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Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders. Burt DeWeese, PT, MCMT Rebound Physical Therapy Vestibular Rehab Specialist [email protected] Background. Graduate of Kansas State University, 1999

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vestibular rehabilitation evaluation and treatment strategies for common vestibular disorders
Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders

Burt DeWeese, PT, MCMT

Rebound Physical Therapy

Vestibular Rehab Specialist

[email protected]

background
Background
  • Graduate of Kansas State University, 1999
  • Master’s in Physical Therapy from Mayo School of Health Sciences, Rochester, MN, 2002
  • Completed APTA Competency Based Certification Course: Vestibular Rehabilitation-Emory University, 2004
  • Working toward manual therapy certification through NAIOMT – will complete level III this year
  • Clinical Director at Rebound Physical Therapy, Topeka, KS
objectives
Objectives
  • Describe the anatomy and physiology of the vestibular system.
  • Describe the pathophysiology of common vestibular disorders.
  • Complete and interview and examination of a person with vestibular dysfunction.
  • Identify appropriate standardized assessment tools for use in vestibular rehabilitation.
  • Demonstrate skill in performing the occulomotor exam.
  • Demonstrate skill in differentiating between types of BPPV.
  • Identify appropriate treatment intervention with patients with vestibular disorders.
anatomy of the ear1
Anatomy of the Ear
  • The External Ear
    • External auditory canal
    • Ends at the tympanic membrane
  • The Middle Ear
    • Space between the tympanic membrane and the inner ear
    • Contains the malleus, incus and stapes
    • Transmits sound into waves inside the cochlea
    • Filled with air
anatomy of the ear2
Anatomy of the Ear
  • The Inner Ear
    • Contains sensory organs for hearing and balance
    • Bony labyrinth within the temporal bone
    • Central portion is names the vestibule
  • Saccule and Utricle
    • Cochlea is anterior and vestibular portion post
    • Tissue layers: bony labyrinth, perilymph, membranous labyrinth, endolymph
the labyrinth
The Labyrinth
  • Bony Labyrinth
  • Perilymph
      • Between bony and membranous labyrinth
    • Membranous labyrinth
  • Endolymph
      • Inside membranous labyrinth

Parnes, 2003

the labyrinth1
The Labyrinth
  • 3 Semicircular Canals
      • Anterior, Posterior Horizontal
  • Cochlea
      • Hearing component
  • Vestibule
      • Saccule and Utricle
the hair cell
The Hair Cell
  • Found in cochlea, semicircular canals, saccule and utricle
  • Send in information to the vestibularcochlear system
  • “Hair” of the hair cell consists of:
      • Sterocilia (40-70 in one hair cell)
      • Kinocilium (1 per hair cell)
semicircular canals
Semicircular Canals
  • Hair Cells
  • Motion Sensors
      • Always sending info to the brain
  • Kilocilia
      • Deflection Towards- Excites
      • Deflection Away- Inhibits
semicircular canals1
Semicircular Canals
  • Provides input about angular head velocity
  • Three canals on each side
      • Anterior (superior), Posterior (inferior) & Horizontal (lateral)
      • 90 degree angle from each other
      • Horizontal canal
          • 30 degree elevation
semicircular canals2
Semicircular Canals
  • Mate on the opposite side
      • L ant/R post, R ant/L post
  • Each semicircular canal has a ampulla housing the sensor organs
      • Hair cells covered by the cupula
  • Both ends terminate in the utricle
the otoliths
The Otoliths
  • Utricle (Linear)
      • Horizontal Movements
      • Head Tilt
  • Saccule (Linear)
      • Up & Down Movements
  • Otoconia “Ear Rocks” (Calcium Carbonate Crystals)
  • Hair Cells

Herdman, 2000

vestibular occular reflex
Vestibular Occular Reflex
  • Allows clear vision through gaze stabilization
      • Coordinates eye and head movements
  • Sensory stimulation sends info to the brainstem region that controls eye movement
  • Example: Head left, eyes turn right while focusing on an object
      • R lat rectus/L med rectus excited and opposite inhibited
causes of vertigo
Causes of Vertigo

Herdman, 2000

causes of vertigo1
Causes of Vertigo
  • BPPV
  • Vestibular Neuritis
  • Labyrinthitis
  • Meniere\'s Disease
  • Bilateral Vestibular Loss
  • Cervicogenic Dizziness
common disorders

Semi-Circular

Canals

Inflammation of the

Vestibular Nerve

Cochlea

Common Disorders
  • Vestibular Neuritis
    • Symptoms
      • Sudden onset of vertigo
      • Nausea/vomiting
      • Imbalance
      • Sensitivity to motion
    • Last hours to days
    • Can result in chronic dysequilibrium
    • Caused by viral infection
    • Treatment

Inner Ear

common disorders1
Common Disorders
  • Vestibular Labyrinthitis
    • Viral or bacterial infection of the membranous labyrinth
    • Acute onset of hearing loss, vertigo, nausea/vomiting
    • Can last 1-4 days
    • Will demonstrate imbalance and sensitivity to head movements
common disorders2
Common Disorders
  • Meniere’s Disease
    • Increased endolymph pressures
    • Episodic
    • Low frequency hearing loss
    • Tinnitus
    • Can last hours to days
common disorders3
Common Disorders
  • Fear of Falling
  • Disuse Dysequilibrium
  • Orthostatic Hypotension
  • Cervicogenic Dizziness
  • Anxiety
common disorders4
Common Disorders
  • Central
    • TBI
    • CVA
    • Multiple Sclerosis
vestibular evaluation
Vestibular Evaluation
  • Subjective component
    • Thorough History
    • Dizziness Handicap Inventory
    • ABC confidence scale
common questions
Common Questions
  • Tell me about your symptoms.
  • When did your symptoms begin?
  • How long did/does your symptoms last?
  • Are your current symptoms better, worse or the same?
  • Can you rate the severity of your symptoms 0-10/10?
  • Do your symptoms increase with positional changes or certain movements?
  • Do you have difficulty with keeping objects in focus?
  • Do you have ear fullness, pressure, ringing or hearing loss?
  • Do you have a history of these symptoms?
  • Have you had any falls or unsteadiness?
  • Currently what meds are you taking?
vestibular evaluation1
Vestibular Evaluation
  • Bedside Exam
    • Occulomotor
        • Smooth Pursuit
        • Saccades
        • VOR
        • VOR cancellation
        • Head Thrust/Head Shake
    • Upper and lower extremity screen
    • Cervical screen-may choose to do first
vestibular evaluation2
Vestibular Evaluation
  • Other testing options
    • Videonystagmogtaphy (VNG)
    • Caloric Testing
        • Test horizontal semicircular canals only
        • External auditory canal is irrigated with warm and cold water with head in 30 degrees flex
        • Significant finding 25% or more reduction indicates a unilateral weakness
observation tools
Observation Tools
  • Frenzel Goggles
  • Video Frenzel Lenses
  • Room Light
vestibular evaluation3
Vestibular Evaluation
  • Functional Testing
    • Dynamic Gait Index-videos
    • Berg Balance Scale
    • Timed Up and Go
    • Static Balance Testing
        • Eyes Open/Eyes Closed
        • Head turns
        • Firm and Foam
timed up and go
Timed Up and Go

Timed Up and Go (secs) (7,12,14)

Back against chair, arms on armrests –get up and walk at comfortable place to line 3 meters away, return to chair and sit down; repeat, take average

Age Male Female

(years)

60-69 8 8

70-79 9 9

80-89 10 10

Time < 10 seconds is normal

11-20 seconds is normal for frail elderly

>14 seconds indicates risk for falls

>20 seconds indicates impaired functional mobility

>30 seconds indicates dependency in most ADL and mobility skills

  • Video
static balance testing
Static Balance Testing
  • Modified CTSIB
  • Ground-Eyes open and closed
  • Foam-Eyes open and closed
  • ½ Tandem and Tandem
  • SLS
  • Computerized Dynamic Posturography
bppv statistics
BPPV Statistics
  • BPPV is the most common cause of vertigo in patients with vestibular disorders (Bath et al, 2000)
  • About 20% of all dizziness is due to BPPV (Hain, 2010)
  • About 50% of all dizziness in older people is due to BPPV (Hain, 2010)
bppv defined
BPPV Defined
  • Benign- It does not signify anything life-threatening. Not malignant.
  • Paroxysmal- Refers to the fact that the episodes are brief and self-limited – "paroxysm" means "attack."
  • Positional-Change in position provokes symptoms.
  • Vertigo-Room spinning sensation.
causes of bppv
Causes of BPPV
  • “Idiopathic”-50%-70%
  • Head injury- 7%-17%
  • Viruses
      • Vestibular neuritis- 15%
  • Degeneration?
slide42
BPPV
  • Nystagmus
    • Non-voluntary oscillation of the eye
    • Defined fast and slow phases in opposite direction
    • Fast phase defines direction of nystagmus
    • Semicircular canals connected to specific eye muscles, which dictates direction of nystagmus
    • Video
bppv nystagmus
BPPV – Nystagmus
  • Posterior canal
      • Up-beating, torsional nystagmus toward involved ear
      • http://youtu.be/siL3MTNUIQI
  • Anterior canal
      • Down-beating, torsional nystagmus toward involved ear
  • Horizontal canal
      • Lateral, slight torsional nystagmus, greater toward involved ear
      • http://youtu.be/MtmkD5rDU0o
occurrence rates
Occurrence Rates
  • Percentages
    • Posterior canal- 92% occurrence
    • Horizontal canal- 6% occurrence
    • Anterior canal- 2% occurrence
  • Once patient has had BPPV, re-occurrence rate is about 25-30%
slide45
BPPV
  • Classic Symptoms
    • Room spinning, nausea, imbalance
    • Brief episodes of vertigo with changes in head position relative to gravity
      • Lying down in bed
        • Sitting up from lying down
        • Rolling over in bed
        • Bending over
        • Looking up- Top Shelf Syndrome
challenges
Challenges
  • Musculoskeletal restrictions
      • Pain
          • cervical, lumbar, shoulder and hips
      • Fear of falling off table in sidelying when spinning
      • Hip replacements
  • Use of table/plinth
bppv clinical exam
BPPV – Clinical Exam
  • Dix-Hallpike Test
      • 45 degree cervical rotation
      • Align canals with gravity
      • Sit to supine with 20 deg of cervical extension
      • Look for nystagmus and symptoms of vertigo
  • Practice

Herdman, 2000

bppv clinical exam1
BPPV – Clinical Exam
  • Typical Nystagmus
    • Latency- before nystagmus starts
        • 1-30 seconds
    • Direction
        • Mixed up-beating, torsional nystagmus (post.)
    • Duration
        • Less than 1 minute
  • Fatigues with repeated testing
bppv clinical exam2
BPPV – Clinical Exam
  • All you need to know…
      • Direction
          • The direction of the elicited nystagmus will tell you which canal is involved
      • Duration
          • Will tell you the type of BPPV
bppv clinical exam3
BPPV – Clinical Exam
  • Two types of BPPV
    • Canalithiasis (A)
    • Cupulolithiasis (B)
bppv canalithiasis
BPPV – Canalithiasis
  • Otoconia are freely moving in the canals
  • Fall to the lowest point in canal
  • Induces flow of endolymph
  • Deflection of cupula
  • Fatiguing Nystagmus
      • Last less than 1 min
bppv canalithiasis1
BPPV – Canalithiasis
  • Video Animation
    • http://youtu.be/IHfU2cA7eRo
bppv cupulolithiasis
BPPV – Cupulolithiasis
  • Otoconia are adherent to the cupula of the semicircular canal
      • Increased density of cupula
      • Sensitive to gravity
      • Persistent-last greater than 1 min

Hain, 2010

patient response
Patient Response
  • Sensation of spinning
      • May feel like they will fall of the table
  • Clammy
  • Sweating
  • Nauseous
  • Vomitus
canal alignment reminder
Canal Alignment Reminder
  • Will treat R post. canal and L ant. canal the same way
  • Opposite eye movement
      • Post-Up beat/Rot
      • Ant-Down/Rot
bppv treatment posterior anterior canals
BPPV Treatment –Posterior/Anterior Canals
  • Canalith Repositioning Technique
  • Starting Position is Dix-Hallpike
  • Nystagmus should be same direction in all positions
  • Practice
liberatory or semont maneuver
Liberatory or Semont Maneuver
  • Used for Cuplulolithiasis
  • Posterior and Anterior Canal
  • Rotate head 45 degrees away from affected side
  • Quick movements to jar otoconia loose

Parnes, 2003

case study
Case Study
  • 74 yo female with past medical history of BPPV
  • Slipped and fell at home
  • Hit her head on the floor
  • Admitted to hospital for 2 days
  • Patient self report of BPPV
  • Dizziness with getting in bed and rolling to the left
  • Patient positive for Left Posterior Canal BPPV
  • Treatment-Left CRT
case study1
Case Study
  • 68 yo male with sudden onset of dizziness
  • Increased with rolling over in bed and looking up
  • Mild imbalance in Romberg eyes closed position
  • Positive R Dix-Hallpike with persistent upbeating and R torsional nystagmus
case study2
Case Study
  • All other evaluation info was negative
  • Treatment
      • Semont Maneuver performed
      • Then performed CRT for post canal BPPV, once otoconia are dislodged from cupula
      • Symptoms were resolved after one visit
horizontal canal bppv
Horizontal Canal BPPV
  • How do you test? Roll Test
  • Head in 30 degrees flexion
  • Rotate head either direction
  • Nystagmus will be lateral
  • Treat the side with greater symptoms

Herdman, 2003

horizontal canal bppv1
Horizontal Canal BPPV
  • Canalithiasis
      • Eyes will beat geotropic
  • Cupulolithiasis
      • Eyes will beat ageotropic

Parnes, 2003

horizontal canal bppv2
Horizontal Canal BPPV
  • Horizontal Canal CRT
      • Barbeque Roll
      • Head rotated to involved side first
      • Roll away from involved side
      • Keep head in 30 degrees flexion

Herdman, 2000

horizontal canal bppv3
Horizontal Canal BPPV
  • HC- Semont maneuver
  • Used for Cuplulolithiasis
  • Horizontal Canal
  • Head in neutral position
  • Quick movements to jar otoconia loose
  • Then perform CRT
bppv treatment
BPPV Treatment
  • Post-Treatment Instructions- typically 24 hours
      • Avoid lying down until you go to bed.
      • Avoid up and down head movements.
      • Prop head up at night with pillows.
      • Avoid sleeping on affected side.
  • Debate
other treatment options
Other Treatment Options
  • Brandt-Daroff
  • Home CRT
  • Balance retraining
  • Surgery-canal plugging
brandt daroff exercises
Brandt-Daroff Exercises
  • 3-5 cycles
  • 3 times per day
  • Hold position for 30 seconds after vertigo stops

Parnes, 2003

home crt
Home CRT
  • Same as CRT
  • Place pillow under shoulders
  • Tip head over pillow and rest on mattress
balance re training
Balance Re-training
  • Progress toward balance activities if the patient continues to have imbalance.
  • Will discuss balance activities in the Vestibular Rehabilitation section.
output of cns
Output of CNS
  • Vestibulo-Ocular Reflex (VOR)
      • Allows clear vision while the head is in motion.
  • Vestibulo-Spinal Reflex (VSR)
      • Generates compensatory body movement in order to maintain head and postural stability.
    • Prevents Falls
vestibular function testing
Vestibular Function Testing
  • Video Infrared Recording
    • Eye Movements and Head Shake
    • BPPV
  • Caloric Testing
  • Head and Eye Movements
    • Saccades, Smooth, Pursuit, Head Thrust, Slow VOR
vestibular testing
Vestibular Testing
  • Computerized Dynamic Posturography
  • Dynamic Visual Acuity
  • Dynamic Gait Index
  • Static Balance Testing
      • Romberg, Sharpened Romberg, SLS
  • Timed Up and Go
treatment theory for dysfunctions
Treatment Theory for Dysfunctions
  • Compensation
      • Response to permanent vestibular lesion.
      • Goals- approximate normal gaze stability and postural control.
      • CNS changes to optimize function.
      • Visual input important.
  • Mechanism for Compensation- Habituation
treatment theory1
Treatment Theory
  • Habituation
      • Long-term reduction of a response to a noxious stimulus.
      • Repeated movements of provocative stimulus.
      • Patients who move more, improve more.
      • Need to provoke symptoms to reduce symptoms.
      • Examples (MSQ)
treatment theory2
Treatment Theory
  • Adaptation
      • Long term changes in neuronal responses.
      • Goals
          • Decrease retinal slip- gaze stabilization.
          • Improve postural stability.
          • Decrease symptoms.
          • Decrease sensitivity.
          • Increase balance and function.
treatment exercises
Treatment Exercises
  • Based on Models of VOR
      • Retinal Slip and Head Movements
  • Main Exercises
      • x1 and x2 Viewing Exercises
treatment exercises1
Treatment Exercises
  • Guidelines
      • Target Seen Clearly
      • Head Movement +/- 30 degrees
      • Smooth
      • Continuous
      • Pushes Upper Limit
treatment exercises2
Treatment Exercises
  • Progression
      • Duration: 1-2 minutes
      • Frequency: 3-5x/day
      • Target Size: Small
      • Position of Head: Level, Slightly Down
      • Position of Patient: Sit, Stand
      • Target Distance: Near, Far
      • Compliant vs. Non-Compliant Surface
treatment exercises3
Treatment Exercises
  • Active Head Movements b/t 2 Targets
  • Remembered Target
  • Walking Fwd/Bwd with Head Turns
  • Bean Bag Toss (1 & 2)
  • 180 & 360 Degree Turns
  • Ball Against Wall
  • Walk in Circle with Ball Toss
treatment exercises4
Treatment Exercises
  • Sit to Stand with head turns
  • Wobble board with head turns
  • Hurdles with ball toss
  • Obstacle course
  • Stairs
balance re training1
Balance Re-training
  • Romberg
  • ½ Romberg
  • Full Romberg
  • On ground and on foam
  • Add head turns
home exercise program
Home Exercise Program
  • All the previous discussed exercises
  • Can modify as needed
  • Can create any exercise incorporating head and eye movements
      • Include balance activities.
billing
Billing
  • PT evaluation- 97001
  • Neuromuscular Re-ed-97112
  • Canalith Repositioning-95992
      • One unit per day
  • Therapeutic Activity-97530
treatment frequency
Treatment Frequency
  • 1-3 times per week
  • Can take up to 8-12 weeks
  • Most often 4 weeks length of treatment
  • BPPV only: 1-3 visits
  • If BPPV and neuritis
      • Treat BPPV first, once resolved, treat neuritis and balance disorders
bibliography
Bibliography
  • Herdman, Susan. Vestibular Rehabilitation. Philadelphia: F.A. Davis Company, 2000.
  • Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003; 169:7 681-693.
  • http://www.dizziness-and-balance.com/disorders/bppv/bppv.html. Timothy Hain, MD. Benign Paroxysmal Positional Vertigo. July 19, 2010.
  • Vestibular Rehabilitation: A Competency Based Course. Emory University. Atlanta, Georgia.
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