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Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders. Burt DeWeese, PT, MCMT Rebound Physical Therapy Vestibular Rehab Specialist firstname.lastname@example.org. Background. Graduate of Kansas State University, 1999
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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@example.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 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?
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 • Video
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
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
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