found orthotropic nystagmus, the maneuver was effective in 81% of the patients, but only in 57% if this nystagmus was not present (Fisher's exact test, p = 0.004; odds ratio, 3.308; 95% confidence interval, 1.492-7.334). The maneuver's efficacy and the presence of orthotropic nystagmus were not affected by the duration of nystagmus status in the Dix-Hallpike test. The duration of the latency period had no effect on the maneuver's efficacy, but it did affect the appearance of orthotropic nystagmus (Mann-Whitney test, p = 0.016).The presence of orthotropic nystagmus in the second position of the Semont maneuver indicates a good prognosis, but its absence does not necessarily mean that the maneuver will fail. Orthotropic nystagmus is more common in patients with shorter latency periods, suggesting that its appearance is related to cupulolithiasis mechanisms.

Vestibular rehabilitation has been found to be effective and safe in patients with instability. There is insufficient evidence, however, for distinguishing between the efficacies of different rehabilitation techniques. The objective of this study is to verify whether there are differences between two instrumental vestibular rehabilitation techniques, computerised dynamic posturography (CDP) and optokinetic stimulation (OKN), in order to establish the optimal strategy for each patient. We conducted a prospective, comparative study of the two techniques (CDP and OKN) in patients with instability due to chronic unilateral peripheral vestibular disorder. We randomly included 12 patients in each group, performing the evaluation with the Dizziness Handicap Inventory and the CDP with the sensorial organisation test (SOT), rhythmic weight shift and limits of stability (LOS). We found a statistically significant improvement in both groups in average balance score according to the SOT. In the OKN group, however, improvement was greater in visual preference. The CDP group showed greater benefits in the visual and vestibular input and LOS. Patients with poor vestibular and visual input or with reduced LOS will benefit more from an exercise protocol with CDP. Patients with poor visual preference, however, are ideal candidates for rehabilitation with OKN.

Endoscopic surgical techniques allow treating various pathological diseases of the cranial base, including cerebrospinal fluid leaks (CSF). These approaches have a high success rate and reduce surgical time and morbidity. However, when they are located in the lateral wall of the sphenoid, the surgery is more complex. In our case, the CSF appeared to be related with a Sternberg's canal. Predisposing factors were also associated with an extensive unilateral pneumatization of the sinus and benign intracranial hypertension. The closure of the leak was achieved using an endoscopic transethmoidal transpterygoid approach for proper exposition of the lateral wall of the sphenoid. After 5 years of monitoring, the patient has had no more episodes of rhinoliquorrhea.

Laryngeal adenocarcinomas are extremely unusual (only 0.35 %-0.5 % of all laryngeal malignancies). It usually behaves as a highly malignant tumour, with tendency for local lymph node and distant organ metastases. We report a case of a 64-year-old man with an adenocarcinoma of the larynx with cervical lymph node involvement at the moment of the diagnosis. The patient was treated with surgery (total laryngectomy and cervical lymph node dissection) and post-operative radiotherapy. Seven months later, the patient had a local recurrence.

The aim of this study was to determine the prevalence of benign paroxysmal positional vertigo (BPPV) in patients diagnosed with endolymphatic hydrops (EH) and to analyze whether this association is a factor for poor prognosis in these patients.A retrospective study was carried out in our department among the patients definitively diagnosed as having Ménière's disease according to the criteria of the American Academy of Otolaryngology and BPPV by the usual triggering manoeuvres.The prevalence of BPPV in our patients with EH was 5.1%. The rate of cure with the repositioning manoeuvres is 90.9%, however success with the first manoeuvre was only 63.36%. Recurrences occurred in up to 22.22%. We found a lower success rate with the first manoeuvre in relation to the rest of the patients with BPPV without EH. This difference is statistically significant (P=0.042).We did not find that these patients to have a lower rate of cure with the repositioning manoeuvres or a higher rate of recurrence. But in our protocol the first manoeuvre had a lower success rate than in the rest of the patients.