Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders

1. Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders Burt DeWeese, PT, MCMT Rebound Physical Therapy Vestibular Rehab Specialist burt@reboundphysicaltherapy.com

2. 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

3. 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.

4. Anatomy and Physiology

5. Anatomy of the Ear

6. 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

7. 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

8. The Labyrinth • Bony Labyrinth • Perilymph • Between bony and membranous labyrinth • Membranous labyrinth • Endolymph • Inside membranous labyrinth Parnes, 2003

9. The Labyrinth • 3 Semicircular Canals • Anterior, Posterior Horizontal • Cochlea • Hearing component • Vestibule • Saccule and Utricle

10. 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)

11. Semicircular Canals • Hair Cells • Motion Sensors • Always sending info to the brain • Kilocilia • Deflection Towards- Excites • Deflection Away- Inhibits

13. 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

14. 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

15. The Otoliths • Utricle (Linear) • Horizontal Movements • Head Tilt • Saccule (Linear) • Up & Down Movements • Otoconia “Ear Rocks” (Calcium Carbonate Crystals) • Hair Cells Herdman, 2000

16. 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

17. Causes of Vertigo Herdman, 2000

18. Causes of Vertigo • BPPV • Vestibular Neuritis • Labyrinthitis • Meniere's Disease • Bilateral Vestibular Loss • Cervicogenic Dizziness

19. 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

20. 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

21. Common Disorders • Meniere’s Disease • Increased endolymph pressures • Episodic • Low frequency hearing loss • Tinnitus • Can last hours to days

22. Common Disorders • Fear of Falling • Disuse Dysequilibrium • Orthostatic Hypotension • Cervicogenic Dizziness • Anxiety

23. Common Disorders • Central • TBI • CVA • Multiple Sclerosis

24. Vestibular Evaluation • Subjective component • Thorough History • Dizziness Handicap Inventory • ABC confidence scale

25. 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?

26. Dizziness Handicap Inventory

27. 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

28. 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

29. Observation Tools • Frenzel Goggles • Video Frenzel Lenses • Room Light

30. 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

31. Dynamic Gait Index

32. Dynamic Gait Index • Video

33. Berg Balance Scale

34. 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

35. Static Balance Testing • Modified CTSIB • Ground-Eyes open and closed • Foam-Eyes open and closed • ½ Tandem and Tandem • SLS • Computerized Dynamic Posturography

37. Computerized Posturogrphy

38. Benign Paroxysmal Positional Vertigo

39. 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)

40. 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.

41. Causes of BPPV • “Idiopathic”-50%-70% • Head injury- 7%-17% • Viruses • Vestibular neuritis- 15% • Degeneration?

42. 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

43. 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

44. 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%

45. 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

46. Challenges • Musculoskeletal restrictions • Pain • cervical, lumbar, shoulder and hips • Fear of falling off table in sidelying when spinning • Hip replacements • Use of table/plinth

47. Use of Plinth

48. 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

49. 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

50. 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