whitney huryta-vestibular rehabilitation in the acute...
TRANSCRIPT
VestibularRehabilitationintheacutesetting
Presentationby:WhitneyWilson,SPT
LearningObjectives
• Attheendofthepresentationyouwillbeableto:– Brieflydescribetheanatomyandphysiologyofthevestibularsystem
– Understandtheroleofvestibularsysteminbalanceandposture
– Describeterminologyrelatedtodizziness– PerformbasicPTexamforPtwithdizziness– DetermineifaPthasBPPVandutilizetheEply maneuver– Prescribevestibularrehabilitationincludingadaptation,habituationexercises
Arewethereyet?
• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture
• Terminologyrelatedtodizziness
• PTexam• BPPVandtheEplymaneuver
• Vestibularrehabilitation
AnatomyandPhysiologyofVestibularSystem1,2
Labyrinth
Organof
hearing
Vestibule
3canals
SemicircularCanals1,2
Angularacceleration
OtolithOrgans:UtricleandSaccule1,2
Staticandlinear
acceleration
VestibularProjectionPathways1,2
PhysiologyoftheVestibularSystem1,2
• 1.VestibularOcularReflex(VOR)– Stabilizationofgazeduringheadmotion
• 2.Vestibulospinal Reflex(VSR)– Posturalresponsestoheadmovementforstabilizationofthebody
• 3.Vestibulo-collic reflex(VCR)– Stabilizationoftheneckmminrelationtoheadmovements
VOR3
VSR4
• MaintainsEquilibriumandcenterofgravity
PhysiologyoftheVestibularSystem:VCR2
MedialVestibularNucleus
MLF
Arewethereyet?
• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture
• Terminologyrelatedtodizziness
• PTexam• BPPVandtheEply maneuver• Vestibularrehabilitation
PurposeoftheVestibularSystem4
• Sensory– Perceptionofmotionandorientation• Angularacceleration• Linearacceleration• Positioninrelationtogravity
• Motor– Controlofeyemovementtopermitclearvisualimageofsurroundings
–Maintenanceofequilibriumandpositioninrelationtogravity
VestibularSystemRolesinBalanceandPosturalControl2,4
• Vestibularmechanismscontrolneck,trunkandhipmmactivationinordertostabilizethehead
Somatosensorymoreresponsible:• Firm,big
surface• Slow,lowamp
perturbation• Mmrecruited
distal-prox• Headinphase
withhips
Vestibularsystemmoreresponsible:• Unstable,small
surface• Fast,largeamp
perturbation• Mmrecruited
prox-distal• Headoutof
phasewithhips
Arewethereyet?
• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture
• Terminologyrelatedtodizziness• PTexam• BPPVandtheEply maneuver• Vestibularrehabilitation
Terminology:Whatdoyoumeandizzy?!
– Dizziness4,6:• Distortionofspatialawareness
– 4Maintypes1,2,4:• 1.Vertigo• 2.Imbalance/Disequilibrium• 3.Lightheadedness/presyncope• 4.Other(psychiatric,hyperventilation,encephalopathies,multisensory,etc.)
Thisbeingsaid…Typeofdizzinessisleastreliablefactor,butwemustworkwithwhatwe’vegot,right?
Vertigo1,4,5
• anillusionofmovement(selforsurroundings)– rotation ismostcommon– canalsobetranslational(rising)orstaticreorientation (tilting)
• BPPV• earinfections• viralneurolabyrinthitis• Meniere’sdisease(orendolymphatichydrops)
Imbalance/Disequilibrium1,4
• “dizzyinyourheadorinyourfeet?”
• Vestibularloss• Proprioceptiveorsomatosensoryloss
• Motorandcerebellarlesions
Lightheadedness/Presyncope4
Lightheaded
OrthostaticChangesofposition Spontaneous
ArrhythmiaOrthostaticHypotension:• Dehydration
• AdverseeffectofCVmed
• CardiacDysfunction
Arewethereyet?
• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture
• Terminologyrelatedtodizziness
• PTexam• BPPVandtheEplymaneuver
• Vestibularrehabilitation
Meclizine4 =CNSdepressant
• Neg.impactonVest.Rehabprogram2/2preventionof
centraladaptation• Dec.Nystagmusandvertigo
responsetotesting
PTevaluationfora“dizzy”Pt1,4
• History• Dizzinessinventory/questionnaire• Medications• Vision/GazeStabilityTesting• VOR/VORcancellation• Positionaltesting• Posturalcontrolassessment/BalanceAssessment
History1,4
• Typeofdizziness• Spontaneousv.motioninduced
• Duration• Frequency• Provocativefactors• Auditorycomplaints• Falls
Red Flags4
• Declineinhearing• Dysarthria• Discoordination• Diplopia• Decreasedmentationandurinaryincontinence• Declineinstrength/weight• Decreasedconsciousness• DysfunctionattributabletoCNdysfunction
D’s
DHI
Medications1
Nystagmus1,7
+DixHallPike
• Namedbyfastphase• Peripheralnystagmus:– fast=awayfromlesion– alwaystosamesidenomatterwheregaze
• Centralnystagmus:– Changesdirections
PTEvaluation1,4,7
• Eyemovement- “H”– Smoothpursuits– Extraoccular eyemovement– Endrangenystagmus
• Convergence• Saccades• VOR• VORcancellation• Headthrust
Practice
HeadThrustTest1,4,7
• TestshighfrequencyVOR• Normal:Ptsgazeshouldremainfixedonexaminer’snose• Abnormal:
– Hypoactive:correctivesaccadeindirectionoppositeheadthrust=diminishedipsi VOR
– Hyperactive:correctivesaccadeindirectionofheadthrust=centralvestibulardysfunction
• Sensitivityismaximizedwhen:– Unpredictableheadthrustsareperformed– Velocity>180deg/sec
HeadThrustVideo
Practice
PeripheralorCentral8?
BalanceAssessment1,4
• Rhomberg/SharpenedRhomberg• FunctionalReach• BergBalanceScale• Tinetti BalanceandGait
Assessment• Timed“UpandGo”test• DynamicGaitIndex• PhysicalPerformanceTest• ClinicalTestofSensory
InteractioninBalance(CTSIB)• BalanceMaster
Otherstoconsider:• Gaitspeed• 5xSTSor30secSTS
• TUG• FunctionalReach
Arewethereyet?• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture• Terminologyrelatedtodizziness• PTexam• BPPVandtheEply maneuver• Vestibularrehabilitation
Alternativecausesofpositionaldizziness/nystagmus
• Migrainous positionalvertigo
• Orthostatichypotension• Peripheralvestibularhypofunction
• phobia
• MS• TumororCVAnearcerebellarvermis
• Superiorcanaldehiscence
• VestibularParoxysmia/vascularcompressionof8thnerve
BenignParoxysmalPositionalVertigo4,9,10
• CommonComplaints:– Rolling– Reachingtofloor,ceilingortopshelf
– Washinghair– Workingundercar– Changinglightbulb– Dentalchair– Diagnosticproceduresinvolvingheadposition
Cupulolithiasis4,9,10
• Otoconia adheretocupulaofaffectedsemicircularcanal
• Canalbecomesgravitysensitive(notnormalfx)
• Characteristics:– Immediateonsetvertigoandnystagmus
– Sx duration:longlasting,graduallydecaysoveraperiodofminutes
Canalithiasis4,9,10
• Freefloatingotoconiawithinthesemicircularcanal=abnormalendolymphaticflowinaffectedcanal
• Characteristics:– Latencyrange:1-40sec– Nystagmusandvertigo
followinglatency(5-45sec)– Reversalofnystagmus– Temporarilyfatigueswith
repetition
TestingManeuvers:PosteriorBPPV• DixHallpike4,9,10
Video• Sidelying11
Video
EyemovementsforBPPV
• PosteriorCanalBPPV- Canalithiasis– Torsionipsi totheeardownandupbeat
• HorizontalCanalBPPV- Canalithiasis– Horizontalgeotrophic (towardtheground)
• HorizontalCanalBPPV- Cupulothiasis– Horizontalageotrophic (awayfromtheground)
• AnteriorCanalBPPV(rare)- Canalith orCupulo– Torsiontotheaffectedsideanddownbeat
TreatmentforBPPV:Eply’s4,9,10,12
PostManeuverInstructions4
• SleepinRecliner– Slightlyelevateheadendofbed:wedge/extrapillow
– Sleeponunaffectedsidetoreducerecurrence(shingeno 2012)
• Education:ItcanreoccursoteachPthowtoself-diagnose
Arewethereyet?• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture
• Terminologyrelatedtodizziness
• PTexam• BPPVandtheEplymaneuver
• Vestibularrehabilitation
GazeStabilizationExercises4,7
VORx1&x2
HabituationExercises13
BalanceExercises7
LearningObjectives
• Attheendofthepresentationyouwillbeableto:– Brieflydescribetheanatomyandphysiologyofthevestibularsystem
– Understandtheroleofvestibularsysteminbalanceandposture
– Describeterminologyrelatedtodizziness– PerformbasicPTexamforPtwithdizziness– DetermineifaPthasBPPVandutilizetheEply maneuver– Prescribevestibularrehabilitationincludingadaptation,habituationexercises
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Yes!We’reThere!AnyQuestions?!
References1. McCulloch K. Vestibular Dysfunction: Physical Therapy Intervention. 2016.2. Kernick. Modulation of Movement by the Cerebellum Part 2. 2016.3. Bajandas FKline L. Neuro-Ophthalmology Review Manual. Thorofare, NJ: Slack Inc.; 1988:Figure 4-6 Horizontal eye movement pathways.4. Walter J. Vestibular Rehabilitation Therapy: Practical Management of the Patient with Dizziness and Balance Dysfunction. 2014.5. Furman JCass S. Balance Disorders. Philadelphia: F.A. Davis; 1996.6. Drachman D. A 69-Year-Old Man With Chronic Dizziness. JAMA. 1998;280(24):2111. doi:10.1001/jama.280.24.2111.7. Otoneurology Index. Dizziness-and-balancecom. 2016. Available at: http://www.dizziness-and-balance.com. Accessed June 14, 2016.8. namrata. Nystagmus. Slidesharenet. 2016. Available at: http://www.slideshare.net/namratagupta96780/nystagmus-namrata. Accessed June 14, 2016.9. Wahlgren APalombaro K. Evidence-Based Physical Therapy for BPPV Using the International Classification of Functioning, Disability and Health Model. Journal of Geriatric Physical Therapy. 2012;35(4):200-205. doi:10.1519/jpt.0b013e318247a243.10. BHATTACHARYYA N, BAUGH R, ORVIDAS L et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology - Head and Neck Surgery. 2008;139(5):S47-S81. doi:10.1016/j.otohns.2008.08.022.11. Cohen H. Side-Lying as an Alternative to the Dix-Hallpike Test of the Posterior Canal. Otology & Neurotology. 2004;25(2):130-134. doi:10.1097/00129492-200403000-00008.12. Helminski J, Zee D, Janssen I, Hain T. Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review. Physical Therapy. 2010;90(5):663-678. doi:10.2522/ptj.20090071.13. Clendaniel R. The Effects of Habituation and Gaze Stability Exercises in the Treatment of Unilateral Vestibular Hypofunction: A Preliminary Results. Journal of Neurologic Physical Therapy. 2010;34(2):111-116. doi:10.1097/npt.0b013e3181deca01.