Vestibular rehabilitation evaluation and treatment strategies for common vestibular disorders
Download
1 / 93

Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders - PowerPoint PPT Presentation


  • 186 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders' - vaughn


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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 Strategies for Common Vestibular Disorders

  • 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 Strategies for Common Vestibular Disorders

  • 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 Strategies for Common Vestibular Disorders


Anatomy of the ear
Anatomy of the Ear Strategies for Common Vestibular Disorders


Anatomy of the ear1
Anatomy of the Ear Strategies for Common Vestibular Disorders

  • 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 Strategies for Common Vestibular Disorders

  • 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 Strategies for Common Vestibular Disorders

  • Bony Labyrinth

  • Perilymph

    • Between bony and membranous labyrinth

  • Membranous labyrinth

  • Endolymph

    • Inside membranous labyrinth

  • Parnes, 2003


    The labyrinth1
    The Labyrinth Strategies for Common Vestibular Disorders

    • 3 Semicircular Canals

      • Anterior, Posterior Horizontal

  • Cochlea

    • Hearing component

  • Vestibule

    • Saccule and Utricle


  • The hair cell
    The Hair Cell Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Hair Cells

    • Motion Sensors

      • Always sending info to the brain

  • Kilocilia

    • Deflection Towards- Excites

    • Deflection Away- Inhibits


  • Semicircular canals1
    Semicircular Canals Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    Herdman, 2000


    Causes of vertigo1
    Causes of Vertigo Strategies for Common Vestibular Disorders

    • BPPV

    • Vestibular Neuritis

    • Labyrinthitis

    • Meniere's Disease

    • Bilateral Vestibular Loss

    • Cervicogenic Dizziness


    Common disorders

    Semi-Circular Strategies for Common Vestibular Disorders

    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 Strategies for Common Vestibular 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 Strategies for Common Vestibular Disorders

    • Meniere’s Disease

      • Increased endolymph pressures

      • Episodic

      • Low frequency hearing loss

      • Tinnitus

      • Can last hours to days


    Common disorders3
    Common Disorders Strategies for Common Vestibular Disorders

    • Fear of Falling

    • Disuse Dysequilibrium

    • Orthostatic Hypotension

    • Cervicogenic Dizziness

    • Anxiety


    Common disorders4
    Common Disorders Strategies for Common Vestibular Disorders

    • Central

      • TBI

      • CVA

      • Multiple Sclerosis


    Vestibular evaluation
    Vestibular Evaluation Strategies for Common Vestibular Disorders

    • Subjective component

      • Thorough History

      • Dizziness Handicap Inventory

      • ABC confidence scale


    Common questions
    Common Questions Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders


    Vestibular evaluation1
    Vestibular Evaluation Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Frenzel Goggles

    • Video Frenzel Lenses

    • Room Light


    Vestibular evaluation3
    Vestibular Evaluation Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders


    Dynamic gait index1
    Dynamic Gait Index Strategies for Common Vestibular Disorders

    • Video


    Berg balance scale
    Berg Balance Scale Strategies for Common Vestibular Disorders


    Timed up and go
    Timed Up and Go Strategies for Common Vestibular Disorders

    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 Strategies for Common Vestibular Disorders

    • Modified CTSIB

    • Ground-Eyes open and closed

    • Foam-Eyes open and closed

    • ½ Tandem and Tandem

    • SLS

    • Computerized Dynamic Posturography


    Computerized posturogrphy
    Computerized Posturogrphy Strategies for Common Vestibular Disorders


    Benign paroxysmal positional vertigo

    Benign Paroxysmal Positional Vertigo Strategies for Common Vestibular Disorders


    Bppv statistics
    BPPV Statistics Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • “Idiopathic”-50%-70%

    • Head injury- 7%-17%

    • Viruses

      • Vestibular neuritis- 15%

  • Degeneration?


  • BPPV Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders


    Bppv clinical exam
    BPPV – Clinical Exam Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Two types of BPPV

      • Canalithiasis (A)

      • Cupulolithiasis (B)


    Bppv canalithiasis
    BPPV – Canalithiasis Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Video Animation

      • http://youtu.be/IHfU2cA7eRo


    Bppv cupulolithiasis
    BPPV – Cupulolithiasis Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    Parnes, 2003


    Patient response
    Patient Response Strategies for Common Vestibular Disorders

    • Sensation of spinning

      • May feel like they will fall of the table

  • Clammy

  • Sweating

  • Nauseous

  • Vomitus


  • Canal alignment reminder
    Canal Alignment Reminder Strategies for Common Vestibular Disorders

    • 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 – Strategies for Common Vestibular DisordersPosterior/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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Canalithiasis

      • Eyes will beat geotropic

  • Cupulolithiasis

    • Eyes will beat ageotropic

  • Parnes, 2003


    Horizontal canal bppv2
    Horizontal Canal BPPV Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders


    Horizontal canal bppv3
    Horizontal Canal BPPV Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Brandt-Daroff

    • Home CRT

    • Balance retraining

    • Surgery-canal plugging


    Brandt daroff exercises
    Brandt-Daroff Exercises Strategies for Common Vestibular Disorders

    • 3-5 cycles

    • 3 times per day

    • Hold position for 30 seconds after vertigo stops

    Parnes, 2003


    Home crt
    Home CRT Strategies for Common Vestibular Disorders

    • Same as CRT

    • Place pillow under shoulders

    • Tip head over pillow and rest on mattress


    Balance re training
    Balance Re-training Strategies for Common Vestibular Disorders

    • Progress toward balance activities if the patient continues to have imbalance.

    • Will discuss balance activities in the Vestibular Rehabilitation section.


    Vestibular rehabilitation

    Vestibular Rehabilitation Strategies for Common Vestibular Disorders


    Output of cns
    Output of CNS Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Computerized Dynamic Posturography

    • Dynamic Visual Acuity

    • Dynamic Gait Index

    • Static Balance Testing

      • Romberg, Sharpened Romberg, SLS

  • Timed Up and Go


  • Treatment theory

    Treatment Theory Strategies for Common Vestibular Disorders


    Treatment theory for dysfunctions
    Treatment Theory for Dysfunctions Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Based on Models of VOR

      • Retinal Slip and Head Movements

  • Main Exercises

    • x1 and x2 Viewing Exercises


  • Viewing exercises
    Viewing Exercises Strategies for Common Vestibular Disorders


    Treatment exercises1
    Treatment Exercises Strategies for Common Vestibular Disorders

    • Guidelines

      • Target Seen Clearly

      • Head Movement +/- 30 degrees

      • Smooth

      • Continuous

      • Pushes Upper Limit


    Treatment exercises2
    Treatment Exercises Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • 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 Strategies for Common Vestibular Disorders

    • Sit to Stand with head turns

    • Wobble board with head turns

    • Hurdles with ball toss

    • Obstacle course

    • Stairs


    Balance re training1
    Balance Re-training Strategies for Common Vestibular Disorders

    • Romberg

    • ½ Romberg

    • Full Romberg

    • On ground and on foam

    • Add head turns


    Home exercise program
    Home Exercise Program Strategies for Common Vestibular Disorders

    • All the previous discussed exercises

    • Can modify as needed

    • Can create any exercise incorporating head and eye movements

      • Include balance activities.


    Billing
    Billing Strategies for Common Vestibular Disorders

    • PT evaluation- 97001

    • Neuromuscular Re-ed-97112

    • Canalith Repositioning-95992

      • One unit per day

  • Therapeutic Activity-97530


  • Treatment frequency
    Treatment Frequency Strategies for Common Vestibular Disorders

    • 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? Strategies for Common Vestibular Disorders


    Bibliography
    Bibliography Strategies for Common Vestibular Disorders

    • 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! Strategies for Common Vestibular Disorders


    ad