1. Investigating a Dizzy patient Dizzy Battery at a Glance
Mohammad, S Asghar
The Ear Institute Audiology Clinic,
Scarborough General Hospital,
Scarborough, ON

2. Some statistics about dizziness/balance disorders
Prevalence: Young adults: 1.8%
Older Adults: 30%
All Population: 25% will have dizziness in there lifetime at least once
Causing considerable morbidity and utilization of health services.
In an other study
Older adults above 60: 65% experience
dizziness or loss of balance, often on a daily basis.

3. Some statistics about dizziness/balance disorders
7 million people in US seek medical help for disequilibrium/vertigo every year.
30 % of US population has experienced at least one episode of vertigo by age 65

4. Definitions
Dizziness: It is a nonspecific term that describes a sensation of altered orientation in space.
Almost half of the patients complaining of dizziness usually have a disorder of vestibular system.
Vertigo: It is defined as an illusion of movement, and it always indicates an imbalance within the vestibular system.

5. Balance Disorder
A balance disorder is a condition that makes you feel unsteady or dizzy.
If you are standing, sitting, or lying down, you might feel as if you are moving, spinning, or floating.
If you are walking, you might suddenly feel as if you are tipping over.

6. The symptoms of vestibular disease .
Illusions of rotational motion (i.e., vertigo)
Illusions of linear motion (e.g., mal de debarquement)
Illusions of spatial disorientation (e.g., tilt illusion) .
Oscillopsia
Imbalance
Drop attacks
Lateropulsion
Autonomic accompaniments: malaise, nausea, vomiting .
Lateropulsion
After- uVD, there is an offset in posture toward the affected side that can be demonstrated by a variety of simple tasks showing that patients with u VD tend to lean or fall toward the affected side, especially in the early period after the UVD. This position offset, called lateropulsion, decreases and disappears within about a month.

7. Which patients are appropriate for testing?
December 27, 2018
Which patients are appropriate for testing?
Any individual with a functional activity limitation resulting from sensory or motor system impairments due to known or unknown pathology
Individuals with the ability to learn motor skills
Question participants “Who is appropriate?”
Challenge participants that they might have to work harder to find a patient who is NOT appropriate for testing.
Anyone who has ANY functional limitation. Balance problems. Those at risk for falls, or who are falling. Dizzy patients. Many patients don’t have a diagnosis.

8. Anatomic and Basic Medical considerations

9. Anatomic and Basic Medical considerations:
Multiple sensory inputs contribute to balance function.
Vestibular end organ
Visual system
And Somatosensory system/proprioceptive system
The information is integrated at the level of brainstem and cerebellum with influence from cerebral cortex including frontal, parietal and occipital lobes. The integrated input information results in various motor and perceptual outputs.

10. Balance system

11. Balance System

12. Dynamic Equilibrium (The concept)
December 27, 2018
Dynamic Equilibrium (The concept)
Sensory
Motor
Determine Body
Position
Central integration
Initiate Automatic/
Voluntary Movements
Compare, Select
and Combine Senses
Select and Adjust
Muscle Contractile Patterns
Visual
System
Let’s use our teaching Dynamic Equilibrium model to put this all together – examining the different systems, their interaction physiologically, as well as with the task and environment.
Left side is the sensory input side - right side is motor output.
The drivers of the balance systems: A Choice of Body Movement (volitional) or a reaction to a change in the environment (response)
Peripheral
Central – sensory integration area #39
[Cortical] – projections to…….
This is a great model. It describes for us what we are trying to evaluate and treat relative to balance control. It also provides a basis for discussion about balance control – and as such is a great marketing (education) tool.
Let’s think about the paradigms of the persons we speak with (market to) about our programs. [ASK THE AUDIENCE, SPECIFIC MEMBERS WHERE POSSIBLE] When I say balance to an ENT, where might they be focusing on this chart? An Audiologist? A Neurologist? An orthopedic therapist? [any other group you can think of based upon the audience’s composition]
Vestibular
System
Somato-
Sensation
Ankle
Muscles
Thigh
Muscles
Trunk
Muscles
Environmental
Interaction
Generation of
Body Movement

13. Motor System Outputs Dynamic Control of the COG
December 27, 2018
Motor System Outputs Dynamic Control of the COG
Reflexes
Automatic and adaptive postural responses
Anticipatory postural set
Voluntary movements
Select and Adjust
Muscle Contractile Patterns
Ankle
Muscles
Thigh
Muscles
Trunk
Muscles
There are four types of motor responses that are of interest to us for balance control…
Discuss each briefly.
Generation of
Body Movement

14. Balance disorder/Different perspective
Audiologist/ENT: Generally look at peripheral vestibular system
Neurologist: Look at mainly central integration and Motor part.
Geriatricians & Orthopedic specialists: Look at motor part and coordination

15. December 27, 2018
International Classification of Functioning, Disability, and Health – ICF
Health condition
(Disorder or Disease)
Body Structure
& Function
Activity
(Limitations)
Participation
(Restrictions)
Environmental
Factors
Personal
Factors
ICF International Classification of Functioning, Disability and Health
Jette AM. Toward a common language for function, disability, and health. Phys Therapy 2006;86:

16. December 27, 2018
International Classification of Functioning, Disability, and Health – ICF
Health condition
(Dizziness/Imbalance)
Vestibular system/Vision & Somatosensory system
Difficulty in focusing while moving head/Cannot walk straight
Cannot participate in daily activities like reading while moving (oscillopsia)
Unstable and unpredictable
environment
Psychological and personal gain factors
ICF International Classification of Functioning, Disability and Health
Jette AM. Toward a common language for function, disability, and health. Phys Therapy 2006;86:

17. Anatomy of the vestibular system
Point to remember: Note the Vestibular nerve innervations of Sup and Inf. Vest N.

18. Inner Ear: Bony and Membranous Labyrinths Medial View

19. Anatomy of Vestibular System

20. Blood supply of Inner Ear
Ant Vest Art follows the Sup Vest N
Post Vest Art follows the In Vest N

21. Irrigation Parallels Innervation
Blood supply Innervation
Basilar A VIIIth N
AICA
Labyrinthine A
Common Cochlear Artery
Main Cochlear Artery Cochlea Auditory Nerve
Vestibulo Cochlear artery Vestibular N
Post Vest A Post SCC Ampulla Inferior division
Majority of Saccule
Ant Vestibular A Anterior SCC Ampulla Superior Division
Horizontal SCC Ampulla
Utricle
Minority of Saccule
It is important to note the nerve distribution and the blood supply of vestibular system. Both can affect the balance. Like nerve can be affected in case of viral neuronitis or labyrinthits and blood supply can be affected by any vascular disease or cva affecting basilar artery or anterior inferior cerebellar artery

22. Arterial Blood supply

23. Vertebro-basilar arteries

24. Vertebro-basilar arteries

25. Lateral Medullary syndrome

26. Vestibular system: central connections
Through Medial Longitudinal fasciculus to Occular Nerve (VOR)
Through Vestibulospinal tract (Vestibulospinal reflex VSR)
Through Vestibulocervical tract (Vestibulocoloic Reflex VCR)

27. Central connections. (Important for rehab)
First order afferents : These are bipolar cells located deep in the internal auditory meatus.
In children the number of cells is around In elderly it is
So you can Imagine the incidence of imbalance in elderly
This is like presbyacoiuses,
It has its implications on rehab. As you can see that there is no tonotopic innervation, so VRT will depend upon functional assessment determined by CDP.

28. Mechanism of Vestibular lesions
Direct insult to peripheral vestibular system like Vestibular neurinitis/labyrinthitis
Blood supply interruptions Like Ant Inf. cerebellar art infarcts
Diseases affecting vestibular nerve like schawnoma.
Central lesions: cerebrovascular accidents, tumours and generalised diseases like MS
Motor system disorders:
Like spinal cord injuries, muscle and joint diseases

29. Neurological Causes of Dizziness.
Mixed peripheral and central lesion
Anxiety and psychogenic dizziness.
Emergency room: Acute Cerebellar infarction.
Migraine associated dizziness.
Disequilibrium of age.
Labyrinthine concussion
Vertebrobasillar insufficiency.
Multisensory disequilibrium

30. Neurological Causes of Dizziness
Cerebellar degeneration
Multiple scleroses.
Head Trauma (combined CNS, Labyrinthine and cervical injury
Migraine related dizziness and anxiety disorder.
Walenberg syndrome (posterior Inferior cerebellar artery syndrome)
Anterior Inf cerebellar artery infarction
Drop attacks
Convergence spasm.

31. Neurological Causes of Dizziness
Occular tilt reaction.
Chiari malformation
Progressive supranuclear palsy.
Wernicks encephalopathy
Vestibular epilepsy
Cervicogenic dizziness
Vascular cross compression syndrome.

32. Rational for
Dizzy test Battery

33. Rationale of dizzy test battery approach
The ear has 10 sensory structure controlling the balance;
Three semicircular canals (SCC) in each ear.
Two Otolith organs Saccule and Utricle in each ear.

34. Rationale of dizzy test battery approach
Innervated by Vestibular Nerve which divides in Sup and Inf vestibular Nerves.
Sup Vest N supplies: Sup and Lateral SCC and Utricle.
Inf Vest N supplies: Post SCC and the Saccule.
If we just do ENG we are just testing the Lateral SCC only and it will only give information about just 2 sensory organs out of 10 and Sup Vest N only. So having a normal ENG is not conclusive of the fact that vestibular system is normal. We can have normal Sup vestibular N function but may have vestibulopathy involving Inf Vestibular N. Therefore a test battery approach is recommended as it will test all the sensory structures and both Sup and Inf vestibular nerves.

35. Includes Dizzy test battery: Complete Audiological Assessment
(PTA, ABR & Ecoch.G)
And Complete vestibular assessment
(ENG, vHIT, VAT, Rotary chair test, VEMP, CDP & DVAT)

36. Vestibular Tests
What do we look for

37. Audiological Evaluation.
Tests
Looks for
Complete Hearing assessment
Type and shape of H Loss may indicate the presence of diseases involving both hearing and balance disorders. Like Meniere’s Disease.
(Fluctuating SN H Loss, Tinnitus, Dizziness and Fullness of ear)
ABR
Rules out Acoustic Neuroma and other retrocochlear pathologies.
Ecoch.G
Diagnostic test for Meniere’s Disease and Endolymphatic hydrops

38. Vestibular Function Tests.
Looks for
ENG
Tests the Lateral SCC and also checks for central lesions involving vestibular system.
Tests the Superior Vestibular Nerve. Also tests the BPPV.
VAT
(Vestibular Autorotation Test)
Tests all the SCC canal including Lateral Sup and Inf SCC. Also tests the high frequency movements which cannot be tested with ENG.
It compliments the results of ENG.

39. Vestibular Function Tests.
Looks for
Rotary Chair Test
Tests the Lateral SCC and also checks for central lesions involving vestibular system.
Tests the Superior Vestibular Nerve.
vHIT
(Video Head Impulse Test)
Tests all the SCC canal including Lateral Sup and Inf SCC. Also tests the high frequency movements which cannot be tested with ENG.
It compliments the results of ENG.

40. Vestibular Function Tests.
cVEMP
(Cervcal Vestibular Evoked Myogenic Potentials)
Checks for Saccule and Inf. vestibular nerve.
The only test which can check the Inf. Vestibular N Function.
oVEMP
(Occular Vestibular Evoked Myogenic Potentials)
Checks for Utricle and Sup Vest Nerve.

41. Vestibular Functional Assessment
Test
BPPV Treatment
Eply‘s, Semont’s and Log roll manouver
CDP
(Computerized dynamic Posturography)
It provides functional rather than site of lesion information.
DVAT (Dynamic Visual Acuity Test)
Test for oscillopsia associated with vestibular disorders.

42. Why Dizzy Battery
As we can See no single test looks at all the vestibular sensory organs completely so the Test battery approach is recommended to completely evaluate the Balance function in a dizzy patient.
This battery of tests performed together completely evaluates hearing and balance part of the ear (VIII N) including Superior and Inferior Vestibular Nerve.

43. What is the best test for balance assessment?
December 27, 2018
What is the best test for balance assessment?
No one test stands alone!
Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age and Ageing. 2006;35(2):ii7-ii11.
Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89:
Lots of people search for a single test or number as a representation of balance. It does not exist given the complexities of balance control.

44. Cost analyses MRI/CT Cost = $ 1300
Only diagnose cause of dizziness in .04% of cases.
Where as dizzy battery of test:
Cost 50% less at least
Can detect cause of dizziness in 50% of patients

45. Team Work
Although testing has become more and more automated but you still need a qualified person behind the computer to accurately interpret the results.
That is why team work is important.
We work closely with our group of ENT doctors to interpret the test results and help our physician properly manage the patients balance issues.

46. Because ear is the cause of vertigo in almost 50% of patient.
Final word
If you are not sure what could be real issue, just ask for a
“Dizzy Test Battery”
Because ear is the cause of vertigo in almost 50% of patient.