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 burt@reboundphysicaltherapy.com. 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

Burt DeWeese, PT, MCMT

Rebound Physical Therapy

Vestibular Rehab Specialist

burt@reboundphysicaltherapy.com


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

  • 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 of the Ear


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 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

  • Bony Labyrinth

  • Perilymph

    • Between bony and membranous labyrinth

  • Membranous labyrinth

  • Endolymph

    • Inside membranous labyrinth

  • Parnes, 2003


    The Labyrinth

    • 3 Semicircular Canals

      • Anterior, Posterior Horizontal

  • Cochlea

    • Hearing component

  • Vestibule

    • Saccule and Utricle


  • 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

    • Hair Cells

    • Motion Sensors

      • Always sending info to the brain

  • Kilocilia

    • Deflection Towards- Excites

    • Deflection Away- Inhibits


  • 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 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

    • Utricle (Linear)

      • Horizontal Movements

      • Head Tilt

  • Saccule (Linear)

    • Up & Down Movements

  • Otoconia “Ear Rocks” (Calcium Carbonate Crystals)

  • Hair Cells

  • Herdman, 2000


    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

    Herdman, 2000


    Causes of Vertigo

    • BPPV

    • Vestibular Neuritis

    • Labyrinthitis

    • Meniere's Disease

    • Bilateral Vestibular Loss

    • Cervicogenic Dizziness


    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 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 Disorders

    • Meniere’s Disease

      • Increased endolymph pressures

      • Episodic

      • Low frequency hearing loss

      • Tinnitus

      • Can last hours to days


    Common Disorders

    • Fear of Falling

    • Disuse Dysequilibrium

    • Orthostatic Hypotension

    • Cervicogenic Dizziness

    • Anxiety


    Common Disorders

    • Central

      • TBI

      • CVA

      • Multiple Sclerosis


    Vestibular Evaluation

    • Subjective component

      • Thorough History

      • Dizziness Handicap Inventory

      • ABC confidence scale


    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


    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 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

    • Frenzel Goggles

    • Video Frenzel Lenses

    • Room Light


    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

    • Video


    Berg Balance Scale


    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

    • Modified CTSIB

    • Ground-Eyes open and closed

    • Foam-Eyes open and closed

    • ½ Tandem and Tandem

    • SLS

    • Computerized Dynamic Posturography


    Computerized Posturogrphy


    Benign Paroxysmal Positional Vertigo


    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

    • 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

    • “Idiopathic”-50%-70%

    • Head injury- 7%-17%

    • Viruses

      • Vestibular neuritis- 15%

  • Degeneration?


  • 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

    • 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

    • 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%


    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

    • 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


    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 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 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 Exam

    • Two types of BPPV

      • Canalithiasis (A)

      • Cupulolithiasis (B)


    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 – Canalithiasis

    • Video Animation

      • http://youtu.be/IHfU2cA7eRo


    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

    Parnes, 2003


    Patient Response

    • Sensation of spinning

      • May feel like they will fall of the table

  • Clammy

  • Sweating

  • Nauseous

  • Vomitus


  • 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

    • Canalith Repositioning Technique

    • Starting Position is Dix-Hallpike

    • Nystagmus should be same direction in all positions

    • Practice


    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

    • 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 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 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

    • 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 BPPV

    • Canalithiasis

      • Eyes will beat geotropic

  • Cupulolithiasis

    • Eyes will beat ageotropic

  • Parnes, 2003


    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


    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

    • 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

    • Brandt-Daroff

    • Home CRT

    • Balance retraining

    • Surgery-canal plugging


    Brandt-Daroff Exercises

    • 3-5 cycles

    • 3 times per day

    • Hold position for 30 seconds after vertigo stops

    Parnes, 2003


    Home CRT

    • Same as CRT

    • Place pillow under shoulders

    • Tip head over pillow and rest on mattress


    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


    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

    • Video Infrared Recording

      • Eye Movements and Head Shake

      • BPPV

    • Caloric Testing

    • Head and Eye Movements

      • Saccades, Smooth, Pursuit, Head Thrust, Slow VOR


    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 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 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 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

    • Based on Models of VOR

      • Retinal Slip and Head Movements

  • Main Exercises

    • x1 and x2 Viewing Exercises


  • Viewing Exercises


    Treatment Exercises

    • Guidelines

      • Target Seen Clearly

      • Head Movement +/- 30 degrees

      • Smooth

      • Continuous

      • Pushes Upper Limit


    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 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 Exercises

    • Sit to Stand with head turns

    • Wobble board with head turns

    • Hurdles with ball toss

    • Obstacle course

    • Stairs


    Balance Re-training

    • Romberg

    • ½ Romberg

    • Full Romberg

    • On ground and on foam

    • Add head turns


    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

    • PT evaluation- 97001

    • Neuromuscular Re-ed-97112

    • Canalith Repositioning-95992

      • One unit per day

  • Therapeutic Activity-97530


  • 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?


    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!


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