Vestibular Autorotation Test (VAT)
Number: 0467
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses vestibular autorotation test (VAT).
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Experimental and Investigational
Aetna considers vestibular autorotation test (VAT) experimental and investigational for the diagnosis of individuals with vestibular disorders, vestibular migraine, or any other indications because its sensitivity, specificity, reproducibility, and clinical utility have not been demonstrated.
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Related Policies
Background
Impairment of the vestibular-ocular reflex (VOR) may result in chronic dizziness and imbalance. The vestibular autorotation test (VAT) is a high-frequency, active head rotation (AHR) test to subjectively evaluate the VOR and its function. Patients wear a light-weight head-strap with a velocity sensor on the back. Conventional electro-olfactogram electrodes placed around the eyes measure patients' eye movements, and other electrodes monitor head movements. While following a moving target with the eyes, the individual moves the head back and forth or up and down in time with gradually accelerating computer generated tones.
Although some published studies have suggested that the VAT may be useful in evaluating patients with vestibular disorders/diseases, there are few studies that examined the sensitivity and specificity of the VAT in evaluating patients with suspected vestibular abnormalities. Furthermore, there is a lack of data supporting the value of the VAT in the management of patients with vestibular disorders/diseases.
- slippage of the head velocity sensor at high frequencies and accelerations during testing,
- contribution of the cervico-ocular reflex to the compensatory eye movement response, and this contribution may be increased significantly in the presence of bilateral, peripheral vestibular pathology,
- results of different head autorotation tests may not be directly comparable, and
- poor test-retest reliability.
In an assessment on vestibular testing techniques in adults and children, the American Academy of Neurology (Fife et al, 2000) stated that AHR testing is not an established technique. This type of testing does not appear useful in detecting unilateral vestibular loss (e.g., as a consequence of unilateral acoustic neuroma, Meniere's disease or vestibular neuritis). Furthermore, a recent study (Tirelli et al, 2004) reported that the test-retest of the Vorteq system, a head-autorotation test is not sufficiently reliable and hence can not be used in clinical practice.
Ozgirgin and Tarhan (2008) noted that the head autorotation tests can be affected with the dynamic changes within the semicircular canals caused by benign paroxysmal positional vertigo (BPPV). The VAT is a method of examining the VOR (especially the VOR that develops at higher frequencies like those that occur in the everyday environment). In this study, 20 patients who had been diagnosed as having posterior semicircular canal BPPV were evaluated with head autorotation tests before and after Epley maneuver. The head autorotation tests were performed just before the use of the Epley maneuver and after the resolution of symptoms and the typical nystagmus pattern. The mean gain values for horizontal rotation tests during the pre-treatment period were 0.823, 0.844, and 0.840 for the frequencies 1, 2, and 3 Hz, respectively. The mean gain values increased by 0.095 (95 % confidence interval) with Epley maneuver. But this difference between the pre-treatment and post-treatment values was not statistically significant. All patients were also evaluated with vertical active tests. The differences between the pre-treatment and post-treatment values were not statistically significant in the vertical autorotation group. The phase values were within normal range in the horizontal and vertical rotation tests and remained so after the Epley maneuver. The stimulation of the VOR caused by BPPV did not affect gain and phase values to a statistically significant degree, and the values noted after the resolution of the patient's symptoms improved slightly but without statistical significance.
Blatt and colleagues (2008) established intra-rater and inter-rater reliability of the VAT in a clinical sample of individuals reporting dizziness. A total of 98 patients with reports of dizziness referred for vestibular function testing performed repeated trials of horizontal VAT. A sub-sample of 49 individuals repeated the test for a second rater. About 66 % of subjects were unable to meet the performance criterion of 6 consecutive trials where data was displayed at frequencies greater than or equal to 3.9 Hz with coherence values held constant trial to trial. There was a good level of intra-rater reliability for gain independent of the effects of practice (intraclass correlation coefficient [ICC] = 0.78 [95 % confidence interval [CI]: 0.69 to 0.87] to 0.95 [(95 % CI: 0.93 to 0.97]). A significant difference in intra-rater reliability was found when the first 3 trials were compared to the last 3 trials for phase (ICC ranged from 0.04 [95 % CI: 0.00 to 0.31] to 0.96 [95 % CI: 0.93 to 0.97]) and asymmetry (ICC ranged from 0.39 [95 % CI: 0.17 to 0.56] to 0.73 [95 % CI: 0.32 to 0.81]) particularly at frequencies greater than or equal to 4.3 Hz. Inter-rater reliability was good to excellent across all variables at frequencies less than or equal to 3.9 Hz. The authors concluded that many patients had difficulty performing the VAT. The reliability estimates for phase and asymmetry, but not gain, were significantly affected by practice. They stated that careful attention to patient preparation, instruction, and test monitoring including sufficient patient practice before data collection are likely to be critical factors to ensure quality data.
Gao et al (2010) evaluated the utility of VAT in the diagnosis of BPPV. Caloric test and VAT were performed on 41 patients with BPPV; VAT results were analyzed according to the affected semicircular canal. Results of VAT were abnormal in 34 (82.93%) patients with BPPV. Fourteen cases were found with abnormal vertical phase, 1 case with abnormal vertical gain in a total of 21 vertical semicircular canal BPPV patients. Six cases with abnormal horizontal phase lead, 5 cases with abnormal horizontal gain, 2 cases with asymmetry were found in 12 patients with horizontal semicircular canal BPPV. Phase lead was abnormal in all frequencies in 4 patients, and in 2 to 3 Hz in 21 patients; 24 (58.5 %) patients showed abnormal canal paresis and direction preference in caloric test. The authors concluded that VAT can indicate information of vestibular function in both vertical as well as horizontal semicircular canal; and phase of VAT is constantly enhanced in BPPV, especially in 2 to 3 Hz. They noted that as the supplement of caloric test, VAT may prove helpful in the assessment of semicircular canal function.
In a retrospective study, Liu and colleagues (2022) examined the dynamic changes of VAT before and after vestibular rehabilitation treatment in patients with unilateral vestibular hypofunction (UVH). This trial enrolled 48 patients who were diagnosed with UVH and underwent vestibular rehabilitation from January 2019 to January 2021. Among them, there were 21 men and 27 women, with an average age of 46.9 years, including 25 cases of Meniere's disease (MD), 13 cases of sudden deafness with vertigo and 10 cases of vestibular neuritis. The course of disease ranged from 5 days to 10 years. Demographic characteristics, detailed case data and routine examination were collected for the patients. The horizontal gain/phase, vertical gain/phase, and asymmetry of VAT at different frequencies before and after vestibular rehabilitation were collected. The absolute value of the difference between the measured value of 2.0 to 5.9 Hz before and after rehabilitation and the standard value were statistically analyzed. Before vestibular rehabilitation, the incidence of abnormal gain was 62.5 % (30/48), the incidence of abnormal phase was 56.3 % (27/48), and the incidence of asymmetry was 16.7 % (8/48). After 4 to 6 weeks of vestibular rehabilitation, the incidence of gain abnormality was 22.9 % (11/48), the incidence of phase abnormality was 31.3 % (15/48), and the incidence of asymmetry was 12.5 % (6/48). The horizontal gain at frequency of 2.0 to 3.9 Hz showed statistically significant difference compared with before vestibular rehabilitation (p < 0.05), and the horizontal gain at frequency of 4.3 to 5.9 Hz showed that there was no significant difference (p > 0.05); the horizontal phase at 5.9-Hz showed that the difference was statistically significant (p = 0.043), and there was no significant difference before and after rehabilitation treatment at 2.0 to 5.5 Hz (p > 0.05); the vertical gain at 4.3-Hz showed the difference was statistically significant (p = 0.020), and the remaining frequency showed no significant difference (p > 0.05). No frequency of asymmetry and vertical phase showed the difference before and after rehabilitation was statistically significant (p > 0.05). The authors concluded that VAT can be used to monitor the change trend of multiple frequency bands before and after vestibular rehabilitation in UVH, in order to provide reference for the formulation of personalized rehabilitation strategies. This was a retrospective study with a relatively small sample size (n = 48) with heterogeneous etiologies; its findings need to be validated by well-designed studies.
Correlational Vestibular Autorotation Test
Hsieh et al (2014) stated that imbalance from degeneration of vestibular end organs is a common problem in the elderly. However, the decline of vestibular function with aging was revealed in few vestibular function tests such as VAT. In the current VAT, there are drawbacks of poor test-retest reliability, slippage of the sensor at high-speed rotations, and limited data about the effect of aging. These researchers developed a correlational-VAT (cVAT) system that included a small, light sensor (less than 20 g) with wireless data transmission technique to evaluate the aging of vestibular function. They enrolled 53 healthy participants aged between 25 and 75 years and divided them into 5 age groups. The test conditions were vertical and horizontal head auto-rotations of frequencies from 0 to 3 Hz with closed eyes or open eyes. The cross-correlation coefficient (CCC) between eye velocity and head velocity was obtained for the head auto-rotations between 1 Hz and 3 Hz. The mean of the CCCs was used to represent the vestibular function. Age was significantly and negatively correlated with the mean CCC for all test conditions, including horizontal or vertical auto-rotations with open eyes or closed eyes (p < 0.05). The mean CCC with open eyes declined significantly at 55 to 65 years old and the mean CCC with closed eyes declined significantly at 65 to 75 years old. The authors concluded that vestibular function evaluated using mean CCC revealed a decline with age, and the function of visual-VOR declined 10 years earlier than the function of VOR. The clinical value of cVAT needs to be ascertained by well-designed studies.
Hsieh et al (2015) developed a cVAT system and evaluated the reliability and applicability of this system. A total of 20 healthy participants and 10 vertiginous patients were enrolled in this study. Vertical and horizontal auto-rotations from 0 to 3 Hz with either closed or open eyes were performed. A small sensor and a wireless transmission technique were used to acquire the electro-ocular graph and head velocity signals. The 2 signals were analyzed using CCCs to assess the functioning of the VOR. The results showed a significantly greater CCC for open-eye versus closed-eye of head auto-rotations. The CCCs also increased significantly with head rotational frequencies. Moreover, the CCCs significantly correlated with the VOR gains at autorotation frequencies greater than or equal to 1.0 Hz. The test-retest reliability was good (intra-class correlation coefficients greater than or equal to 0.85). The vertiginous participants had significantly lower individual CCCs and overall average CCC than age- and-gender matched controls. These preliminary findings need to be validated in well-designed studies.
Vestibular Migraine
Barbosa and Villa (2016) noted that approximately 1 % of the general population suffers from vestibular migraine (VM). Despite the recently published diagnostic criteria, it is still under-diagnosed condition. The exact neural mechanisms of VM are still unclear, but the variability of symptoms and clinical findings both during and between attacks suggested an important interaction between trigeminal and vestibular systems. Vestibular migraine often begins several years after typical migraine and has a variable clinical presentation. In patients with VM, the neurological and neurotological examination is mostly normal and the diagnosis will be based in the patient clinical history. Treatment trials that specialize on VM are scarce and therapeutic recommendations are based on migraine guidelines. The authors concluded that controlled studies on the efficacy of pharmacologic interventions in the treatment of VM should be performed.
Thungavelu and colleagues (2017) examined the characteristics and clinical utility of VAT in patients with VM. This study included 2 groups, an experimental group (441 patients) and a control group (65 healthy subjects). Both groups undertook VAT; the parameters evaluated were horizontal gain/phase, vertical gain/phase and asymmetry. The differences in VAT results between the 2 groups were investigated. There were no statistical differences between the VAT data of the control group when compared to the reference value from the manufacturer (p > 0.05). There were statistically significant differences in VAT results between the experimental and control group, namely elevated horizontal gain at frequency 2-, 3-, 4- and 5-Hz, horizontal phase delay at frequency 2-, 4-, 5- and 6-Hz, elevated vertical gain at frequency 2 6-Hz and vertical phase delay at frequency 4 6-Hz. The authors concluded that the findings of this study using VAT in VM patients demonstrated elevated horizontal gain, vertical gain and delay in horizontal phase, vertical phase. They suggested the application of VAT as a diagnostic tool that may provide objective evidence that can contribute to the diagnosis of VM and also in differential diagnosis.
Wang and colleagues (2018) examined the characteristics and clinical utility of VAT in patients with VM. This study included 2 groups, a VM group (441 patients from Tianjin First Center Hospital between January 2015 and May 2016) and a control group (65 healthy subjects). Both groups undertook VAT; the parameters evaluated were horizontal gain/phase, vertical gain/phase and asymmetry. The differences in VAT results between the 2 groups were examined. There were statistically significant differences in VAT results between the VM and the control group, namely elevated horizontal gain at frequency 2, 3, 4 and 5 Hz, delay horizontal phase at frequency 2, 4, 5 and 6 Hz, elevated vertical gain at frequency 2-6 Hz and delay vertical phase at frequency 4-6 Hz. There was no significant difference in asymmetric values between the VM group and the control group. The authors concluded that the findings of this study showed that VM patients had elevated horizontal gain and vertical gain, and delay horizontal phase and vertical phase. It is suggested that VAT represents a useful diagnostic tool which may provide objective evidence for the diagnosis and differential diagnosis of VM.
Furthermore, an UpToDate review on “Vestibular migraine” (Robertson, 2018) does not mention vestibular autorotation test as a diagnostic tool.
Yao and colleagues (2022) noted that although the diagnostic criteria of VM have already been defined, various clinical manifestations of VM and the lack of pathognomonic biomarker resulted in high rate of misdiagnosis and mismanagement. A timely and accurate diagnosis tool for the evaluation of VM is highly needed. These investigators examined the potential feasibility of cervical vestibular evoked myogenic potential (cVEMP) and VAT as a diagnosis tool for VM. A total of 211 subjects were recruited into this trial with all participants meeting the inclusion and exclusion criteria. The subjects were divided into 3 groups: healthy control group, general migraine group and VM group. cVEMP and VAT were carried out in all the groups, and the generated data were statistically compared. Compared with the other 2 groups, cVEMP P13-N23 amplitudes of VM patients showed a significant decline. Mean latency values of the VM group had no significant difference in comparison with other groups. Asymmetry ratios showed increased level in VM patients compared to the control groups, without significant difference. VAT results showed that all the horizontal gain, horizontal phase, vertical gain and vertical phase differed from the other 2 groups to varying degrees at higher frequency. The authors concluded that cVEMP and VAT results have shown significant difference between patients with VM and healthy/migraine controls, suggesting their potential usage in the assessment of VM. Moreover, these researchers stated that their future study will examine the correlation of the cVEMP and VAT abnormalities with the characteristics such as age, clinical severity and disease duration to further understand this disease.
Guo et al (2022) examined the difference between the VAT in the peripheral and central acute vestibular syndrome (AVS). Patients with AVS diagnosed by clinical manifestation admitted to the 3rd affiliated hospital of Qiqihar Medical College from January 2019 to January 2021 were enrolled and divided into peripheral AVS (peripheral group) and central AVS (central group) according to the results of the MRI examination. A total of 332 patients with AVS were recruited, including 282 patients in the peripheral group and 50 patients in the central group. The horizontal gain of both groups showed a downward trend at 2 to 6 Hz. There was no significant change in the horizontal phase between the 2 groups at 2 to 6 Hz. The horizontal gain of the 2 groups was stable at 2 to 6 Hz with no significant changes in the horizontal phase between 2 to 6 Hz in both groups. The central group showed a significantly lower proportion of gain increase coupled with loss and a strikingly higher proportion of gain increase without a loss than in the peripheral group (all p < 0.001). The authors concluded that the increased horizontal and vertical gain of VAT in patients with AVS was of high value in the diagnosis of ACS. Significant differences in the results of VAT in patients with central and peripheral AVS could provide a reference for diagnosis.
The authors stated that this study had several drawbacks. First, this study was a single-center study. Second, the investigators were not blinded, resulting in certain results bias. Third, this study only compared the differences in VAT results between peripheral and central AVS, and did not compare the diagnostic value of the corresponding indicators of VAT.
Liu et al (2022) noted that VM and MD share multiple features in terms of clinical presentations and auditory-vestibular functions; thus, more accurate diagnostic tools to distinguish between the 2 disorders are needed. In a retrospective study, these researchers examined the data of 69 MD patients, 79 VM patients and 72 MD with migraine patients. A total of 5 VAT parameters, i.e., horizontal gain/phase, vertical gain/phase and asymmetry were subjected to logistic regression. The receiver operating characteristic (ROC) curves were generated to determine the accuracy of the different parameters in the differential diagnosis of MD and VM. The results showed that the horizontal gain of VAT significantly out-performed other parameters in distinguishing MD and VM. Furthermore, the sensitivity, specificity and accuracy of the horizontal gain were 95.7 %, 50.6 % and 71.6 %, respectively, for the differentiation between VM and MD. In most MD patients, the horizontal gain decreased in the range of 3 to 4 Hz, while in most VM patients, horizontal gain increased in the range between 2 to 3 Hz. More MD with migraine patients had an increased horizontal gain when the frequency was less than 5.0 Hz and had a decreased horizontal gain when the frequency was greater than 5.0 Hz. The authors concluded that the findings of this study suggested the VAT, especially the horizontal gain, as an indicator, may serve as a sensitive and objective indicator that would aid in distinguishing between MD and VM. Moreover, VAT, due to its non-invasive and all-frequency nature, might be an important part of a test battery.
The authors stated that this study had several drawbacks. First, this was a retrospective study carried out in a tertiary care hospital, which might have resulted in a selection bias towards patients with more severe forms of MD and VM. Second, retrospective VAT data of patients were collected during the non-ictal phase, as data were generally not available for the acute phase. As a result, these researchers were uncertain if the 2 different phases had the same results. Third, to help resolve these uncertainties, a prospective, larger study should be performed for MD, VM and MD with migraine patients in definite or probable symptomatic periods.
References
The above policy is based on the following references:
- Barbosa F, Villa TR. Vestibular migraine: Diagnosis challenges and need for targeted treatment. Arq Neuropsiquiatr. 2016;74(5):416-422.
- Blatt PJ, Schubert MC, Roach KE, Tusa RJ. The reliability of the vestibular autorotation test (VAT) in patients with dizziness. J Neurol Phys Ther. 2008;32(2):70-79.
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- Fife TD, Tusa RJ, Furman JM, et al. Assessment: Vestibular testing techniques in adults and children: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2000;55(10):1431-1441.
- Furman JM, Durrant JD. Head-only rotational testing in the elderly. J Vest Res. 1998;8(5):355-361.
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- Nachum Z, Gordon CR, Shahal B, et al. Active high-frequency vestibulo-ocular reflex and seasickness susceptibility. Laryngoscope. 2002;112(1):179-182.
- Ozgirgin ON, Tarhan E. Epley maneuver and the head autorotation test in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2008;265(11):1309-1313.
- Robertson CE. Vestibular migraine. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2018.
- Thungavelu Y, Wang W, Lin P, et al. The clinical utility of vestibular autorotation test in patients with vestibular migraine. Acta Otolaryngol. 2017;137(10):1046-1050.
- Tirelli G, Bigarini S, Russolo M, et al. Test-retest reliability of the VOR as measured via Vorteq in healthy subjects. Acta Otorhinolaryngol Ital. 2004;24(2):58-62.
- Wang W, Yogun T, Chen TS, et al. The characteristics and clinical significance of vestibular autorotation test in patients with vestibular migraine. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2018;53(12):909-913.
- Yao Y, Zhao Z, Qi X, et al. cVEMP and VAT for the diagnosis of vestibular migraine. Eur J Clin Invest. 2022;52(1):e13657.
