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