QUESTION: Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness presenting to specialist vestibular centres and accounts for approximately 20–30% of referrals to these clinics. In spite of the amount of clinical knowledge surrounding its diagnosis and management, the treatment of BPPV remains challenging for even the most experienced clinicians. This study outlines the incidence of BPPV in a specialised vestibular physiotherapy clinics and discusses the various nuances encountered during assessment and treatment of BPPV. DESIGN: Observational Study PARTICIPANTS: 314 patients with various forms of Benign Paroxysmal Positional Vertigo (BPPV) INTERVENTION: Canalith repositioning manoeuvres (CRP) for posterior canal (PC) or horizontal canal (HC) BPPV depending on the canal and variant of BPPV. OUTCOME MEASURES: Negative Dix-Hallpike (DHP) or Supine roll test (SRT) examination. RESULTS: In 91% of cases, PC BPPV was effectively treated in 2 manoeuvres or less. Similarly, 88% of HC BPPV presentations were effectively managed with 2 treatments. Bilateral PC, multiple canal or canal conversions required a greater number of treatments. There was no noticeable difference in treatment outcomes for patients who had nystagmus and symptoms during the Epley manoeuvre (EM) versus those who did not have nystagmus and symptoms throughout the EM. Nineteen percent of patients experienced post treatment down-beating nystagmus (DBN) and vertigo or “otolithic crisis” after the first or even the second consecutive EM. CONCLUSION: Based on the data collected, we make several clinical recommendations for assessment and treatment of BPPV. Firstly, repeated testing and treatment of BPPV within the same session is promoted as a safe and effective approach to the management of BPPV with a low risk of canal conversion. Secondly, vertigo and nystagmus throughout the EM is not indicative of treatment success. Thirdly, clinicians must remain vigilant and mindful of the possibility of post treatment otolithic crisis following the treatment of BPPV. This is to ensure patient safety and to prevent possible injurious falls. Our results challenge several clinical assumptions about the assessment and treatment of BPPV including the utility of certain markers of treatment success; hence influencing the current clinical guidelines and clinical practice and paving the way for future studies of the assessment and management of patients with BPPV.

Cerebellar damage can often result in disabilities affecting the peripheral regions of the body. These include poor and inaccurate coordination, tremors and irregular movements that often manifest as disorders associated with balance, gait and speech. The severity assessment of Cerebellar ataxia (CA) is determined by expert opinion and is likely to be subjective in nature. This paper investigates automated versions of three commonly used tests: Finger to Nose test (FNT), test for upper limb Dysdiadochokinesia Test (DDK) and Heel to Shin Test (HST), in evaluating disability due to CA. Limb movements associated with these tests are measured using Inertial Measurement Units (IMU) to capture the disability. Kinematic parameters such as acceleration, velocity and angle are considered in both time and frequency domain in three orthogonal axes to obtain relevant disability related information. The collective dominance in the data distributions of the underlying features were observed though the Principal Component Analysis (PCA). The dominant features were combined to substantiate the correlation with the expert clinical assessments through Linear Discriminant Analysis. Here, the Pearson correlation is used to examine the relationship between the objective assessments and the expert clinical scores while the performance was also verified by means of cross validation. The experimental results show that acceleration is a major feature in DDK and HST, whereas rotation is the main feature responsible for classification in FNT. Combining the features enhanced the correlations in each domain. The subject data was classified based on the severity information based on expert clinical scores. For the predominantly translational movement in the upper limb FNT, the rotation captures disability and for the DDK test with predominantly rotational movements, the linear acceleration captures the disability but cannot be extended to the lower limb HST. The orthogonal direction manifestation of ataxia attributed to sensory measurements was determined for each test. Human Research and Ethics Committee, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia (HREC Reference Number: 11/994H/16).

Cerebellar Ataxia (CA) leads to deficiencies in muscle movement and lack of coordination that is often manifested as gait and balance disabilities. Conventional CA clinical assessments are subjective, cumbersome and provide less insight into the functional capabilities of patients. This cross-sectional study investigates the use of wearable inertial sensors strategically positioned on the front-chest and upper-back locations during the Romberg and Trunk tests for objective assessment of human postural balance due to CA. The primary aim of this paper is to quantify the performance of postural stability of 34 patients diagnosed with CA and 22 healthy subjects as controls. Several forms of entropy descriptions were considered to uncover characteristics of movements intrinsic to CA. Indeed, correlation with clinical observation is vital in ascertaining the validity of the inertial measurements in addition to capturing unique features of movements not typically observed by the practicing clinician. Both of these aspects form an integral part of the underlying objective assessment scheme. Uncertainty in the velocity contained a significant level of information with respect to truncal instability and, based on an extensive clustering and discrimination analysis, fuzzy entropy was identified as an effective measure in characterising the underlying disability. Front-chest measurements demonstrated a strong correlation with clinical assessments while the upper-back measurements performed better in classifying the two cohorts, inferring that the standard clinical assessments are relatively influenced by the frontal observations. The Romberg test was confirmed to be an effective test of neurological diagnosis as well as a potential candidate for objective assessment resulting in a significant correlation with the clinical assessments. In contrast, the Trunk test is observed to be relatively less informative.

Cerebellar damage can result in peripheral dysfunction manifesting as poor and inaccurate coordination, irregular movements and tremors. Conventionally, the severity assessment of Cerebellar ataxia (CA) is primarily based on expert clinical opinion and hence likely to be subjective. In order to establish inter rater concordance with enhanced reliability and effectiveness in the assessment of upper limb function, a novel automated system employing Microsoft Kinect is considered to capture the motion of the patient’s finger for objective assessment. This essentially mimics the commonly used finger tracking task clinically assessed through subjective observation. A clinical trial was conducted involving 42 CA patients and 18 age matched healthy subjects. The relevant kinematically diagnostic features of CA patients allowed a classification accuracy of 97% using the Bayesian Quadratic Discriminant Analysis (QDA). The correlation (severity) between the extracted features and the independent severity scores from expert clinicians were collated to achieve a high correlation (r=0.86,p<0.001) with the Scale for the Assessment and Rating of Ataxia (SARA). The proposed system can efficiently generate objective information of severity as a result of features that are not necessarily observable during standard bedside clinical testing. Furthermore, the superior performance of the Ballistic (finger chase) test indeed supports the credence of the Ramp test redundancy that exist among the wider clinical community.

Cerebellar ataxia (CA) refers to the disordered movement that occurs when the cerebellum is injured or affected by disease. It manifests as uncoordinated movement of the limbs, speech, and balance. This study is aimed at the formation of a simple, objective framework for the quantitative assessment of CA based on motion data. We adopted the Recurrence Quantification Analysis concept in identifying features of significance for the diagnosis. Eighty-six subjects were observed undertaking three standard neurological tests (Romberg's, Heel-shin and Truncal ataxia) to capture 213 time series inertial measurements each. The feature selection was based on engaging six different common techniques to distinguish feature subset for diagnosis and severity assessment separately. The Gaussian Naive Bayes classifier performed best in diagnosing CA with an average double cross-validation accuracy, sensitivity, and specificity of 88.24%, 85.89, and 92.31%, respectively. Regarding severity assessment, the voting regression model exhibited a significant correlation (0.72 Pearson) with the clinical scores in the case of the Romberg's test. The Heel-shin and Truncal tests were considered for diagnosis and assessment of severity concerning subjects who were unable to stand. The underlying approach proposes a reliable, comprehensive framework for the assessment of postural stability due to cerebellar dysfunction using a single inertial measurement unit.