Welcome to Fall CE Event 2015�

Basic Vestibular Function, Examination Procedures,

Diagnosis, and Intervention

Mark Amos, BA, DC, DACNB, FABVR

What’s It About? �

� Fall prevention � 6 million people/ year � Balance disorders and dizziness in top

3 complaints among elderly � Falls leading cause of death and

disability in elderly � 85% of falls are vestibular

Who Falls?�

� Over 55 years old � Someone who has fallen and develops

fear of falling � History of head or neck trauma � Should be evaluated

Anatomy and Physiology of Vertigo and Balance �

� Humans have a very complex system to maintain balance and eye position

� The system relies on vestibular, visual, and proprioceptive input

� This input is translated into neurological signals

Things to Remember �

� Intensity of movement determines intensity of signal

� Vestibular system is capable of self regulation of sensitivity

Localization�

� Vertigo (feeling of motion) is cortical disruption in interpreting spatial orientation

� Nystagmus results from direction specific imbalance of VOR

� Postural imbalance results from inappropriate activation of vestibulospinal pathways

Localization�

� Autonomic symptoms (nausea, vomiting, anxiety) results from activation of the vestibulo-autonomic pathways

Visual System�

� What needs to be said? � Get new glasses � Get checked for cataracts � Get checked for glaucoma

Proprioceptive System�

� Moving joints – it’s what we do � Decreased motion = decreased input � Restored motion = increased input

� More later with cervicogenic vertigo

Vestibular System�

� Works with the other two � Weakness in one will lead to

compensation by the others

Example �

� A diabetic patient with peripheral neuropathy

� Cannot feel his legs or feet � Decreased proprioception � Walks by looking at his feet � Turn off the lights and see what

happens

Vestibular Rehabilitation�

� Certain exercises and maneuvers can correct or mitigate vestibular disturbance

� That’s what we will explore today

2 Vestibular Sensations�

� Otolithic System � Linear acceleration � Static head position

� Canal System � Rotational acceleration

Why Review Anatomy? �

� Understanding anatomy leads to understanding of pathology

� Understanding pathology leads to understanding of treatment � The why’s and how’s

How It Works�� The hair cells stick

straight up � The “hairs” are

ion channels � In the upright

position they are closed

� Note the channels are connected

How It Works�� The “hairs”

deflect with motion of the macula or cupula

� The connections open the ion channels

� Ions rush into the channels and depolarize the cell

How It Works�� The hair cells stick

straight up � The “hairs” are

ion channels � In the upright

position they are closed

� Note the channels are connected

How It Works�

� When the kinocilium bends the opposite direction it makes it harder to open the channel and depolarize the cell

� Inhibition

Otolithic System�

� Utricle- horizontal acceleration � Saccule- vertical acceleration � Utilize otoliths

Otolith System

MaculaCalcium CarbonateOtoliths

Vestibular Nerve

Otolith System

Vestibular Nerve

Head Motion ! (+)

Otolith System

Vestibular Nerve

!Head Motion (-)

Bear 1996

Purves 2001.

Canals �

� 3 canals- angular acceleration � 90º orientation � Ampulla � Cupula

Semicircular Canal

Ampulla

Cupula

CristaAmullaris

Hair

Vestibular Nerve

Semicircular Canal

Ampulla

Cupula

CristaAmullaris Vestibular Nerve

EndolymphFlow ! (+)

Semicircular Canal

Ampulla

Cupula

CristaAmullaris Vestibular Nerve

Endolymph ! Flow(-)

Horizontal Canal

Anterior Canal

Posterior Canal

Top View

Anterior and Posterior Canals �

� Anterior canal activates when the head moves FORWARD and lateral

� Posterior canal activates when the head moves BACK and lateral

Lesions �

Cervicogenic Vertigo �� Whiplash or cervical trauma � Affects COR cervico-ocular reflexes � Affects CSR cervicospinal reflexes � Involves muscle spasm � May be confused with BPPV � Subluxation indicators apply

� Upper cervical � Horizontal canal orientation � Cervical mechanoreceptors develop before vestibular

3 Basic Types �

� Bilateral peripheral loss- patient has feeling of up and down head movement while walking, gait instability, increased difficulty with darkness and uneven ground

� Acute/subacute unilateral loss- causes imbalance in tone, vertigo, body positioning, nystagmus, autonomic symptoms

3 Basic Types �

� Paroxysmal stimulation- short attacks of vertigo

Two Locations�

� Peripheral vestibular lesion � Central vestibular lesion

Peripheral vs. Central�

� Peripheral � Intermittent � Motion provoked � Cause nausea � Consistent

nystagmus

� Central � Constant (usually) � Not motion

dependent � Only fluctuates in

intensity � Variable nystagmus

Peripheral Lesions�

� BPPV � Neuritis � Labyrinthitis � Meniere disease � Fistula-dehiscience � Nerve compression � Bilateral vestibular loss

BPPV�

� Benign paroxysmal positional vertigo � Results from head/neck trauma � Medication use � Dislodges otolithis from the utricle and

saccule into the semicircular canals

BPPV�

� 2 models � Canalolithiasis � Cupulolithiasis

� Otolithic debris causes extreme vertigo, nausea with head position

Normal Canal Function�

Endolymph

!Head Motion

Canalithisiasis �

Canaliths

Canalolithiasis �

� Responds well to repositioning maneuvers

� Purpose is to move the crystals out of the canal

Normal Canal Function�

Endolymph

!Head Motion

Cupulolithiasis �

Cupulolithiasis

Cupulolithiasis �

� Does not respond to canalith repositioning

� Responds well to a liberatory maneuver to break it free

BPPV�

� 3 canals � 3 forms � 90%, 9%, 1% � Posterior, horizontal, anterior

Vestibular Neuritis�

� Acute unilateral viral infection � Usually superior portion of vestibular

nerve (anterior and lateral canals) � Associated with GI or upper respiratory

infection � Lasts 48-72 hours

Labyrinthitis�

� Infection of the membranous labyrinth � Often with upper respiratory infection � Dizziness with hearing loss � Gradual return to function (months)

Meniere Disease �

� Endolymphatic hydrops � Overproduction of endolymph � Feeling of fullness in the ear � Ringing + vertigo � Newer information shows correlation

with autoimmune disorders and migraine

Meniere Disease �

� Does not respond well to vestibular rehabilitation

� Intermittent � Episodes may last minutes to hours � Standard treatment is salt restriction

and /or surgery

Meniere Disease �

� Patient will experience fullness of the ear and ringing

� The there is a sudden change as the membranes rupture

� Tumarkin otolithic crisis

Meniere Disease �

Fistula/Dehiscience�

� Head or neck trauma � Tears an opening in the membranous

labyrinth results in new window and decreased pressure

� Changing pressure or loud noise causes vertigo

Fistula/Dehiscience�

Nerve Compression�

� Will often involve hearing loss

� Often affects facial nerve and trigeminal nerve

� All three emerge at the cerebellopontine angle

Acoustic Neuroma�

Bilateral Vestibular Loss�

� Often medicinal/toxic (mycin drugs) � May be autoimmune � May be infectious � May be longstanding Meniere � May or may not involve hearing � Often has oscillopsia and gait ataxia

Central Lesions�

� Stroke/degeneration/scarring � Constant

� Ischemia � Hyperventilation � Low cardiac output

� Possible low blood sugar

Medulla Lesion�

� Habituation is the key � System will decrease sensitivity

� Chiropractic is a piece of this puzzle � Increase input � Normalize function

� Cawthorn Cooksey exercises

Hyperventilation�

� The exception to the constant rule � May be intermittent � Often with fear of falling leading to

anxiety attack � Anxiety attack leads to hyperventilation

which leads to fall

How?�

� Capillaries have chemoreceptors for carbon dioxide

� More carbon dioxide in the blood means more capillary dilation

� Less carbon dioxide in blood means less capillary dilation and ischemia

How?�

� Decreased CO2 means heart and brainstem ischemia

� Brainstem ischemia leads to dizziness and anxiety and panic and hyperventilation

How?�

� Decreased CO2 means heart and brainstem ischemia

� Heart ischemia leads to angina and therefore panic attack over heart attack and hyperventilation

Hyperventilation�

History Considerations�

BPPV VestibularNeuritis

Labyrinthitis Meniere'sDisease

FistulaDehiscience

NerveCompression

BilateralLoss

Vertigo Yes Yes Yes Yes Yes Yes No

Nystagmus Yes Yes Yes Yes Yes Yes No

Duration 30 sec-2 min

24-72 hours Months 30 min- 24hours

Seconds Seconds tominutes

Periodic

Nausea Yes Yes Yes Yes No Yes No

Specificity Onset withposition

Acute onsetw/ viral inf

Acute onsetw/ viral inf

Fullnessand tinnitis

Tullio orpressure

Frequent tinnitis Severegait

ataxia

Hearing Loss No No Yes Yes No Yes Possible

PrecipitatingAction

Posturalchange

None None None Valsalva Increased ICPFacial

weakness

Drugs

Evaluation �

CTSIB�

� Clinical Test of Sensory Organization in Balance

� Foam Dome Test � 6 conditions

� Help reveal which has failed: vision, proprioception, vestibular

Sensory Organization Test�

� Condition 1 � Stable platform � Eyes open � Utilizes all 3

sensory modalities

Sensory Organization Test�

� Condition 2 � Stable platform � Eyes closed � Relies on

somatosensory and vestibular

Sensory Organization Test�� Condition 3 � Stable platform � Eyes open � Environment moves-

provides false sense of motion

� Patient MUST suppress vision and rely on somatosensory input and vestibular input

Sensory Organization Test�� Condition 4 � Unstable platform � Eyes open � Patient must rely

on vestibular and visual input

Sensory Organization Test�

� Condition 5 � Unstable platform � Eyes closed � Patient must rely

solely on vestibular input

Sensory Organization Test�

� Condition 6 � Unstable platform � Moving environment � Patient must rely entirely on vestibular

input

Positional�

� Head in extension + rotation � Vertebral artery � Cervicogenic � Posterior canal

Cervicogenic Test �

� Patient seated in a spinning stool � Stabilize patient’s head � Rotate patient with head horizontal � Dizziness = Cervical problem � Do what we do best

Vertebrobasilar Artery Test�

� Have patient seated leaning forward � Neck is in extension � Have patient rotate head to one side

then hold 30 seconds � Repeat to other side and hold � Hautant test

Eye Movement Testing �

� Observe nystagmus while stationary � Pursuit � Saccade � Vestibulo-ocular reflex VOR

Pursuit!

!!Cardinal fields of gaze

!! H pattern + convergence

!!Patient should follow smoothly to all positions

Saccade!!!Hold fingers 14

apart !!1-2 in front of

patient !!Patient goes to one

side on command !!Back to neutral !!Go to side on

command

Vestibulo-ocular Reflex!

!!Ask the patient to fixate on doctor

!!Doctor slowly turns head side to side

!!Patient should maintain fixation on doctor

!!Head Thrust Test !!Test VOR a little

faster

Dizziness Simulation Battery�

� Designed to reproduce dizziness � The portion of the test reproducing

dizziness is the cause and then may be addressed

� Helps aid the patient in understanding the cause

Dizziness Simulation Battery�

� Seating vs. standing blood pressure � Carotid sinus reflex � Valsalva test or Tullio � Hyperventilation provocative test � Hallpike Dix maneuver � Lateral canal maneuver � Anterior canal test

Hallpike Dix Maneuver�

� Patient’s head is turned 45º

� This sets the posterior canal parallel to the table

Hallpike Dix Maneuver�

� Patient is quickly lowered back to a head off the table position

� This view shows testing the right posterior canal

� Nystagmus indicates BPPV

Hallpike Dix Movie!

Horizontal Canal

Anterior Canal

Posterior Canal

Top View

Hallpike Dix Position

Anterior Canal

Posterior Canal

Hallpike Dix Maneuver�

� The test focuses on the posterior canal by putting it in a gravity dependent position

� Patient complains of dizziness or develops nystagmus to make the test (+)

Hallpike Dix (+)!

!!Patient is leaned back in the right posterior canal position

!!Eyes will beat upward and right

Nystagmus �

� Will point toward the affected ear � Hallpike Dix will give the plane of the

problem � Observation of nystagmus will reveal

whether it is the posterior canal or the OPPOSITE anterior canal

Horizontal Canal Testing�

� Lay patient supine � Flex head 30º � Turn head side to side � Nystagmus toward the affected ear will

reveal which horizontal canal is involved

Horizontal Canal Movie!

!!The video shows a purely horizontal nystagmus

!!The position places the horizontal canal in a purely vertical orientation

Treatment�

Based Upon Cause �

� Cervicogenic = adjustment � Orthostatic = send patient back to MD � Fistula = rest in bed for several days

until it heals, possible surgery � VBAI = light force adjustment, doppler

unltrsound, MRA � Infection- re-evaluate and VRT as

needed

Hyperventilation�

� Breathing exercises � Lots available on line � 10 breaths/ minute in 2, hold 2, out 2 � Andrew Weil 4, 7, 8 � Work to six breaths per minute � Start 5 minutes work up to 1/2 hour

BPPV�

� Cupulolithiasis = liberatory maneuvers (Semont)

� Canalolithiasis = repositioning maneuvers Epley, Lempert

� ????? = Brandt Daroff

Semont Maneuver�

� To liberate the stuck on cupulolithiasis � Preloads endolymph � Then slams the head opposite � Washes the crystals off the cupula

Semont’s Maneuver �

Posterior Canal Semont!!!Starts like Hallpike !!Turning head lines up

the posterior canal with direction of motion

!!Fall and wait 2-3 minutes

!!Flip and wait 5 minutes !!Important to slam

patient into table repetitively

Horizontal Semont!

!!Clears the horizontal canal by liberating crystals off the cupula

Epley’s Maneuver �

� Specific to posterior canal � Also will clear opposite anterior canal � Starts with Hallpike-Dix position � Moves free floating otoliths through the

canal to drop out into the vestibule � Hold each position 30 seconds or until

dizziness/nystagmus stops

Epley’s Maneuver �

Epley Video!

Vertigone Movie!

DizzyFix�

Bar-B-Que Roll�

� Lempert maneuver � Clears horizontal canal � Put the patient on a spit

Lempert’s Maneuver �

Bar-B-Que Roll Movie!

!!Starts with affected ear down

!!Then is a 450º roll to the opposite side

Anterior Canal!

!!This is the rarest form

!!Patients often have confusing contradictory symptoms

Brandt Daroff Maneuver �

� This is the WTF maneuver � If all else fails maneuver � Promotes habituation � Fall and stay there until the dizziness

stops � Then go the other way

Brandt Daroff Maneuver �

Brandt Daroff Movie!

!!This is used also in conjunction with other maneuvers to promote habituation.

Central Lesion�

� Cawthorn Cooksey Exercise � Starts with eyes � Then head moves � Then seated � Then standing

Cawthorn Cooksey Exercise �

� In Bed Supine � Eye movements done slow then quick � Gazing up and down � Gazing side to side � Accommodation 3 feet to 1 foot � Head movements done slow, then quick,

eyes open, then closed � Flexion extension � Rotation

Cawthorn Cooksey Exercise �

� Sitting � Bed exercises 1-5 � Shoulder shrugging and circles � Bend forward to pick up objects from the

ground

Cawthorn Cooksey Exercise �

� Standing � Bed exercises 1-5 � Sitting exercise 6 �  Sitting to standing eyes open and closed �  Doing same with a turn � Throwing ball hand to hand above eye level � Throwing a ball hand to hand below the

knees

Cawthorn Cooksey Exercise �� While moving � Circle round a person while playing catch � Walking with eyes open and closed � Walking up and down a slope eyes open and

closed � Walk up and down steps eyes open then

closed � Performing stooping, stretching and aiming

motions

Vestibular Rehabilitative Therapy (VRT) �

� Main types � Gaze stabilization � Adaptation exercises � Substitution exercises

Gaze Stabilization�

� Just as it says � Do pursuit exercises

� Track moving target side to side, up and down

� Do Saccade exercises � Look from side to side, up and down

� Do VOR exercises � Look at stationary target move head side

to side and up and down

Gaze Stabilization!!!Combine the above !!x2 viewing- move target and head in opposite

directions !!OKN plus

Adaptation Exercises �

� For unilateral vestibular loss � Main goal is to restore VOR � Use Gaze stabilization exercises � Use head moving exercises

� Walking with head turns � Walking on foam

Substitution Exercises�

� For bilateral vestibular lesion � No restoration of of VOR (no V) � These train patients to use vision and

mechanoreception in place of VOR � Exercises include 1 leg stand, sit to

stand, balance beam, foam walk � Patients also need balance hygiene

Documentation�

� WHO is gearing more toward quality of life

� Describes how a balance disorder may turn into a handicap

� This underscores the importance of rehabilitation

Documentation�

� The patient perception of the problem is the handicap or disability

� Even the patient who has been rehabilitated with no symptoms may be disabled by fear of falling or recurrence

� Documentation = patient education? � Documentation = psychological

recovery?

Documentation�

� Activities-Specific Balance Confidence Scale

� Dizziness handicap inventory � Vertigo score card

Activities-Specific Balance Confidence ScalePatients are asked to fill in one of the following percentages for each individual question.Even if the patient does not perform the activity now, the patient should consider theactivity and assign a confidence rating. A rating of 100% indicates certainty thatunsteadiness or loss of balance will not result from that activity. If an aid is usually usedto perform the activity, rate the activity as though performing with the aid.

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%No Confidence Complete Confidence

_____ 1. Walking around the house._____ 2. Walking up and down stairs inside the home._____ 3. Picking up a slipper or something from the floor_____ 4. Reaching at eye level._____ 5. Reaching overhead while standing on toes._____ 6. Reaching overhead while standing on a chair._____ 7. Sweeping the floor._____ 8. Walking outside to a nearby car._____ 9. Getting in and out of a car or other transportation._____ 10. Walking across a parking lot._____ 11. Walking up and down a ramp._____ 12. Walking in a crowded area where people walk rapidly past you._____ 13. Being bumped while walking in a crowd._____ 14. Using an escalator while holding the railing._____ 15. Using an escalator while holding packages without holding the railing._____ 16. Walking on slippery floors or icy sidewalks.

Total Average Score _____ (< 68% = low mobility, increased fear)

Powers and Myers, 1995.

Dizziness Handicap Inventory

Patient Name: ______________________________ Date: _______________

The purpose of this scale is to identify difficulties that you may be experiencing becauseof your dizziness or unsteadiness. Please answer "Yes," "No," or "Sometimes" to eachquestion by writing the corresponding letter in the blanks to the right of the questions.Answer each question as it pertains to your dizziness or unsteadiness only.

Y = Yes S = Sometimes N = No

Physical 1. Does looking up increase your problem?Emotional 2. Because of your problem do you feel frustrated?Functional 3. Because of your problem, do you restrict your travel for business or recreation?Physical 4. Does walking down the aisle of a supermarket increase your problem?Functional 5. Because of your problem, do you have difficulty getting into, or out of bed?

Functional 6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to movies, dancing, or to parties?

Functional 7. Because of your problem, do you have trouble reading?

Physical 8. Does performing ambitious activities like sports, dancing, household chores such as sweeping or putting dishes away increase your problem?

Emotional 9. Because of your problem are you afraid to leave your home, without having someone to accompany you?

Emotional 10. Because of your problem, have you been embarrassed in front of others?Physical 11. Do quick movements of your head increase your problem?Functional 12. Because of your problem, do you avoid heights?Physical 13. Does turning over in bed increase your problem?

Functional14. Because of your problem, is it difficult for you to do strenuous housework or yard work?

Emotional 15. Because of your problem, are you afraid people may think you are intoxicated?Functional 16. Because of your problem, is it difficult for you to go for a walk by yourself?Physical 17. Does walking down a sidewalk increase your problem?Emotional 18. Because of your problem, is it difficult for you to concentrate?

Functional19. Because of your problem, is it difficult for you to walk around your house in the dark?

Emotional 20. Because of your problem, do you feel handicapped?Emotional 21. Because of your problem, are you afraid to stay home alone?Emotional 22. Has your problem placed strain on you relationships with family and friends?Emotional 23. Because of your problem, are you depressed?Functional 24. Does your problem interfere with your job or household responsibilities?Physical 25. Does bending over increase your problem?

FOR OFFICE USE ONLY: ___ Initial Visit ___ Follow-up VisitFunctional (36) ___ Emotional (36) ___ Physical (28) ___Scoring: Yes = 4; Sometimes = 2; No = 0

Jacobson and Newman 1990.

Vertigo Score CardPosition Changing StimuliDo You Get Dizzy…….. No Yes1. Bending down to pick up something from the floor?2. Looking up?3. On first laying in bed?4. Upon turning left or right?5. When walking in the dark?Subtotal

No = 1Yes = 0

Visual StimuliDo You Get Dizzy……….. No Yes1. Walking between shelves in a store?2. Sitting in a moving vehicle?3. Ironing striped material?4. Walking up or down stairs?5. Walking up an escalator?Subtotal

Total

Developed by Savundra 1993