10.14639/0392-100X-N2287
Objectives. This investigation aimed to propose a new rehabilitation technique that combines voice exercises and instrumental postural rehabilitation for patients with muscle tension dysphonia (MTD). Methods. We enrolled nine dysphonic patients (8 women and 1 man, aged 22‑55 years). Voice assessment included strobovideolaryngoscopy, Maximum Phonation Time (MPT), perceptual evaluation by GRBAS scale and patient’s self‑rating by Italian version of the Voice Handicap Index (VHI). Vestibular function was evaluated by the Bed Side Examination and Video Head Impulse test (VHIT). Postural control was evaluated by Dynamic Posturography (DP) using the Sensory Organization Test (SOT) and analysing the Equilibrium Score (ES) and balance subsystems (somatosensorial, visual, vestibular). Results. All cases underwent different types of voice exercises combined with balance training based on NeuroCom Balance Master Protocols, once a week for six 35‑minutes sessions. After therapy, an improvement in MPT, VHI, GRBAS scores and endoscopic laryngeal features was obtained. DP results at baseline were normal and after therapy we showed a slight improvement of ES (somatosensorial and visual components). Conclusions. A combined rehabilitation technique for MTD, by improving the attention to postural control, allows for significant improvement in vocal symptoms.
text/xml
1827-675X
2287
en
Lucia D'Alatri
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
postural control
Combined treatment of muscle tension dysphonia: voice therapy with instrumental postural rehabilitation
Text.Serial.Journal
https://www.actaitalica.it/
43
Laryngology
2023-05-23
2022-08-24
2023-07-25
2023-07-25
245-251
1
Lucia D'Alatri
2023/05/23
10.14639/0392-100X-N2287
245
Complex Unit of Otolaryngology, Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, “Agostino Gemeolaryngology, University Department Head-Neck and Selli” IRCCS, Rome, Italy; Section of Otorhinnse Organs, Catholic University of the Sacred Heart, Rome, Italy
1827-675X
postural control
en
251
Combined treatment of muscle tension dysphonia: voice therapy with instrumental postural rehabilitation
https://www.actaitalica.it/article/download/2287/1002
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:245-251; doi: 10.14639/0392-100X-N2287




Laryngology


Combined treatment of muscle tension dysphonia:
voice therapy with instrumental postural rehabilitation
Trattamento combinato della disfonia muscolo tensiva: terapia logopedica
e riabilitazione posturale strumentale

Pasqualina Maria Picciotti1,2, Maria Raffaella Marchese1, Ylenia Longobardi1, Giuseppe Oliveto 1, Lea Calò1,2,
Lucia D’Alatri1,2
1
 Complex Unit of Otolaryngology, Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, “Agostino Gemelli”
IRCCS, Rome, Italy; 2 Section of Otorhinolaryngology, University Department Head-Neck and Sense Organs, Catholic University of
the Sacred Heart, Rome, Italy


SUMMARY
Objectives. This investigation aimed to propose a new rehabilitation technique that com-
bines voice exercises and instrumental postural rehabilitation for patients with muscle ten-
sion dysphonia (MTD).
Methods. We enrolled nine dysphonic patients (8 women and 1 man, aged 22‑55 years).
Voice assessment included strobovideolaryngoscopy, Maximum Phonation Time (MPT),
perceptual evaluation by GRBAS scale and patient’s self‑rating by Italian version of the
Voice Handicap Index (VHI). Vestibular function was evaluated by the Bed Side Examina-
tion and Video Head Impulse test (VHIT). Postural control was evaluated by Dynamic Pos-
turography (DP) using the Sensory Organization Test (SOT) and analysing the Equilibrium
Score (ES) and balance subsystems (somatosensorial, visual, vestibular).
Results. All cases underwent different types of voice exercises combined with balance
training based on NeuroCom Balance Master Protocols, once a week for six 35‑minutes
sessions. After therapy, an improvement in MPT, VHI, GRBAS scores and endoscopic la-                 Received: September 20, 2022
ryngeal features was obtained. DP results at baseline were normal and after therapy we               Accepted: March 22, 2023
showed a slight improvement of ES (somatosensorial and visual components).
Conclusions. A combined rehabilitation technique for MTD, by improving the attention to              Correspondence
postural control, allows for significant improvement in vocal symptoms.                              Ylenia Longobardi
                                                                                                     Complex Unit of Otolaryngology, Department of
KEY WORDS: voice, muscle tension dysphonia, rehabilitation, postural control                         Aging, Neurological, Orthopedic and Head and
                                                                                                     Neck Sciences, “Agostino Gemelli” IRCCS, largo
                                                                                                     A. Gemelli 8, 00168 Rome, Italy
RIASSUNTO                                                                                            Tel. +39 06 30154439
Obiettivi. Scopo di questo lavoro era proporre una tecnica riabilitativa che combinasse              E-mail: ylenia.longobardi@policlinicogemelli.it
esercizi vocali e riabilitazione posturale strumentale per pazienti con disfonia muscolo
tensiva (MTD).
Metodi. Abbiamo arruolato nove pazienti disfonici (8F e 1M, età 22‑55 anni). La valuta-                How to cite this article: Picciotti PM, Marchese
                                                                                                       MR, Longobardi Y et al. Combined treatment
zione includeva: videostroboscopia, tempo massimo fonatorio (TMF), valutazione percet-                 of muscle tension dysphonia: voice therapy
tiva (GRBAS) e autovalutazione del paziente mediante Voice Handicap Index (VHI) per la                 with instrumental postural rehabilitation. Acta
voce; Bed Side Examination e Video Head Impulse Test (VHIT) per la funzione vestibolare;               Otorhinolaryngol Ital 2023;43:245-251. https://
Posturografia Dinamica (DP) con Test di Organizzazione Sensoriale (SOT), analizzando                   doi.org/10.14639/0392-100X-N2287
l’Equilibrium Score (ES) e i sottosistemi di equilibrio (Somatosensoriale, Visivo, Vestibo-
lare) per il controllo posturale. Tutti i casi sono stati sottoposti a esercizi vocali associati a   © Società Italiana di Otorinolaringoiatria
                                                                                                     e Chirurgia Cervico-Facciale
un training sull’equilibrio basato sui protocolli NeuroCom Balance Master, una volta alla
settimana per sei sedute da 35 minuti.
                                                                                                                    OPEN ACCESS
Risultati. Dopo la terapia è stato riscontrato un miglioramento nel TMF, nei punteggi al
VHI e alla GRBAS e nel quadro endoscopico laringeo. Dopo la terapia è stato riscontrato              This is an open access article distributed in accordance with
                                                                                                     the CC-BY-NC-ND (Creative Commons Attribution-Non-
un lieve miglioramento della componente ES, somatosensoriale e visiva.
                                                                                                     Commercial-NoDerivatives 4.0 International) license. The
Conclusioni. Un trattamento combinato per la MTD, migliorando l’attenzione sul control-              article can be used by giving appropriate credit and mentio-
lo posturale, permette di ottenere un miglioramento significativo dei sintomi vocali.                ning the license, but only for non-commercial purposes and
                                                                                                     only in the original version. For further information: https://
PAROLE CHIAVE: voce, disfonia muscolo tensiva, riabilitazione, controllo posturale                   creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                             245
P.M. Picciotti et al.




Introduction                                                      functional dysphonias in relation to posture after clinical
                                                                  assessment and recordings of posture obtained using a sta-
Muscle tension dysphonia (MTD) is one of the most com-
                                                                  bilometric platform. The rationale of this study is to com-
mon voice disorders. It occurs when the muscles around            bine vestibular postural rehabilitation techniques (Neuro-
the larynx (voice box) are so tense while speaking that the       Com Balance Master training protocols) to voice exercises,
voice box does not work efficiently. MTD is more prevalent        in an attempt to optimise the effectiveness of MTD through
among people in the 40 to 50 age group, particularly in           better posture control. The limits of other treatments are
women.                                                            related to the lack of attention to postural involvement. This
The “traditional” rehabilitation techniques include training      condition represents both the basis and the consequence of
in correct vocal hygiene, semi‑occluded vocal tract, fre-         voice alterations. We propose a new method, adding inno-
quency modulation and nasalisation, vocal function, pneu-         vative postural exercises to classic rehabilitation, in order
mo‑phono‑articulatory coordination exercises and larynge-         to improve both patient outcomes and compliance in an at-
al manipulation. All of these aim to promote improvement          tractive manner, overcoming the limits of other treatments.
in intraoral and subglottal pressure, positive alterations
in the glottal contact quotient, significant changes in the
measurements of the fundamental frequency, an increase            Materials and methods
in the Maximum Phonation Time (MPT) and reduction in              Subjects affected by MTD were enrolled in the study. The
the degree of voice roughness 1. In particular, phonation ex-     recruitment took place at the Phoniatric Unit of the Fon-
ercises in air tubes and in tubes immersed in water have          dazione Policlinico “A. Gemelli” IRCCS of Rome. Two
positive effects on subglottic, oral and transglottic pressure,   expert otolaryngologists of the same Unit, not involved
as well as on the vocal folds adduction quotient 2. Looking       in this study, provided a diagnosis of MTD. The inclusion
beyond traditional approaches, it is well known that there        criteria were: age within 18‑65 years, Italian mother lan-
is a correlation between the postural system and the phona-       guage, onset of dysphonia for at least 6 months, absence
tory system and this relationship may influence and regu-         of auditory and visual sensory deficits, negative history
late voice quality. Nevertheless, to date, the relationship       of smoking, BMI < 30 kg/m2, no previous voice therapy.
between voice and posture seems contradictory.                    Vocal fold benign lesions, audio‑vestibular diseases, ha-
In fact, on one hand, an anomaly in postural control can          bitual use of ototoxic drugs, cervical hernia, alcohol abuse,
lead to a dysfunction of the glottic signal, due to both struc-   chronic inflammatory diseases of upper aerodigestive tract,
tural damage of osteoarticular elements and to an increase        gastro‑oesophageal reflux, endocrinological and neurolog-
in perylaryngeal tension. On the other hand, it is also true      ic disorders, previous thyroid, spine or orthopaedic surgery
that a condition of dysphonia can modify postural reflexes        and accident‑related neck injuries were exclusion criteria.
and awareness, increasing muscle tension and moving the           Nine subjects (8 women and 1 man) aged between 22 and
head forward 3.                                                   55 years were enrolled. In all cases multidimensional voice
In a recent review, Cardoso et al. 3 confirmed that correct       assessment was performed before and 30 days after the end
posture is important for efficient voice production and that      of treatment.
multidisciplinary treatment can optimise the assessment           Strobovideolaryngoscopy was carried out using the DI-
and rehabilitation of functional dysphonia. The authors, in       VAS XION software and a flexible fibreoptic laryngoscope
fact, highlighted that correct postural control allows bet-       (model XionGmbh Video‑Nasopharyingoscope EV‑NE,
ter balancing of muscle tension with enhanced laryngeal           Germany). The presence of endoscopic features of MTD
movements and a benefit on voice production.                      were evaluated by two examiners using the Morrison‑Ram-
Several authors have investigated the relationship between        mage classification 10 (Tab. I).
voice characteristics and posture using a stabilometric plat-     MPT was obtained by asking the patient to sustain the vow-
form 4‑8. A significant correlation between postural anoma-       el /a/ as long as possible on a single breath. The longest of
lies and increased perylaryngeal tension as well as an im-        three attempts was calculated as the MPT.
provement in postural control of patients with MTD after          Blind auditory‑perceptual evaluation using the GRBAS
voice rehabilitation were demonstrated 4‑6.                       (Grade, Roughness, Breathiness, Asthenia, Strain) scale 11
Postural alterations and imbalances can be treated through        was performed on recorded voice samples by two speech
vestibular rehabilitation that allows functional recovery.        therapists who were not involved in the patients’ voice treat-
Starting from aforementioned notions and studies, we were         ment. Patients were asked to read aloud the first three sen-
inspired by an interesting paper by Lobryeau‑Desnus et al. 9      tences (53 words, 107 syllables) of the passage “Il deserto”
describing the improvement of rehabilitation strategies of        by Schindler 12. Acoustic signals were digitised at 20 kHz.



246
                                                     Combined treatment of muscle tension dysphonia: voice therapy with instrumental postural rehabilitation




Table I. Morrison‑Rammage classification of muscle tension dysphonia 10.        the objectives presented. Each patient was then asked to
 MTD                                                                            maintain or shift weight to ensure that the representation of
 Type 1       The laryngeal isometric   Isometric contraction of the larynx     their centre of gravity reached the targets visually presented
                                        associated with posterior adductor      on the monitor. The arrangement of the stimuli varied ac-
                                                       deficit
                                                                                cording to the exercises and the level of complexity of the
 Type 2        Lateral hyperadduction      Supra‑glottic contraction with
                 state: supra‑glottic        adduction in the midline
                                                                                training. Each exercise lasted from 60 to 120 seconds.
                                                                                The movement exercises provided by the training consisted
 Type 3              Supraglottic         Anteroposterior contraction at
                  antero‑posterior        supraglottic level with reduced       of “Pelvic Tilt” (forward and backward), “Lateral Slides”
                     contraction           space between epiglottis and         (left and right), “Weight Shifts” with trials to right, left,
                                                    arytenoids                  back and forth and finally “Circles” (Fig. 1). At the end of
 Type 4              Squeeze                 Extreme anteroposterior            each exercise, a percentage score, which depended on the
                                             contraction of the larynx
                                                                                accuracy of the task performed, was obtained.
                                                                                This experimental approach involved a body awareness
                                                                                path at the beginning of each session with exercises for
Each recorded speech sample was made anonymous and                              muscle relaxation and posture perception, followed by the
distributed to the raters in a random order. Finally, patient                   setting of correct diaphragmatic breathing, essential for a
self‑assessment was carried out using the Italian version of
                                                                                good pneumo‑phono‑articulatory coordination.
the Voice Handicap Index (VHI) 13.
                                                                                Voice exercises performed on the platform while trying to
Vestibular evaluation included Bed Side Examination 14
                                                                                hit the target marked on the monitor, included: emissions
(Romberg test, Fukuda test, assessment of spontaneous nys-
                                                                                of an occlusive alveolar consonant (/t) + the vibrating con-
tagmus, Head Shaking test, Head Impulse test, research of
                                                                                sonant /r/ isolated or associated with the vowel /a/ or the
position and positioning nystagmus) and Video Head Impulse
                                                                                vowel /a/ and the nasal consonant /m/; vocalisations with
test 15. Patients were also submitted to balance examinations
                                                                                single vowels, in pairs and in triplets; production of contin-
by dynamic posturography (DP) performed with Equitest,
                                                                                uous sound with fricatives (/f/, /s/, /∫/) + vowel; production
Neurocom International, Inc., Clackamas, Oregon, USA, us-
                                                                                of automatic series; reading of word lists with soft attack.
ing the Sensory Organization Test (SOT) 16. Parameters evalu-
ated were equilibrium score (ES), numerical index of the
                                                                                Statistical analysis
subject’s equilibrium, and sensory analysis (SA) in order to
                                                                                Statistical analysis was performed using commercially
evaluate functional integrity of the 3 balance subsystems (So-
matosensorial, Visual and Vestibular). In order to evaluate the                 available software (Excel; Microsoft Corp; Redmond,
presence of vestibular symptoms we used the Italian Dizzi-                      Washington). Continuously distributed outcomes were
ness Handicap Inventory (DHI), a questionnaire widely used                      summarised as the mean and categorical outcomes with
in clinical practice that can quantify dizziness‑related physical               frequencies and percentages. Quantitative data were com-
and emotional symptoms and restrictions in daily activities 17.                 pared using the Mann‑Whitney test. Wilcoxon test for ordi-
We also used the Conley Scale to assess the risk of falls 18.                   nal data was used to compare pre‑ and post‑treatment GR-
As for multidimensional voice assessment, vestibular func-                      BAS scores. The significance level was set at 0.05.
tion, postural control, DHI and Conley Scale were assessed
before and 30 days after therapy.
All patients underwent voice exercises combined with bal-
ance training (see below) once a week for a total of 6 ses-
sions of 35 minutes.
The equipment for combined therapy included the Neuro-
com Balance Master, a dual force plate system composed
of 4 load cells that detect pressure, connected to a computer
and monitor. The system provides a visual representation of
the gravity centre of the subject.
During vocal exercises, subjects were seated on wooden
supports and saw fixed or mobile targets on a monitor
placed at an adequate distance to have correct visual aim.
                                                                                Figure 1. (A) position of the patient during combined voice therapy; (B) rep‑
The platform allowed the displacement of the centre of grav-                    resentation of the patient and targets on the monitor (circles); (C) representa‑
ity necessary for patients to move and try to visually achieve                  tions of patients and targets on the monitor (lateral slides).



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P.M. Picciotti et al.




Table II. Altman’s (1999) levels of agreement and symbolic codes.                       Regarding the GRBAS scale, significant improvement of
 Cohen’s Kappa             Level of agreement             Symbol                        the following parameters was obtained: Grade (p = 0.01),
 <0                                    Absent                          x                Breathiness (p = 0.01), Asthenia (p = 0.02) and Strain
 0.00‑0.2                               Poor                           #                (p = 0.02). Table IV reports the number of patients with
 0.21‑0.4                             Sufficient                       *                a given score for each parameter in both the pre‑ and
 0.41‑0.6                             Moderate                         †                post‑treatment settings. For all parameters of the GRBAS
 0.61‑0.8                               Good                           ¥                scale, the degree of inter‑rater agreement in both the base-
 0.81‑1                               Very good                        §                line and post‑treatment assessments was greater than 0.61.
                                                                                        Vestibular clinical results showed a normal vestibular func-
                                                                                        tion in all patients before and after therapy for both bedside
Table III. Pre‑ and post‑treatment VHI mean scores with p-values.                       examination and VHIT.
 VHI                   Pre-treatment Post-treatment           P-values                  The postural control evaluated by DP was also normal: in
 Functional subscale        21.50 ± 9.38            9.66 ± 15.04            0.01        particular, for the Equilibrium Score before therapy the me-
 Emotional subscale         12.47 ± 7.14             8.32 ± 6.52           < 0.01       dian was 71 with a slight improvement after therapy (me-
 Physical subscale          24.33 ± 5.63            20.76 ± 8.57            0.02        dian 75). Sensory analysis showed: normal values of the
 Total score                58.3 ± 12.15           38.74 ± 20.13            0.03        somatosensory component (median 95) with an improve-
                                                                                        ment after treatment (median 98). The visual component
                                                                                        had a median of 76 before therapy and 83 after therapy,
For all subjective ratings (strobovideolaryngoscopy and                                 and the vestibular component was also normal with median
perceptual analysis) the inter‑rater reliability of each pa-                            values ranging from 65 before to 66 after therapy (Fig. 2).
rameter was calculated with the Cohen Kappa coefficient.                                Finally, DHI results demonstrated normal values of func-
For the interpretation of the strength of the agreement, the                            tional, emotional and physical scores before and after treat-
nomenclature of Altman 19 was used (Tab. II).                                           ment. Likewise, the Conley Scale did not demonstrate a
                                                                                        risk of falls for patients before or after therapy.
Results
Before treatment based on strobovideolaryngoscopy fea-                                  Discussion
tures, cases were distributed as follows: 7/9 (77.8%) MTD                               The aim of this study was to propose a new method of reha-
Type 2, 2/9 (22.2%) MTD Type 3. After treatment 8/9                                     bilitation for MTD that combines voice exercises with an in-
(88.9%) patients showed a physiologic adduction pattern,                                strumental technique for rehabilitation of balance and posture.
and 1/9 (11.1%) showed a persistent lateral supraglottic                                The results showed significant improvements in MPT, VHI
contraction (MTD Type 2). The degree of inter‑rater agree-                              scores and perceptual voice evaluation (GRBAS). These
ment at both baseline and post‑treatment assessments was                                results were associated with a physiologic laryngeal adduc-
greater than 0.61. The mean MPT improved significantly                                  tion pattern highlighted by strobovideolaryngoscopy in all
after therapy, increasing from 10.0 (± 3.07) seconds to 12.4                            cases except one.
(± 3.77) seconds (p < 0.05). The pre‑ and post‑treatment                                The rationale for the new type of treatment proposed is
VHI results are shown in Table III.                                                     based on literature data on postural changes after voice
A significant improvement was found between pre‑treat-                                  treatment in subjects with dysfunctional dysphonia 4‑6, and
ment and post‑treatment scores in each subscales and in the                             in particular on the positive effects that treatment for bal-
total score.                                                                            ance disorders has on voice quality 20.


Table IV. Number of patients with a given score for each parameter in the pre‑ and post‑treatment settings according to the GRBAS scale.
                             G                            R                          B                            A                         S
 Score                    Pre            Post             Pre              Post     Pre           Post      Pre          Post        Pre          Post
 0                         0               7               5                7       1              8         1            7           2            9
 1                         1               1               1                1       3              0         0            1           0            0
 2                         2               1               1                1       1              1         2            0           6            0
 3                         6               0               2                0       4              0         6            1           1            0
 P                               0.01                             > 0.05                   0.01                   0.02                     0.02
G: Grade; R: Roughness; B: Breathiness; A: Asthenia; S: Strain.




248
                                                    Combined treatment of muscle tension dysphonia: voice therapy with instrumental postural rehabilitation




                             Equilibrium score        Somatosensory          Visual component         Vestibular component
                                                      component




Figure 2. Results of dynamic posturography before and after combined rehabilitation.


Our results are in agreement with those of Bruno et al. 4                      musician‑singers singing with and without an instrument:
and Caçador et al. 6,20 who showed that posturographic val-                    they found that the body posture selected by the musician
ues in dysphonic patients at baseline were within normal                       while playing the instrument may affect expiration and
ranges. On the contrary, Nacci et al. 5 and Lobryeau‑Desnus                    phonation.
et al. 9 found postural alterations in baseline conditions with                An interesting correlation could be with laryngopharyn-
a significant improvement in the stabilometric parameters                      geal reflux (LR), which represents an important cause of
after speech rehabilitation. Postural control impairment at                    voice disorders. In our small series, none of the patients
the baseline could be due to the vocal effort to speak of                      referred LR and therefore no dietary recommendations
dysphonic patients, as reported by Giovanni and Grini 7,8.                     could be proposed as suggested by Lechien et al. 26, such
However, in another investigation, Nacci et al. 5 did not find                 as low fat, low‑quick‑release sugar, high‑protein, alkaline,
a pathological pattern at baseline stabilometry in dysphonic                   and plant‑based.
patients affected by polyps, cysts or Reinke’s oedema, but                     However, in our results we also found that somatosensory
only in patients with vocal cord nodules with a slight modi-                   and visual inputs improved slightly after therapy. Contrary
fication. Finally, after surgery, no important stabilometric                   to Caçador et al. 6, in our experience, the vestibular com-
changes were evident 21.                                                       ponent did not change because the therapy itself did not
Franco et al. in 2014 22 studied sagittal spine alignment be-                  improve a normal situation. The sitting position of the pa-
tween normal and dysphonic speakers, finding significant                       tients during the rehabilitation session justifies the greater
differences. They concluded that postural measurements                         improvement of visual inputs compared to the somatosen-
add important information to speech assessment protocols                       sory ones found in our sample. In relation to normal ves-
that is useful for treatment strategies.                                       tibular function, as shown in bedside evaluation and VHIT,
Other interesting reports regarded teachers who require                        we only tried to improve some postural aspects that could
the use of voice for long time, without breaks and in dif-                     potentially influence voice quality.
ficult conditions during their profession. Both Cardoso                        Our results after therapy with the vestibular instrumental
et al. 23 and Kooijman et al. 24 investigated the associations                 technique for rehabilitation are also in agreement with
between incorrect posture, excessive tension of the exter-                     Caçador et al. 20, who investigated the association between
nal muscles of the larynx, and voice handicap in teach-                        voice and balance disorders. The study analysed vocal dif-
ers. Two studies confirmed the importance of assessment                        ferences (clinical, video‑endostroboscopic, audio‑percep-
of muscular tension and body posture in the diagnosis of                       tual and acoustic vocal parameters) in patients with ves-
voice disorders. Longo et al. 25 recently evaluated the ef-                    tibular dysfunction treated with vestibular rehabilitation.
fect of body posture on voice parameter in professional                        The authors demonstrated that all patients had supraglottic



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P.M. Picciotti et al.




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Conflict of interest statement                                          ucatives des dysphonies dysfonctionnelles et capacités posturales
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Author contributions                                               13
                                                                        Schindler A, Ginocchio D, Atac M, et al. Reliability of the Italian IN-
PMP: study conception and design; YL, GO, LC: data col-                 FVo scale and correlations with objective measures and VHI scores.
lection; MRM, PMP, LDA: analysis and interpretation of                  Acta Otorhinolaryngol Ital 2013;33:121‑127.
results; PMP, YL, LDA: draft manuscript preparation.               14
                                                                        Straumann D. Bedside examination. Handb Clin Neurol 2016;137:91‑101.
                                                                        https://doi.org/10.1016/B978-0-444-63437-5.00007-8
PMP, MRM, YL, GO, LC, LDA: reviewed the results and                15
                                                                        MacDougall HG, Weber KP, McGarvie LA, et al. The video head im-
approved the final version of the manuscript.                           pulse test: diagnostic accuracy in peripheral vestibulopathy. Neurol-
                                                                        ogy 2009;73:1134‑1141.
Ethical consideration                                              16
                                                                        Hong SK, Park JH, Kwon SY, et al. Clinical efficacy of the Romberg
This study was approved by the Institution “Fondazione                  test using a foam pad to identify balance problems: a comparative
                                                                        study with the sensory organization test. Eur Arch Otorhinolaryngol
Policlinico Universitario A. Gemelli IRCCS ‑ Università                 2015;272:2741‑2747. https://doi.org/10.1007/s00405-014-3273-2
Cattolica del Sacro Cuore” (Prot. N. 0038806/21).                  17
                                                                        Nola G, Mostardini C, Salvi C, et al. Validity of Italian adaptation of
The research was conducted ethically, with all study pro-               the Dizziness Handicap Inventory (DHI) and evaluation of the qual-
cedures being performed in accordance with the require-                 ity of life in patients with acute dizziness. Acta Otorhinolaryngol Ital
ments of the World Medical Association’s Declaration of                 2010;30:190-197.
Helsinki.
                                                                   18
                                                                        Guzzo AS, Meggiolaro A, Mannocci A, et al. Conley Scale: assess-
                                                                        ment of a fall risk prevention tool in a General Hospital. J Prev Med
Written informed consent was obtained from each partici-                Hyg 2015;56:E77‑E87.
pant/patient for study participation and data publication.         19
                                                                        Altman DG. Practical statistics for medical research. New York:
                                                                        Chapman & Hall/CRC Press; 1999.
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