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Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders
Burt DeWeese, PT, MCMT Rebound Physical Therapy Vestibular Rehab Specialist
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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
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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.
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Anatomy and Physiology
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Anatomy of the Ear
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Anatomy of the Ear The External Ear The Middle 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
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Anatomy of the Ear The Inner Ear Saccule and Utricle
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
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The Labyrinth Bony Labyrinth Perilymph Membranous labyrinth Endolymph
Between bony and membranous labyrinth Membranous labyrinth Endolymph Inside membranous labyrinth Parnes, 2003
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The Labyrinth 3 Semicircular Canals Anterior, Posterior Horizontal
Cochlea Hearing component Vestibule Saccule and Utricle
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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)
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Semicircular Canals Hair Cells Motion Sensors Kilocilia
Always sending info to the brain Kilocilia Deflection Towards- Excites Deflection Away- Inhibits
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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
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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
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The Otoliths Utricle (Linear) Horizontal Movements Head Tilt
Saccule (Linear) Up & Down Movements Otoconia “Ear Rocks” (Calcium Carbonate Crystals) Hair Cells Herdman, 2000
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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
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Causes of Vertigo Herdman, 2000
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Causes of Vertigo BPPV Vestibular Neuritis Labyrinthitis
Meniere's Disease Bilateral Vestibular Loss Cervicogenic Dizziness
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Common Disorders Vestibular Neuritis
Semi-Circular Canals Inflammation of the Vestibular Nerve Cochlea 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
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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
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Common Disorders Meniere’s Disease Increased endolymph pressures
Episodic Low frequency hearing loss Tinnitus Can last hours to days
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Common Disorders Fear of Falling Disuse Dysequilibrium
Orthostatic Hypotension Cervicogenic Dizziness Anxiety
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Common Disorders Central TBI CVA Multiple Sclerosis
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Vestibular Evaluation
Subjective component Thorough History Dizziness Handicap Inventory ABC confidence scale
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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?
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Dizziness Handicap Inventory
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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
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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 degrees flex Significant finding 25% or more reduction indicates a unilateral weakness
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Observation Tools Frenzel Goggles Video Frenzel Lenses Room Light
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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
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Dynamic Gait Index
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Dynamic Gait Index Video
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Berg Balance Scale
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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) 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
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Static Balance Testing
Modified CTSIB Ground-Eyes open and closed Foam-Eyes open and closed ½ Tandem and Tandem SLS Computerized Dynamic Posturography
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Computerized Posturogrphy
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Benign Paroxysmal Positional Vertigo
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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)
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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.
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Causes of BPPV “Idiopathic”-50%-70% Head injury- 7%-17% Viruses
Vestibular neuritis- 15% Degeneration?
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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
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BPPV – Nystagmus Posterior canal Anterior canal Horizontal canal
Up-beating, torsional nystagmus toward involved ear Anterior canal Down-beating, torsional nystagmus toward involved ear Horizontal canal Lateral, slight torsional nystagmus, greater toward involved ear
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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%
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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
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Challenges Musculoskeletal restrictions Use of table/plinth Pain
cervical, lumbar, shoulder and hips Fear of falling off table in sidelying when spinning Hip replacements Use of table/plinth
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Use of Plinth
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BPPV – Clinical Exam Dix-Hallpike Test Practice
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
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BPPV – Clinical Exam Typical Nystagmus Fatigues with repeated testing
Latency- before nystagmus starts 1-30 seconds Direction Mixed up-beating, torsional nystagmus (post.) Duration Less than 1 minute Fatigues with repeated testing
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BPPV – Clinical Exam All you need to know… Direction Duration
The direction of the elicited nystagmus will tell you which canal is involved Duration Will tell you the type of BPPV
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BPPV – Clinical Exam Two types of BPPV Canalithiasis (A)
Cupulolithiasis (B)
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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
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BPPV – Canalithiasis Video Animation
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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
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Repositioning Procedures
Parnes, 2003
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Patient Response Sensation of spinning Clammy Sweating Nauseous
May feel like they will fall of the table Clammy Sweating Nauseous Vomitus
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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
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BPPV Treatment – Posterior/Anterior Canals
Canalith Repositioning Technique Starting Position is Dix-Hallpike Nystagmus should be same direction in all positions Practice
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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
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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
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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
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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
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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
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Horizontal Canal BPPV Canalithiasis Cupulolithiasis
Eyes will beat geotropic Cupulolithiasis Eyes will beat ageotropic Parnes, 2003
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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
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BPPV – Flow Chart
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Horizontal Canal BPPV HC- Semont maneuver Used for Cuplulolithiasis
Head in neutral position Quick movements to jar otoconia loose Then perform CRT
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BPPV Treatment Post-Treatment Instructions- typically 24 hours Debate
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
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Other Treatment Options
Brandt-Daroff Home CRT Balance retraining Surgery-canal plugging
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Brandt-Daroff Exercises
3-5 cycles 3 times per day Hold position for 30 seconds after vertigo stops Parnes, 2003
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Home CRT Same as CRT Place pillow under shoulders
Tip head over pillow and rest on mattress
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Balance Re-training Progress toward balance activities if the patient continues to have imbalance. Will discuss balance activities in the Vestibular Rehabilitation section.
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Vestibular Rehabilitation
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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
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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
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Vestibular Testing Computerized Dynamic Posturography
Dynamic Visual Acuity Dynamic Gait Index Static Balance Testing Romberg, Sharpened Romberg, SLS Timed Up and Go
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Treatment Theory
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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
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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)
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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.
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Treatment Exercises Based on Models of VOR Main Exercises
Retinal Slip and Head Movements Main Exercises x1 and x2 Viewing Exercises
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Viewing Exercises
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Treatment Exercises Guidelines Target Seen Clearly
Head Movement +/- 30 degrees Smooth Continuous Pushes Upper Limit
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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
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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
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Treatment Exercises Sit to Stand with head turns
Wobble board with head turns Hurdles with ball toss Obstacle course Stairs
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Balance Re-training Romberg ½ Romberg Full Romberg
On ground and on foam Add head turns
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Home Exercise Program All the previous discussed exercises
Can modify as needed Can create any exercise incorporating head and eye movements Include balance activities.
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Billing PT evaluation- 97001 Neuromuscular Re-ed-97112
Canalith Repositioning-95992 One unit per day Therapeutic Activity-97530
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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
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Any Questions?
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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: 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.
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Thank You!
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