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Vestibular Rehabilitation
Amy E. Rosen, SDPT
“I am dizzy”
 Vestibular Disorders Association1
◦ Recognizes 19 different types of vestibular disorders
 “Dizziness” is one of the most common
complaints to physicians by persons over 65
years of age2
 Dizziness Definitions1,2
◦ Vertigo: illusion of movement, rotation and/or
spinning- either of the self or surrounding objects
◦ Disequilibrium: feeling of being unsteady, loss of
balance; often accompanied by spatial disorientation
◦ Presyncope: a feeling of
faintness, lightheadedness, or sense of falling;
sudden decrease in BP
Balance3
 “…a complex process involving the reception and
integration of sensory inputs and the planning and
execution of movement to achieve a goal requiring upright
posture”
◦ Ability to control the COG over BOS in a sensory environment
Choice of body
movement
Determination of
body position
Compare, select &
combine senses
Neck
Muscle
s
Trunk
Muscle
s
Thigh
Muscle
s
Ankle
Muscle
s
Somato-
sensatio
n
Vestibula
r System
Vision
Environmental
Interaction
Select & adjust muscle
contractile pattern
Generation of
body movement
Dizziness and Fall Risk
APTA Fact Sheet4
 Those with a vestibular dysfunction & self reported dizziness
were 12x more likely to fall (Yuri, 2010)
◦ Pt. with vestibular dysfunction alone was also shown to be at a
higher risk for falling
 Increased risk of fall & recurrent falls in those reporting
dizziness. (Tromp, 2001)
 Dizziness when standing correlates with falls & recurrent falls.
(Grassfmans, 1996)
 Pt. with bilateral vestibular dysfunction were shown to have
significant increase in falls compare to general population
(Herdman, 2000)
 Dizziness & vertigo were found to be the leading cause of falls
(Gananca, 2006)
◦ Indiivduals who fell due to dizziness/vertigo were more likely to
experience 2 or more falls
 Those with chronic dizziness were found to be at increased risk
of fall (Tinetti, 2000)
 Those reporting dizziness 2x more likely to fall (O’Loughlin, 1993)
ANATOMY REVIEW
Image:
greymattersjournal.com
Vestibular Labyrinth3
 3 Semi- circular canals
◦ Anterior, Posterior &
Lateral
◦ Angular Accelerations
◦ High Frequency
 2 Otolith Organs
◦ Utricle & Saccule
◦ Sensitive to gravity
◦ Linear Accelerations
◦ Low Frequency
Processing3
 CN 8: Vestibulocochlear Nerve
◦ Tonic firing
 Deflections toward kinocilium cause depolarization
 Deflections away from kinocilium cause hyperpolarization
 Central Processing
◦ CN8 projects information ipsilaterally to 4 Vestibular
nuclei in dorsal Pons & Medulla
◦ Vestibular nuclei send output to
 Cerebellum to coordinate movements & monitor
performance
 CN3,4,6: contralateral CN6 then projects to Medial
Longitudinal fasciculus (MLF) to contralateral Oculomotor
Nucleus
 Spinal Cord descending pathways to adjust limbs and trunk
to regain balance
 Reticular Formation to adjust circulation & breathing for new
body position
 Through the thalamus to Somatosensory Cortex for
Without you realizing…3
 Motor Output Reflexes
◦ Vestibulo-ocular Reflex (VOR)
 Allows for stable vision upon head movements
 Eye movements in opposite direction of head in
1:1 ratio
 CN3: Oculomotor, CN4: Trochlear, CN6:
Abducens
◦ Vestibulo-spinal Reflex (VSR)
 Stabilize the head and body
 Lateral & Medial Vestibulospinal Tracts
 Reticulospinal Tract
 Nystagmus
◦ Involuntary, rhythmic oscillation of the eyes
characterized by the direction of the fast
phase
◦ Can derive from physiologic, pathologic,
peripheral &/or central lesions
◦ Can cause reduced visual acuity and vertigo
Putting it all together
Image:
Reference 1
DISORDERS
General: Vestibular Disorders2,3
Peripheral Central
 Nystagmus generally
horizontal
 Vertigo as severe as
nystagmus
◦ Response typically fatigues
or habituates
 More intense feeling of
vertigo
 Hearing loss & tinnitus
frequent
 Long-tract sensory, motor
involvement are unusual
 Nystagmus can be
horizontal, rotatory or
vertical; multi-directional
 Vertigo relatively mild or
absent
◦ persistent
 Hearing loss & tinnitus
rare
 Associated sensory,
motor, cerebellar, & other
CN involvement more
common
BPPV1-3,5
 Between 17-42% of dizzy patients diagnosed with
vertigo
 Benign Paroxysmal Positional Vertigo
◦ Form of Positional Vertigo
 Spinning sensation produced by changes in head position
relative to gravity
 BPPV- characterized by repeated episodes of positional
vertigo
◦ Canalithiasis: otoconial debris become free floating in the
endolymph of SCC
◦ Cupulolithiasis: otoconial debris dislodged from otolithic
organs deposits upon cupula of SCC
 ~85% Posterior Canal & 10-15% Horizontal Canal
 Most common in 5-7th decades of life
◦ Degeneration of cilia during natural aging
 Characterized by: acute, discrete episodes of brief
positional vertigo without associated hearing loss
Differential Diagnosis of BPPV5
Peripheral Central
 Meniérès Disease
 Vestibular neuritis
 Labyrinthitis
 Superior Canal
dehiscence syndrome
 Post-traumatic vertigo
 Migraine-associated
dizziness
 Vertebrobasilar
insufficency
 Demyelinating diseases
 CNS lesions
Other: Anxiety or panic disorder, cericogenic vertigo, medication
side effects, and postural hypotension
Meniérès Disease1-3,5
 ~10% of Pt. presenting with vertigo
 Chronic disorder due to abnormalities in
quantity, composition &/or pressure of endolymph
◦ Mixing of endolymph & perilymph
 Characterized by attacks:
◦ Attacks can last 20min- 24hrs
◦ Attack frequency: few per week to years between
◦ Early Stage: spontaneous & disabling vertigo, fluctuating
hearing loss, ear fullness &/or tinnitus
◦ Between Attacks: fatigue, anxiety, LOB, headache, vision
difficulties, vomiting/nausea, neck pain, sound sensitivity
◦ Late Stage: hearing loss, tinnitus, constant struggle with
vision and balance
 Any age, most common 40-60yo
 Tx: medication, reduce- sodium diet, vestibular
rehab, surgery
Neuritis/Labyrinthitis1-3,5
 ~41% of Pt. presenting with vertigo
 Inflammation of inner ear caused by viral or
bacterial infection
◦ Vestibular hypofunction
◦ Unilateral or Bilateral
◦ Acute or chronic, lasting several wks.
 Neuritis: inflammation of the nerve affecting
vestibular ganglion
 Labyrinthitis: inflammation of the labyrinth affecting
both branches of CN8
 Sx: very sudden attacks of severe dizziness,
vertigo, nausea and imbalance lasting for hours or
even days.
◦ Labyrinthitis- tinnitus &/or hearing loss
 Secondary conditions:
◦ Neuritis: BPPV & Labyrinthlitis: Endolymphatic hydrops
Neuritis/Labyrinthitis1-3,5
Image:
http://www.lookfordiagnosis.com/mesh_info.php?term=Neuritis&lang=1
Migraine-Associated Vertigo (MAV)
1-3,5
 Migraine is one of the most debilitating chronic disorder in
US
◦ ~40% of Pts with migraines have a vestibular component
affecting balance &/or dizziness
 Characterized by migraine with:
◦ Episodic vestibular symptoms
 Dizziness, motion intolerance, spontaneous vertigo attacks,
diminished eye focus with photosensitivity, LOB and ataxia
◦ Sound sensitivity & tinnitus, cervioalgia with muscle spasms,
anxiety, confusion, spatial disorientation
◦ No other cause of vertigo
 Cause: combinations of vascular events, neuritis of
portion of vestibular nerve as result of migraine.
◦ Utricle is typically more affected
 Difficult to diagnosis
◦ Vestibular-evoked myogenic potentials (VEMP) testing
◦ Common to also have true BPPV
Cervicogenic Dizziness1-3,5
 A clinical syndrome of disequilibrium & disorientation
in patients with neck problem, ie. cervical trauma,
whiplash, cervical arthritis/denegerative, and others1
 Characterized by:
◦ Dizziness worse during head movements or after
maintaining one head position for prolonged time
◦ Dizziness after the neck pain
◦ May be accompanied by headache
◦ Dizziness can last minutes-hours
◦ Also complain of general imbalance, increasing with
head movements
 No diagnostic test to confirm
◦ Difficult to truly diagnose- rule out other conditions
 Dizziness typically improves with conservative
treatment of underlying neck issue.
CLINICAL EXAM
What to look for3,5,6
 Take thorough history of symptoms
◦ Frequency, Duration, Severity & Description of Sensation
◦ Current vestibular suppressant medications?
 Oculomotor Exam
◦ Test VOR
 BPPV testing
 Test for hearing loss
 Caloric Testing
 Assess static and dynamic balance
 Assess routine postural transitions
◦ Sit-supine, rolling, forward leaning, history
 Also assess for strength, ROM and functional
limitations
Oculomotor Exam3
 Gaze nystagmus
◦ Gaze at target 20-30° off midline for 20sec (R & L)
 Look for nystagmus or change in characteristics of gaze
 Smooth Pursuit
◦ Tracking H
 Look for saccadic substitution
 Saccades
◦ Jump gaze between 2 pts ~12in apart (Vertical & Horizontal)
 Look for speed, accuracy and conjugate EOM
 Alteration in oculomotor movements indicate central origin
of vestibular dysfunction7
◦ Electronystagmograph vs. MRI
 83.3% sensitivity & 21.2% specificity
 Severe alterations: 71.4% sensitivity & 50% specifity
 MAV: saccadic eye motion testing generally normal1
Testing VOR2,3
 Head Trust (Impulse) test
◦ Visual fixation on a target
◦ Rapid, passive rotation to one side
 Perform slowly first & ensure adequate Cspine ROM
◦ Look for loss of fixation with saccadic reacquisition
 Test function of ipsilateral ear to thrust
 Head Shaking test
◦ Seated, with head tilted 30°, head shake @20Hz for
20 seconds
◦ Look for nystagmus after head shake
 Peripheral Origin: fast phase of nystagmus toward
stronger/intact labyrinth
 Central Origin: prolonged nystagmus, dysconjugate
nystagmus, or vertical nystagmus after horizontal stimulus
Testing for Posterior BPPV3, 5
 Hallpike- Dix
◦ Head turned 45° to one side
◦ Quickly from seated position
to supine, head 20° below
horizontal
◦ Observe for latency,
direction & duration of
nystagmus
 Latency: 5-20sec
 Direction: mixed torsional &
vertical components with fast
phase (upper pole) toward
dependent ear
 Duration: should resolve
within 60seconds
◦ Sit up & repeat contralateral
ear, if necessary.
Testing for Horizontal BPPV3,5
 Pagnini-McClure Maneuver
◦ aka: Supine Roll Test
 Pt. supine with head in neutral
 Quickly rotate head 90° to one side
 Observe for nystagmus
 Head returned to neutral then quickly rotated 90° to other
side
 Observe for nystagmus
◦ In most cases, Geotropic nystagmus is produced
 Fast component toward the ground
 Less common Apogeotropic nystagmus is toward upper
ear
◦ Affected ear is thought to be the one to which the
side of rotation produced the more intense
nystagmus/vertigo
Exclusions for BPPV testing5
 Pt with physical limitations including:
◦ Cervical stenosis
◦ Serve kyphoscoliosis
◦ Limited cervical ROM
◦ Down syndrome
◦ Severe rheumatoid arthritis
◦ Cervical radiculopathies
◦ Paget’s disease
◦ Morbid obesity
◦ Ankylosing spondylitis
◦ Low back dysfunction
◦ Spinal cord injuries
Tests for hearing loss2,3
 Rinne Test
◦ Place vibrating tuning fork (512Hz) against Pt’s
mastoid bone, ask Pt to tell you when sound is no
longer heard
◦ Once sound is no longer heard, place still vibrating
tuning fork 1-2 cm from the auditory canal, ask Pt to
tell if they are able to hear tuning fork
 Normal Hearing: Air conduction should be greater than bone
conduction
 Weber Test
◦ Place tuning fork (256Hz) in the middle of the Pt’s
forehead, equidistant from each ear.
◦ Pt asked to report which ear the sound is heard
louder
 Normal Hearing: Equal in both
Caloric Testing2, 3, 8
 To evaluate integrity of unilateral vestibular apparatus.
◦ Determine unilateral vestibular hypofunction, ie neuritis/labrynthitis
 Performed irrigation to external auditory canal in supine
with head elevated 30°
◦ Cold & warm water for 30secs
◦ 5mins between each condition
 Normal: COWS
◦ Cold opposite, Warm same
 Cooling- increase, Warming- decrease in the specific gravity of the endolymph
 Measure time of onset of nystagmus from beginning
irrigation, duration & direction of each side under each
condition
◦ Approx. 20% different is considered significantly abnormal
◦ Ask Pt about sensation, intensity and any differences they experience
 80% accurate at diagnosing nerve damage as a cause of
vertigo
◦ Electronystagmograph
 Central origin dizziness/vertigo
Outcome Measures3
 Dynamic Gait Index9
◦ Time to Administer <10min
◦ Assess ability to modify
balance while walking in the
presence of external
demands
◦ Vestibular
disorders, geriatrics, PD, po
st-stroke, brain injury & MS
 ≤19/24 increased fall risk
◦ Pt. with vestibular disorders
scoring ≤19/24 are 2.58
times more likely to have a
fall in last 6 months
 Excellent test-retest
reliability (ICC= 0.86)
 Four Square Step Test10
◦ Time to Administer <5min
◦ Active stepping for
Functional Tasks
◦ Vestibular disorders,
geriatrics, PD, post-stroke
& transtibial amp.
 Increased Risk of Falls
◦ Vestibular: >12s
◦ Geriatric: >15s
◦ Acute Stroke: >15s
 Excellent test-retest
reliability (ICC= 0.93)
Helpful Tools for
Assessment3,5
 Frenzel Goggles
◦ Video or optical
◦ Enlarge (and record)
oculomotor function
◦ Help monitor performance
& oculomotor function
during testing (Nystagmus)
Gordon College: Center for Balance, Mobility, and Wellness
(Wenham, MA)
http://www.interacoustics.es/com_en/Pages/Product/BalanceSystems/_in
dex.htm?prodid=57249
 “Balance Master”
 Computerized Dynamic
Posturography
 6 conditions
 Pt. relative reliance
on
visual, vestibular, an
d somatosensory
inputs
INTERVENTION
Treating the “Dizzy”
Patient2,3,5,6
 Vestibular Rehabilitation
◦ Goals:
 to help retrain the ability of the body and brain to process balance
information1
 to allow free head movement without dizziness, especially during gait6
 Enhace gaze stability, postural stability, improve dizziness/vertigo &
activities of daily living
◦ Canalith repositioning exercises (CRP), postural control
exercises, fall prevention training, relaxation training, strength
conditioning exercises, functional skills retraining, education
and…
 Habituation
◦ Retrain brain to manage offending stimuli
◦ Conditioning
 Adaptation
◦ Active head movements to compensate for retinal slip
 Substitution
◦ Visual and somatosensory systems to compensation
Treating Posterior BPPV3,5
 Epley maneuver
 Pt in upright position with head turned 45° toward affected ear
 Rapidly laid back to supine head-hanging position, held 20-30sec
 Head turned 90° toward unaffected side, held 20sec
 Head turned further 90° (switch Pt to s/l facing floor), held 20-30sec
 Bring Pt to upright sitting position
◦ Most researched and most effective in short and long term treatment
◦ Canal switch occurs in 6-7% of those treated with CRP
 Semont’s maneuver
 Pt in upright position with head turned 45° away from affected ear
 Rapidly moved to s/l position, looking up at ceiling, held 30sec
 Rapidly move to opposite s/l position, looking at table, held 30s
 Bring Pt to upright sitting position
◦ Less researched than Epley maneuver and possibly less effective long
term
 Brandt- Daroff Exercises
◦ Overall less effective but good for HEP as Habituation Exercises
◦ Self-administered CRP appeared to be more effective, 64%
improvement, than self-treatment with Brandt-Daroff exercises, 23%
improvement . (Radtke, 1999)
Effectiveness of Posterior Canal
BPPV treated with Epley
Maneuver5
Treating Horizontal BPPV3,5
 Lempert Roll Maneuver
◦ ~75% effective in treating Lateral BPPV
 Begin supine, turn head slowly toward unaffected side
 Maintain each step for 15sec.
 Complete maneuver, Pt brought to upright with head bowed
30°
http://www.tinnitusjournal.com/detalhe_artigo.asp?id=
Therapeutic Intervention2,3,5,6
 Pt’s with BPPV
◦ Evaluate & Treat, if positive, prior to beginning other treatment
◦ Should be re-evaluated after 1month from initial CPR
◦ Discuss safety and possible reoccurrence
 Challenge the systems
◦ Reduce influence of dominant sensory systems, strengthen the weak
 Visual
 Somatosensory
 Vestibular
 Gaze stabilization
◦ Most common exercises for peripheral vestibular hypofunction
 Work at tolerable level of dizziness
◦ Increase in symptoms should last no longer than 20mins following
treatment
 Frequency & Duration of treatment are dependent on Pt. &
symptoms
◦ 2-3 times per week to 1 time every 2-3 weeks
◦ 1-2 weeks to several months
Activities3,6
 Get Creative & Consider Real-Life Function
◦ Gaze stabilization: active head and eye movements
 Adjust for distance, speed & frequency, plane of movement, BOS, posture, surface, etc.
◦ Static stance
 EC/EO, change surfaces, change BOS, vary combinations
◦ Walking
 head turns, change speed, change direction, change surface, change BOS, navigate
obstacles, etc.
◦ Manipulate BOS for functional activities
◦ Reaching out of BOS
◦ Vary surfaces
 Foam, Trampoline, Dyna Discs, balance boards, BOS
 Transfers from one surface to another- stepping stones
◦ Physioballs for sitting balance
 Add EC, add bouncing, add feet on foam
◦ Hurdles
◦ Cones
◦ Obstacle Course
Do Not forget general strengthening, stretching & conditioning for functional
activities.
Effectiveness of Vestibular
Rehab11
Systematic Review of 71 articles dated until 2006
 Strong evidence for vestibular rehab
◦ Vestibular hypofunction: Neuritis/Labyrinthitis
◦ Multisensory dizziness
◦ Meniérès Disease
 Moderately strong evidence
◦ After vestibular surgery
 Insufficient evidence
◦ BPPV
◦ PPV
◦ Neurological causes of dizziness
◦ Dizziness from whiplash-associated disorder
◦ Migraine- associated dizziness
STRONG EVIDENCE: VESTIBULAR REHAB FOR VESTIBULAR
DISORDERS
Practice Makes Perfect
 Oculomotor testing
 VOR testing
 BPPV testing
 Outcome Measures
◦ Dynamic Gait Index
◦ Four Square Step Test
 Instructional Exercises
Vestibular Rehabilitation
Gordon College: Center for Balance, Mobility & Wellness (Wenham,
References
1. Vestibular Disorders Association. Understanding Vestibular Disorders. Available at:
http://vestibular.org/understanding-vestibular-disorder/types-vestibular-disorders
2. Reeves AG, Swenson RS. Disorders of the Nervous System. Dartmouth Medical School. Chapter
6, 14. Copyright 2008. Available at: http://www.dartmouth.edu/~dons/.
3. Umphred DA, Lazaro RT, Roller ML, Burton GU. Umphred’s Neurological Rehabilitation, Sixth Ed.
Chapter 22. Elsevier, Inc. Copyright 2013.
4. Bloom M. Research Studies that Associate Dizziness and Falls: Fact Sheet. APTA, Section of
Neurology. Available at: http://www.neuropt.org/docs/vsig-physician-fact-sheets/research-studies-
that-associate-dizziness-and-falls.pdf?sfvrsn=2
5. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo.
Otolaryngology-Head and Neck Surgery 2008; 139, S47-S81
6. Hoffer M, Balaban C, Whitney S, Sparto P. Principles of vestibular physical therapy rehabilitation.
Neurorehabilitation [serial online]. July 2011;29(2):157-166. Available from: CINAHL Complete,
7. Tirelli G, Rigo S, Bullo F, Meneguzzi C, Gregori D, Gatto A. Saccades and smooth pursuit eye
movements in central vertigo. Acta Otorhinolaryngologica Italica: Organo Ufficiale Della Società
Italiana Di Otorinolaringologia E Chirurgia Cervico-Facciale [serial online]. April 2011;31(2):96-102.
Available from: MEDLINE
8. MedlinePlus. Caloric Stimulation. Last modified: 2/26/14. Available at:
www.nlm.nih.gov/medlineplus/ency/article/003429.htm
9. Rehabilitation Measures Database. Rehab Measures: Dynamic Gait Index. Last modified 1/30/14.
Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=898
10. Rehabilitation Measures Database. Rehab Measures: Four Step Square Test. Last modified:
1/31/14. Available at:
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900
11. Hansson EE. Vestibular rehabilitation-For whom and how? A systematic review. Advances in
Physiotherapy. 2007; 9: 106-116

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Vestibular Rehabilitation Inservice

  • 2. “I am dizzy”  Vestibular Disorders Association1 ◦ Recognizes 19 different types of vestibular disorders  “Dizziness” is one of the most common complaints to physicians by persons over 65 years of age2  Dizziness Definitions1,2 ◦ Vertigo: illusion of movement, rotation and/or spinning- either of the self or surrounding objects ◦ Disequilibrium: feeling of being unsteady, loss of balance; often accompanied by spatial disorientation ◦ Presyncope: a feeling of faintness, lightheadedness, or sense of falling; sudden decrease in BP
  • 3. Balance3  “…a complex process involving the reception and integration of sensory inputs and the planning and execution of movement to achieve a goal requiring upright posture” ◦ Ability to control the COG over BOS in a sensory environment Choice of body movement Determination of body position Compare, select & combine senses Neck Muscle s Trunk Muscle s Thigh Muscle s Ankle Muscle s Somato- sensatio n Vestibula r System Vision Environmental Interaction Select & adjust muscle contractile pattern Generation of body movement
  • 4. Dizziness and Fall Risk APTA Fact Sheet4  Those with a vestibular dysfunction & self reported dizziness were 12x more likely to fall (Yuri, 2010) ◦ Pt. with vestibular dysfunction alone was also shown to be at a higher risk for falling  Increased risk of fall & recurrent falls in those reporting dizziness. (Tromp, 2001)  Dizziness when standing correlates with falls & recurrent falls. (Grassfmans, 1996)  Pt. with bilateral vestibular dysfunction were shown to have significant increase in falls compare to general population (Herdman, 2000)  Dizziness & vertigo were found to be the leading cause of falls (Gananca, 2006) ◦ Indiivduals who fell due to dizziness/vertigo were more likely to experience 2 or more falls  Those with chronic dizziness were found to be at increased risk of fall (Tinetti, 2000)  Those reporting dizziness 2x more likely to fall (O’Loughlin, 1993)
  • 6. Vestibular Labyrinth3  3 Semi- circular canals ◦ Anterior, Posterior & Lateral ◦ Angular Accelerations ◦ High Frequency  2 Otolith Organs ◦ Utricle & Saccule ◦ Sensitive to gravity ◦ Linear Accelerations ◦ Low Frequency
  • 7. Processing3  CN 8: Vestibulocochlear Nerve ◦ Tonic firing  Deflections toward kinocilium cause depolarization  Deflections away from kinocilium cause hyperpolarization  Central Processing ◦ CN8 projects information ipsilaterally to 4 Vestibular nuclei in dorsal Pons & Medulla ◦ Vestibular nuclei send output to  Cerebellum to coordinate movements & monitor performance  CN3,4,6: contralateral CN6 then projects to Medial Longitudinal fasciculus (MLF) to contralateral Oculomotor Nucleus  Spinal Cord descending pathways to adjust limbs and trunk to regain balance  Reticular Formation to adjust circulation & breathing for new body position  Through the thalamus to Somatosensory Cortex for
  • 8. Without you realizing…3  Motor Output Reflexes ◦ Vestibulo-ocular Reflex (VOR)  Allows for stable vision upon head movements  Eye movements in opposite direction of head in 1:1 ratio  CN3: Oculomotor, CN4: Trochlear, CN6: Abducens ◦ Vestibulo-spinal Reflex (VSR)  Stabilize the head and body  Lateral & Medial Vestibulospinal Tracts  Reticulospinal Tract  Nystagmus ◦ Involuntary, rhythmic oscillation of the eyes characterized by the direction of the fast phase ◦ Can derive from physiologic, pathologic, peripheral &/or central lesions ◦ Can cause reduced visual acuity and vertigo
  • 9. Putting it all together Image: Reference 1
  • 11. General: Vestibular Disorders2,3 Peripheral Central  Nystagmus generally horizontal  Vertigo as severe as nystagmus ◦ Response typically fatigues or habituates  More intense feeling of vertigo  Hearing loss & tinnitus frequent  Long-tract sensory, motor involvement are unusual  Nystagmus can be horizontal, rotatory or vertical; multi-directional  Vertigo relatively mild or absent ◦ persistent  Hearing loss & tinnitus rare  Associated sensory, motor, cerebellar, & other CN involvement more common
  • 12. BPPV1-3,5  Between 17-42% of dizzy patients diagnosed with vertigo  Benign Paroxysmal Positional Vertigo ◦ Form of Positional Vertigo  Spinning sensation produced by changes in head position relative to gravity  BPPV- characterized by repeated episodes of positional vertigo ◦ Canalithiasis: otoconial debris become free floating in the endolymph of SCC ◦ Cupulolithiasis: otoconial debris dislodged from otolithic organs deposits upon cupula of SCC  ~85% Posterior Canal & 10-15% Horizontal Canal  Most common in 5-7th decades of life ◦ Degeneration of cilia during natural aging  Characterized by: acute, discrete episodes of brief positional vertigo without associated hearing loss
  • 13. Differential Diagnosis of BPPV5 Peripheral Central  Meniérès Disease  Vestibular neuritis  Labyrinthitis  Superior Canal dehiscence syndrome  Post-traumatic vertigo  Migraine-associated dizziness  Vertebrobasilar insufficency  Demyelinating diseases  CNS lesions Other: Anxiety or panic disorder, cericogenic vertigo, medication side effects, and postural hypotension
  • 14. Meniérès Disease1-3,5  ~10% of Pt. presenting with vertigo  Chronic disorder due to abnormalities in quantity, composition &/or pressure of endolymph ◦ Mixing of endolymph & perilymph  Characterized by attacks: ◦ Attacks can last 20min- 24hrs ◦ Attack frequency: few per week to years between ◦ Early Stage: spontaneous & disabling vertigo, fluctuating hearing loss, ear fullness &/or tinnitus ◦ Between Attacks: fatigue, anxiety, LOB, headache, vision difficulties, vomiting/nausea, neck pain, sound sensitivity ◦ Late Stage: hearing loss, tinnitus, constant struggle with vision and balance  Any age, most common 40-60yo  Tx: medication, reduce- sodium diet, vestibular rehab, surgery
  • 15. Neuritis/Labyrinthitis1-3,5  ~41% of Pt. presenting with vertigo  Inflammation of inner ear caused by viral or bacterial infection ◦ Vestibular hypofunction ◦ Unilateral or Bilateral ◦ Acute or chronic, lasting several wks.  Neuritis: inflammation of the nerve affecting vestibular ganglion  Labyrinthitis: inflammation of the labyrinth affecting both branches of CN8  Sx: very sudden attacks of severe dizziness, vertigo, nausea and imbalance lasting for hours or even days. ◦ Labyrinthitis- tinnitus &/or hearing loss  Secondary conditions: ◦ Neuritis: BPPV & Labyrinthlitis: Endolymphatic hydrops
  • 17. Migraine-Associated Vertigo (MAV) 1-3,5  Migraine is one of the most debilitating chronic disorder in US ◦ ~40% of Pts with migraines have a vestibular component affecting balance &/or dizziness  Characterized by migraine with: ◦ Episodic vestibular symptoms  Dizziness, motion intolerance, spontaneous vertigo attacks, diminished eye focus with photosensitivity, LOB and ataxia ◦ Sound sensitivity & tinnitus, cervioalgia with muscle spasms, anxiety, confusion, spatial disorientation ◦ No other cause of vertigo  Cause: combinations of vascular events, neuritis of portion of vestibular nerve as result of migraine. ◦ Utricle is typically more affected  Difficult to diagnosis ◦ Vestibular-evoked myogenic potentials (VEMP) testing ◦ Common to also have true BPPV
  • 18. Cervicogenic Dizziness1-3,5  A clinical syndrome of disequilibrium & disorientation in patients with neck problem, ie. cervical trauma, whiplash, cervical arthritis/denegerative, and others1  Characterized by: ◦ Dizziness worse during head movements or after maintaining one head position for prolonged time ◦ Dizziness after the neck pain ◦ May be accompanied by headache ◦ Dizziness can last minutes-hours ◦ Also complain of general imbalance, increasing with head movements  No diagnostic test to confirm ◦ Difficult to truly diagnose- rule out other conditions  Dizziness typically improves with conservative treatment of underlying neck issue.
  • 20. What to look for3,5,6  Take thorough history of symptoms ◦ Frequency, Duration, Severity & Description of Sensation ◦ Current vestibular suppressant medications?  Oculomotor Exam ◦ Test VOR  BPPV testing  Test for hearing loss  Caloric Testing  Assess static and dynamic balance  Assess routine postural transitions ◦ Sit-supine, rolling, forward leaning, history  Also assess for strength, ROM and functional limitations
  • 21. Oculomotor Exam3  Gaze nystagmus ◦ Gaze at target 20-30° off midline for 20sec (R & L)  Look for nystagmus or change in characteristics of gaze  Smooth Pursuit ◦ Tracking H  Look for saccadic substitution  Saccades ◦ Jump gaze between 2 pts ~12in apart (Vertical & Horizontal)  Look for speed, accuracy and conjugate EOM  Alteration in oculomotor movements indicate central origin of vestibular dysfunction7 ◦ Electronystagmograph vs. MRI  83.3% sensitivity & 21.2% specificity  Severe alterations: 71.4% sensitivity & 50% specifity  MAV: saccadic eye motion testing generally normal1
  • 22. Testing VOR2,3  Head Trust (Impulse) test ◦ Visual fixation on a target ◦ Rapid, passive rotation to one side  Perform slowly first & ensure adequate Cspine ROM ◦ Look for loss of fixation with saccadic reacquisition  Test function of ipsilateral ear to thrust  Head Shaking test ◦ Seated, with head tilted 30°, head shake @20Hz for 20 seconds ◦ Look for nystagmus after head shake  Peripheral Origin: fast phase of nystagmus toward stronger/intact labyrinth  Central Origin: prolonged nystagmus, dysconjugate nystagmus, or vertical nystagmus after horizontal stimulus
  • 23. Testing for Posterior BPPV3, 5  Hallpike- Dix ◦ Head turned 45° to one side ◦ Quickly from seated position to supine, head 20° below horizontal ◦ Observe for latency, direction & duration of nystagmus  Latency: 5-20sec  Direction: mixed torsional & vertical components with fast phase (upper pole) toward dependent ear  Duration: should resolve within 60seconds ◦ Sit up & repeat contralateral ear, if necessary.
  • 24. Testing for Horizontal BPPV3,5  Pagnini-McClure Maneuver ◦ aka: Supine Roll Test  Pt. supine with head in neutral  Quickly rotate head 90° to one side  Observe for nystagmus  Head returned to neutral then quickly rotated 90° to other side  Observe for nystagmus ◦ In most cases, Geotropic nystagmus is produced  Fast component toward the ground  Less common Apogeotropic nystagmus is toward upper ear ◦ Affected ear is thought to be the one to which the side of rotation produced the more intense nystagmus/vertigo
  • 25. Exclusions for BPPV testing5  Pt with physical limitations including: ◦ Cervical stenosis ◦ Serve kyphoscoliosis ◦ Limited cervical ROM ◦ Down syndrome ◦ Severe rheumatoid arthritis ◦ Cervical radiculopathies ◦ Paget’s disease ◦ Morbid obesity ◦ Ankylosing spondylitis ◦ Low back dysfunction ◦ Spinal cord injuries
  • 26. Tests for hearing loss2,3  Rinne Test ◦ Place vibrating tuning fork (512Hz) against Pt’s mastoid bone, ask Pt to tell you when sound is no longer heard ◦ Once sound is no longer heard, place still vibrating tuning fork 1-2 cm from the auditory canal, ask Pt to tell if they are able to hear tuning fork  Normal Hearing: Air conduction should be greater than bone conduction  Weber Test ◦ Place tuning fork (256Hz) in the middle of the Pt’s forehead, equidistant from each ear. ◦ Pt asked to report which ear the sound is heard louder  Normal Hearing: Equal in both
  • 27. Caloric Testing2, 3, 8  To evaluate integrity of unilateral vestibular apparatus. ◦ Determine unilateral vestibular hypofunction, ie neuritis/labrynthitis  Performed irrigation to external auditory canal in supine with head elevated 30° ◦ Cold & warm water for 30secs ◦ 5mins between each condition  Normal: COWS ◦ Cold opposite, Warm same  Cooling- increase, Warming- decrease in the specific gravity of the endolymph  Measure time of onset of nystagmus from beginning irrigation, duration & direction of each side under each condition ◦ Approx. 20% different is considered significantly abnormal ◦ Ask Pt about sensation, intensity and any differences they experience  80% accurate at diagnosing nerve damage as a cause of vertigo ◦ Electronystagmograph  Central origin dizziness/vertigo
  • 28. Outcome Measures3  Dynamic Gait Index9 ◦ Time to Administer <10min ◦ Assess ability to modify balance while walking in the presence of external demands ◦ Vestibular disorders, geriatrics, PD, po st-stroke, brain injury & MS  ≤19/24 increased fall risk ◦ Pt. with vestibular disorders scoring ≤19/24 are 2.58 times more likely to have a fall in last 6 months  Excellent test-retest reliability (ICC= 0.86)  Four Square Step Test10 ◦ Time to Administer <5min ◦ Active stepping for Functional Tasks ◦ Vestibular disorders, geriatrics, PD, post-stroke & transtibial amp.  Increased Risk of Falls ◦ Vestibular: >12s ◦ Geriatric: >15s ◦ Acute Stroke: >15s  Excellent test-retest reliability (ICC= 0.93)
  • 29. Helpful Tools for Assessment3,5  Frenzel Goggles ◦ Video or optical ◦ Enlarge (and record) oculomotor function ◦ Help monitor performance & oculomotor function during testing (Nystagmus) Gordon College: Center for Balance, Mobility, and Wellness (Wenham, MA) http://www.interacoustics.es/com_en/Pages/Product/BalanceSystems/_in dex.htm?prodid=57249  “Balance Master”  Computerized Dynamic Posturography  6 conditions  Pt. relative reliance on visual, vestibular, an d somatosensory inputs
  • 31. Treating the “Dizzy” Patient2,3,5,6  Vestibular Rehabilitation ◦ Goals:  to help retrain the ability of the body and brain to process balance information1  to allow free head movement without dizziness, especially during gait6  Enhace gaze stability, postural stability, improve dizziness/vertigo & activities of daily living ◦ Canalith repositioning exercises (CRP), postural control exercises, fall prevention training, relaxation training, strength conditioning exercises, functional skills retraining, education and…  Habituation ◦ Retrain brain to manage offending stimuli ◦ Conditioning  Adaptation ◦ Active head movements to compensate for retinal slip  Substitution ◦ Visual and somatosensory systems to compensation
  • 32. Treating Posterior BPPV3,5  Epley maneuver  Pt in upright position with head turned 45° toward affected ear  Rapidly laid back to supine head-hanging position, held 20-30sec  Head turned 90° toward unaffected side, held 20sec  Head turned further 90° (switch Pt to s/l facing floor), held 20-30sec  Bring Pt to upright sitting position ◦ Most researched and most effective in short and long term treatment ◦ Canal switch occurs in 6-7% of those treated with CRP  Semont’s maneuver  Pt in upright position with head turned 45° away from affected ear  Rapidly moved to s/l position, looking up at ceiling, held 30sec  Rapidly move to opposite s/l position, looking at table, held 30s  Bring Pt to upright sitting position ◦ Less researched than Epley maneuver and possibly less effective long term  Brandt- Daroff Exercises ◦ Overall less effective but good for HEP as Habituation Exercises ◦ Self-administered CRP appeared to be more effective, 64% improvement, than self-treatment with Brandt-Daroff exercises, 23% improvement . (Radtke, 1999)
  • 33. Effectiveness of Posterior Canal BPPV treated with Epley Maneuver5
  • 34. Treating Horizontal BPPV3,5  Lempert Roll Maneuver ◦ ~75% effective in treating Lateral BPPV  Begin supine, turn head slowly toward unaffected side  Maintain each step for 15sec.  Complete maneuver, Pt brought to upright with head bowed 30° http://www.tinnitusjournal.com/detalhe_artigo.asp?id=
  • 35. Therapeutic Intervention2,3,5,6  Pt’s with BPPV ◦ Evaluate & Treat, if positive, prior to beginning other treatment ◦ Should be re-evaluated after 1month from initial CPR ◦ Discuss safety and possible reoccurrence  Challenge the systems ◦ Reduce influence of dominant sensory systems, strengthen the weak  Visual  Somatosensory  Vestibular  Gaze stabilization ◦ Most common exercises for peripheral vestibular hypofunction  Work at tolerable level of dizziness ◦ Increase in symptoms should last no longer than 20mins following treatment  Frequency & Duration of treatment are dependent on Pt. & symptoms ◦ 2-3 times per week to 1 time every 2-3 weeks ◦ 1-2 weeks to several months
  • 36. Activities3,6  Get Creative & Consider Real-Life Function ◦ Gaze stabilization: active head and eye movements  Adjust for distance, speed & frequency, plane of movement, BOS, posture, surface, etc. ◦ Static stance  EC/EO, change surfaces, change BOS, vary combinations ◦ Walking  head turns, change speed, change direction, change surface, change BOS, navigate obstacles, etc. ◦ Manipulate BOS for functional activities ◦ Reaching out of BOS ◦ Vary surfaces  Foam, Trampoline, Dyna Discs, balance boards, BOS  Transfers from one surface to another- stepping stones ◦ Physioballs for sitting balance  Add EC, add bouncing, add feet on foam ◦ Hurdles ◦ Cones ◦ Obstacle Course Do Not forget general strengthening, stretching & conditioning for functional activities.
  • 37. Effectiveness of Vestibular Rehab11 Systematic Review of 71 articles dated until 2006  Strong evidence for vestibular rehab ◦ Vestibular hypofunction: Neuritis/Labyrinthitis ◦ Multisensory dizziness ◦ Meniérès Disease  Moderately strong evidence ◦ After vestibular surgery  Insufficient evidence ◦ BPPV ◦ PPV ◦ Neurological causes of dizziness ◦ Dizziness from whiplash-associated disorder ◦ Migraine- associated dizziness STRONG EVIDENCE: VESTIBULAR REHAB FOR VESTIBULAR DISORDERS
  • 38. Practice Makes Perfect  Oculomotor testing  VOR testing  BPPV testing  Outcome Measures ◦ Dynamic Gait Index ◦ Four Square Step Test  Instructional Exercises
  • 39. Vestibular Rehabilitation Gordon College: Center for Balance, Mobility & Wellness (Wenham,
  • 40. References 1. Vestibular Disorders Association. Understanding Vestibular Disorders. Available at: http://vestibular.org/understanding-vestibular-disorder/types-vestibular-disorders 2. Reeves AG, Swenson RS. Disorders of the Nervous System. Dartmouth Medical School. Chapter 6, 14. Copyright 2008. Available at: http://www.dartmouth.edu/~dons/. 3. Umphred DA, Lazaro RT, Roller ML, Burton GU. Umphred’s Neurological Rehabilitation, Sixth Ed. Chapter 22. Elsevier, Inc. Copyright 2013. 4. Bloom M. Research Studies that Associate Dizziness and Falls: Fact Sheet. APTA, Section of Neurology. Available at: http://www.neuropt.org/docs/vsig-physician-fact-sheets/research-studies- that-associate-dizziness-and-falls.pdf?sfvrsn=2 5. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. Otolaryngology-Head and Neck Surgery 2008; 139, S47-S81 6. Hoffer M, Balaban C, Whitney S, Sparto P. Principles of vestibular physical therapy rehabilitation. Neurorehabilitation [serial online]. July 2011;29(2):157-166. Available from: CINAHL Complete, 7. Tirelli G, Rigo S, Bullo F, Meneguzzi C, Gregori D, Gatto A. Saccades and smooth pursuit eye movements in central vertigo. Acta Otorhinolaryngologica Italica: Organo Ufficiale Della Società Italiana Di Otorinolaringologia E Chirurgia Cervico-Facciale [serial online]. April 2011;31(2):96-102. Available from: MEDLINE 8. MedlinePlus. Caloric Stimulation. Last modified: 2/26/14. Available at: www.nlm.nih.gov/medlineplus/ency/article/003429.htm 9. Rehabilitation Measures Database. Rehab Measures: Dynamic Gait Index. Last modified 1/30/14. Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=898 10. Rehabilitation Measures Database. Rehab Measures: Four Step Square Test. Last modified: 1/31/14. Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900 11. Hansson EE. Vestibular rehabilitation-For whom and how? A systematic review. Advances in Physiotherapy. 2007; 9: 106-116

Notas del editor

  1. Anterior: 45d anterior to coronal/frontal planePosterior: 45d posterior to coronal/frontal planeHorizontal: 30d superior to transverse plane
  2. Lateral: stabilize body; input from otoliths &amp; cerebellum via IPSILATERAL lateral vestibular nucleus-postural and LE musculatureMedial: stabilize head in space; input from SCC via CONTRALATERAL medial, superior, and descending vestibular nuclei- cervical musculatureReticulo: postural adjustments, balance reflexes; input from all vestibular nuclei, ipsi &amp; contralateral componenets- allows for inputs from alternative sensory systems
  3. Tinnitus- ringing in the ears
  4. +Perilymph: extracellular fluid in the cochlea+Unknown cause, could be related to: circulation problems, viral infection, allergies, autoimmune reaction, migraine or possible genetic component
  5. Most common: Viral, unilateral and acuteEndolymphatichydrops: abnormal fluctuations in endolymph, similar to MenieresDisease sx.
  6. Vestibular-evokedmyogenic potentials (VEMP) testing of Pt. with migraine: test to determine the function of otolithic organs. After migraine- hyperresponsiveMeneires- hyporesponsive BPPV- latency response is typically prolonged
  7. MEDS:Anithistamines and benzodiazepines: Meclizine, Lorazepam, Clonazepam, Dimenhydrinate, Diazepam, Amitriptyline.Other things you would check in typical head and neck pts: VBI etc.
  8. Impulse test: unilateral- Unilateral vestibdeafferentation bilateral-often ototoxicity
  9. Mastoid bone right behind ear
  10. cold- 86F/30C degrees or belowWarm- 111.2F/44C or above
  11. Active Stepping: the ability to change the BOS without balance loss then to reestabilish COG stability over the new BOS is a balance-dependent skill critical for functional activities
  12. 6 conditions: 1. static EO, 2. staticEC, 3. sway-reference walls, 4.sway-reference floor, 5.sway-reference floor&amp; EC, 6.sway-reference walls&amp;floor -Ratios used to compare and identify impairments: SOM: 1/2, VIS 4/1, VEST 5/1, Visual Preference (3+6)/(2+5)
  13. B-D exercises: 1. sit on the edge of your bed 2. lie down onto the side that causes your dizziness to increase, look towards the ceiling. Stay in this position for 2 mins. 3. sit upright and then wait for 30seconds. 4.Move rapidly to the opposite side for 2mins. 5. Repeat 4-5 times. 6. Do exercises 3x per day for 1 week or until you have been clear of dizziness for 3days.
  14. Summarizes recent RCT’s- treatment effects between CRP and control Pts. Tended to diminish over time. Typically at 1wk, the CRP is very effective at providing symptom resolution for posterior canal BPPV
  15. Also: Gufoni Maneuver &amp; Vannucchi-Asprellaliberatory maneuver
  16. +phobic postural vertigo: 1. dizziness&amp;balance disturbances in upright static position &amp; during motions 2. postural vertigo described as fluctuating unsteadiness 3.vertigo attacks that can occur spontaneously 4. anxiety &amp; distressing vegetative symptoms accompanying &amp; subsequent to the vertigo attacks 5. OCD that affect lability and mild depression 6. increased stress after illness, vestibular disorder