Vestibular Assessment from the Physiotherapy Perspective

Bronwyn Kaiser

A.Physiotherapy Coordinator

SCGH Care Coordination Team

Anatomy

Anatomy: Extra Occular Eye Muscles

- Pairing of SCC- SCC paired with 2 Muscles

Muscle CN Pairing Semicircular Canal SCC dyfunction

Medial RectusIII

} HorizontalAbnormal M/L

mvt

Lateral RectusVI

Superior RectusIII

} Posteriorvertical +

torsional mvt

Inferior ObliqueIII

Inferior RectusIII

} Anteriorvertical +

torsional mvt

Superior ObliqueIV

Vestibular dysfunction

• Vertigo and imbalance– Diagnosis needs to determine central

(cerebellum) vs peripheral (labyrinth and semicircular canals of the inner ear) cause

– Multiple peripheral causes (not just BPPV)

Subjective questioning

Headache Migraine Head injury

Visual changes (blurred/double)Photophobia

TinnitusHearing LossAural fullnessPain Recent

URTI/LRTISinus pain

Subjective

• Symptoms– “dizzy”– vertigo, light headed, faint, drop attacks, nausea,

auditory/visual disturbances• Tempo

– latency– Duration– episodic

• Circumstance– When– Where– Easing factors

Objective Eyes Assessment

• Eye ROM

• Gaze Stability

• Saccade Testing

• Smooth Pursuit

• Vestibular Ocular Reflex– Screen– Head Thrust– Dynamic Visual Actuity

Take Home Message

Occular motor testingSee something that isn’t suspected – likely

to have a central origin.– Exceptions:

Non-direction changing gaze evoked nystagmus+ ve Head thrust

Regardless, +ve to any occulomotor test should to be referred on for Medical (ENT/ neuro) opinion

Objective Tests

• Cerebellar tests– Dysdiadokinesia, finger-nose, heel-shin

• Rhomberg test– FTEO vs FTEC

• Sharpened Rhomberg– Feet in front of each other EO vs EC

• Gait– Heel-toe walk

Objective Tests – Semicircular canals

• Dix-Hallpike – anterior and posterior canal– Contra-indications

• MSc: disc prolapse, cervical injury/fracture/trauma• Neuro: cervical myelopathy/radiculopathy• Vascular: dissection carotid/vertebral artery

– Caution• Cardiac surgery within 3/12• Severe orthopnoea • Severe back pain

Dix Hallpike Manoeuvre

Objective tests – horizontal canal

• Horizontal roll test

Differential Diagnoses  Tempo Symptoms Circumstance

BPPV episodic,<1min Vertigo, N&V head changes relative to Gravity

VBI episodic,<1minVertigo, N&V, dipolpia, blurred vision, drop attack EOR E/rotation

Postural Hypotension episodic Faint, dizzy getting up

Vestibular labrythitis

crisis, constant for <4 days

Vertigo, N&V, hearing loss, dysequilibruim

constant, exacerbated with movement, visual disturbance

Vestibular neuritis

crisis, constant for <4 days

Vertigo, N&V, No hearing loss, dysequilibruim

constant, exacerbated with movement, visual disturbance

Menieresepisodic, 20min to 24 hours

Vertigo, N&V, hearing loss, tinnitus, fullness in ear spontaneous and episodic

CVA constant Vertigo, N&V, OTHER NEURO SIGNS constant

Migrane spells for minutes Vertigo, motion sensitivity, dizziness spontaneous or motion provoked

Gentamycin Toxicity constant Vertigo, dysequilibruim, post 1 Dose

Treatments

• Post/ant canal BPPV

– Epley manoeuvre

– Semont Liberatory manoeuvre/ modified Semont

• Horizontal canal BPPV

– BBQ roll / Appiani manoeuvre

– Cassani manoeuvre

• Gaze stabilization exercises

• Substitution exercises

• Habituation exercises

CANALITH REPOSITIONING TREATMENT

LIBERATORY MANOUVER

BRANDT-DAROFF

BBQ TREATMENT

APPIANI MANOUVER

CASANI MANOUVER

POST TREATMENT

• Post Treatment Instructions

THERE ARE NONE!

• Re-Assessment- you can reassess 10 minutes after treatment if the patient is not overly symptomatic

- treat again if necessary

- review as appropriate for your clinical area

CONTRAINDICATIONS & RED FLAGS

• CONTRAINDICATIONS: neck surgery, recent neck trauma, severe RA, atlantoaxial + occipitoatlantal instability, Cx myelopathy or radicaulopathy, carotid sinus syncope, Chiari malformation or vascular dissection syndromes.

• RED FLAGS:- direction changing nystagmus- tinnitus- hearing loss- aural fullness- additional neurological S+S- failure to respond to conservative Rx

***REFER ON to ENT or Neurologist