Vestibular Rehabilitation Inservice
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Transcript of Vestibular Rehabilitation Inservice
Vestibular RehabilitationAmy 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-
sensation
Vestibular
SystemVision
Environmental Interaction
Select & adjust muscle contractile pattern
Generation of body movement
Dizziness and Fall RiskAPTA 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 conscious perception of orientation & rotation
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 systems
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 CanalMost common in 5-7th decades of life
◦ Degeneration of cilia during natural agingCharacterized by: acute, discrete episodes of brief
positional vertigo without associated hearing loss◦ Resolution of sx within 60sec.of sustained position
Differential Diagnosis of BPPV5
Peripheral Central
Meniérès DiseaseVestibular neuritisLabyrinthitisSuperior 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 vertigoChronic 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 balanceAny age, most common 40-60yoTx: 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
movementsNo diagnostic test to confirm
◦ Difficult to truly diagnose- rule out other conditionsDizziness 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 testingTest for hearing lossCaloric TestingAssess static and dynamic balanceAssess routine postural transitions
◦ Sit-supine, rolling, forward leaning, historyAlso 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,
5Hallpike- 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◦ Also used in testing for brainstem lesions. Bilateral hyper- or hypo-
reflectivity
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, post-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/_index.htm?prodid=57249
“Balance Master” Computerized Dynamic
Posturography 6 conditions Pt. relative reliance on
visual, vestibular, and 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=483
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 PerfectOculomotor testingVOR testingBPPV testingOutcome Measures
◦Dynamic Gait Index◦Four Square Step Test
Instructional Exercises
Any Questions?
Vestibular Rehabilitation
Gordon College: Center for Balance, Mobility & Wellness (Wenham, MA)
References1. 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