Vestibular rehabilitation evaluation and treatment strategies for common vestibular disorders
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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

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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 and physiology

Anatomy and Physiology


Anatomy of the ear

Anatomy of the Ear


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?


    Dizziness handicap inventory

    Dizziness Handicap Inventory


    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


    Dynamic gait index

    Dynamic Gait Index


    Dynamic gait index1

    Dynamic Gait Index

    • Video


    Berg balance scale

    Berg Balance Scale


    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


    Computerized posturogrphy

    Computerized Posturogrphy


    Benign paroxysmal positional vertigo

    Benign Paroxysmal Positional Vertigo


    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?


  • Vestibular rehabilitation evaluation and treatment strategies for common vestibular disorders

    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%


    Vestibular rehabilitation evaluation and treatment strategies for common vestibular disorders

    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


  • Use of plinth

    Use of 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


    Repositioning procedures

    Repositioning Procedures

    Parnes, 2003


    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


    Bppv flow chart

    BPPV – Flow Chart


    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.


    Vestibular rehabilitation

    Vestibular Rehabilitation


    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

    Treatment Theory


    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


  • Viewing exercises

    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


    Any questions

    Any Questions?


    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.


    Thank you

    Thank You!


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