In-service project for clinical affiliation with Hingham PT, Inc. (Januay 2014-April 2014)
Review of vestibular system, common diagnosis and how to examine, evaluate and treat.
I also reviewed and supplied the clinic with the Four Step Square Test and Dynamic Gait Index in order to allow them to implement these outcome assessments into their clinic for individuals with balance/vestibular deficits
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
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)
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
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
Anterior: 45d anterior to coronal/frontal planePosterior: 45d posterior to coronal/frontal planeHorizontal: 30d superior to transverse plane
Lateral: stabilize body; input from otoliths & 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 & contralateral componenets- allows for inputs from alternative sensory systems
Tinnitus- ringing in the ears
+Perilymph: extracellular fluid in the cochlea+Unknown cause, could be related to: circulation problems, viral infection, allergies, autoimmune reaction, migraine or possible genetic component
Most common: Viral, unilateral and acuteEndolymphatichydrops: abnormal fluctuations in endolymph, similar to MenieresDisease sx.
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
MEDS:Anithistamines and benzodiazepines: Meclizine, Lorazepam, Clonazepam, Dimenhydrinate, Diazepam, Amitriptyline.Other things you would check in typical head and neck pts: VBI etc.
cold- 86F/30C degrees or belowWarm- 111.2F/44C or above
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
6 conditions: 1. static EO, 2. staticEC, 3. sway-reference walls, 4.sway-reference floor, 5.sway-reference floor& EC, 6.sway-reference walls&floor -Ratios used to compare and identify impairments: SOM: 1/2, VIS 4/1, VEST 5/1, Visual Preference (3+6)/(2+5)
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.
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
Also: Gufoni Maneuver & Vannucchi-Asprellaliberatory maneuver
+phobic postural vertigo: 1. dizziness&balance disturbances in upright static position & during motions 2. postural vertigo described as fluctuating unsteadiness 3.vertigo attacks that can occur spontaneously 4. anxiety & distressing vegetative symptoms accompanying & subsequent to the vertigo attacks 5. OCD that affect lability and mild depression 6. increased stress after illness, vestibular disorder