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Background Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness. Methods/design The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity. Discussion Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol. Trial registration www.clinicaltrials.gov, ID: NCT02655575 . Registered on 14 January 2016.

Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms. We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions. A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people. Australian New Zealand Clinical Trials Registry ACTRN12612000379819.

Introduction Residual dizziness (RD) is common in patients with benign paroxysmal positional vertigo (BPPV) after successful canalith repositioning procedures. This study aimed to investigate the therapeutic effects of vestibular rehabilitation (VR) on BPPV patients experiencing RD, and to explore the impact of VR on functional connectivity (FC), specifically focusing on the bilateral parietal operculum (OP) cortex. Methods Seventy patients with RD were randomly assigned to either a four-week VR group or a control group that received no treatment. Assessments included the dizziness Visual Analog Scale (VAS), Dizziness Handicap Inventory (DHI), Hamilton Anxiety/Depression Scale (HAMA/HAMD), and resting-state functional magnetic resonance imaging. Results The VR group exhibited a significant decline in scores on VAS, DHI, HAMA and HAMD following training (all p  < 0.05). Furthermore, the VR group demonstrated increased FC between the left OP and both the left precuneus and left middle frontal gyrus (MFG), and between the right OP and the right MFG (voxel-level p  < 0.001; cluster-level p  < 0.05, FDR corrected). Additionally, these changes in FC were found to correlate with clinical features, including scores on HAMA ( p  = 0.012, r =  − 0.513) and DHI ( p  = 0.022, r =  − 0.475) after the intervention. Conclusion This study demonstrated the therapeutic effects of VR in alleviating RD and emotional disorders, as well as in improving overall quality of life. Notably, these positive outcomes might be associated with increased FC between brain regions involved in mood regulation and vestibular processing. Our findings offer novel neuroimaging evidence that supports the hypothesis that VR facilitates dynamic vestibular compensation.

Background Functional dizziness is one of the most common causes of chronic dizziness. Associated psychiatric diseases such as depression and anxiety lead to significant impairment, possibly due to autonomic nervous system imbalance. We investigated whether heart rate variability (HRV) biofeedback can modulate autonomic function in patients with functional dizziness. Methods We performed a randomized controlled study in 24 patients diagnosed functional dizziness for the first time. Patients received six 20 min sessions of HRV biofeedback or no intervention. We assessed HRV (time and frequency domains), sympathetic vasomotor function, sympathetic skin response and psychometric assessments at baseline, immediately post-intervention (or control period) and another 3 and 6 weeks later. Results Patients in the HRV biofeedback group showed improved cardiac autonomic function with elevated HRV time-dependent parameters immediately post-intervention [Root Mean Square of Successive Differences (RMSSD): 71.2 ms ± 38 ms vs. 38.2 ms ± 18.5 ms, p = 0.014; Standard Deviation of all NN Intervals (SDNN): 78.3 ms ± 35.9 ms vs. 48.1 ms ± 20.5 ms, p  = 0.001], increased HRV frequency-dependent parameter [Low Frequency (LF): p  = 0.001], as well as reduced depressiveness (BDI-II: p  = 0.0236). None of these parameters were changed in control patients ( p  = ns). Dizziness-associated symptoms and sympathetic function of vasculature and sweat glands were unaltered in both study arms. Conclusion In a randomized controlled pilot study, HRV biofeedback led to improved autonomic cardiac function and alleviated symptoms of depression in patients with functional dizziness, most likely mediated by a predominantly parasympathetic effect.

To investigate the effectiveness in individuals with chronic whiplash-associated disorders (WADs) of neck-specific exercise (NSE) supervised by a physiotherapist twice a week for 12 weeks versus neck-specific exercise with internet support and four physiotherapy visits (NSEIT) regarding dizziness, unsteadiness and balance, and to investigate the differences between WAD grades. This is a secondary analysis of a prospective randomised multicentre study (RCT) with concealed allocation (ClinicalTrials.gov Protocol ID: NCT03022812). The outcomes were dizziness measured on the Dizziness Handicap Inventory (DHI); dizziness at rest and during activity and unsteadiness using visual analogue scales; and standing on one leg with eyes closed (SOLEC). Participants (n = 140) were randomised to NSE or NSEIT. Measurements were obtained at baseline, and at three- and 15-month follow-ups by assessor-blinded investigators. There were no significant differences between NSEIT and NSE in any of the outcomes (p>0.38). Both NSEIT and NSE improved over time (p<0.02; effect size (ES) = 0.74-1.01) in DHI score and dizziness during activity. There was a significant group-by-time interaction effect in dizziness (at rest: p = 0.035; ES: 0.66; and during activity: p = 0.016; ES: 1.24) between WAD grades. Individuals with WAD grade 3 had dizziness/unsteadiness to a greater extent and improved in all outcomes over time (p<0.04) compared to those with WAD grade 2, except for SOLEC. There were no significant group differences between NSEIT and NSE. Both groups decreased in terms of self-reported dizziness (DHI, dizziness during activity), with medium to large effect size. Those with WAD grade 3 have dizziness/unsteadiness to a greater extent than those with WAD grade 2. Despite improvements, many participants still reported dizziness at 15-month follow-up, and additional balance training and/or vestibular exercise may be investigated for potential additional effect.

Background The evaluation and management of acute vertigo presentations is challenging for both patients and physicians. Benign paroxysmal positional vertigo (BPPV), acute unilateral vestibulopathy (e.g., vestibular neuritis), and stroke are priority diagnostic considerations in this circumstance. Existing evidence can be used to guide the diagnosis and treatment, however high value care opportunities—such as the Dix-Hallpike test (DHT), canalith repositioning maneuver (CRM), and gaze stabilization exercises (GSE)—are often underused, while neuroimaging studies are often overused. Methods This trial contains a health system focused stepped wedge intervention and an embedded individually patient randomized clinical trial. The study will start with a 6-month pre-intervention period. This will be followed by staggered intervention at the engaged EDs in 11 waves and then an approximately 6-month post-intervention period. Concurrently, patients will be recruited before and after the physician level intervention is implemented at each ED. Enrolled participants will complete baseline survey and then be randomized individually, stratified by sex, age, and medical center, to the intervention or control arm patient materials using central computerized randomization. The intervention arm will be sent intervention materials and the control arm will be sent the hospital’s standard post-discharge materials. The primary outcome of the physician-based part of the trial is use of evidence-based care practices during the index ED visit. The primary outcome of the patient focused part of the trial is the dizziness handicap index over 4 weeks. Discussion The DIZZTINCT-2 trial addresses key areas of uncertainty in how to improve the care of emergency department patients with acute vertigo. In addition, follow up data on how much and how fast patients improved was needed. DIZZTINCT-2 will address these key knowledge gaps efficiently. Trial registration Clinicaltrials.gov NCT05634902. Registered on November 2022.

Purpose Propofol can be used alone or in combination with opioids during gastroscopy. This study aimed to assess the efficacy and safety of intravenous propofol and different doses of alfentanil in patients undergoing gastroscopy. Methods A total of 300 patients undergoing sedative gastroscopy were randomly divided into four groups, and 0.9% saline (group A), 2 μg/kg alfentanil (group B), 3 μg/kg alfentanil (group C) or 4 μg/kg alfentanil (group D) were injected intravenously 1 min before the intravenous injection of 1.5 mg/kg propofol. If body movement and coughing occurred during the procedure, 0.5 mg/kg propofol would be administered intravenously. The primary outcome (awakening time) and secondary outcomes were recorded and analyzed, including hemodynamic changes, the incidences of body movement, coughing, hypoxemia, hypotension, hypertension, bradycardia, tachycardia, nausea and vomiting, drowsiness and dizziness. Results Patients in group C (7.0 [5.0 to 8.0] min) and group D (6.0 [5.0 to 7.0] min) woke up significantly earlier than those in group A (8.0 [6.0 to 10.0] min) ( P  < 0.001). Patients in group A experienced more body movement ( P  = 0.001) and coughing ( P  < 0.001) than the other groups. With the increasing dose of alfentanil, the morbidity of hypotension and bradycardia increased significantly ( P  = 0.001), while the incidence of dizziness decreased significantly ( P  = 0.037). The incidences of hypoxemia, tachycardia, drowsiness, nausea and vomiting were similar among the four groups ( P  > 0.05). Conclusions Intravenous 1.5 mg/kg propofol combined with 3 μg/kg alfentanil is more suitable for patients undergoing gastroscopy, and the dose of alfentanil can be reduced according to the patient’s actual physical condition.

Background Orthostatic intolerance (OI) is a significant problem for those with chronic fatigue syndrome (CFS). We aimed to characterize orthostatic intolerance in CFS and to study the effects of exercise on OI. Methods CFS (n = 39) and control (n = 25) subjects had recumbent and standing symptoms assessed using the 20-point, anchored, ordinal Gracely Box Scale before and after submaximal exercise. The change in heart rate (ΔHR ≥ 30 bpm) identified Postural Orthostatic Tachycardia Syndrome (POTS) before and after exercise, and the transient, exercise-induced postural tachycardia Stress Test Activated Reversible Tachycardia (START) phenotype only after exercise. Results Dizziness and lightheadedness were found in 41% of recumbent CFS subjects and in 72% of standing CFS subjects. Orthostatic tachycardia did not account for OI symptoms in CFS. ROC analysis with a threshold ≥ 2/20 on the Gracely Box Scale stratified CFS subjects into three groups: No OI (symptoms < 2), Postural OI (only standing symptoms ≥ 2), and Persistent OI (recumbent and standing symptoms ≥ 2). Conclusions Dizziness and Lightheadedness symptoms while recumbent are an underreported finding in CFS and should be measured when doing a clinical evaluation to diagnose orthostatic intolerance. POTS was found in 6 and START was found in 10 CFS subjects. Persistent OI had symptoms while recumbent and standing, highest symptom severity, and lability in symptoms after exercise. Trial registration The trial was registered at the following: https://clinicaltrials.gov/ct2/show/NCT03567811

BackgroundThe literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed.MethodsWe systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsWe identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed.ConclusionsAfter acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.