vestibular rehabilitation inservice
DESCRIPTION
In-service project for clinical affiliation with Hingham PT, Inc. (Januay 2014-April 2014) Review of vestibular system, common diagnosis and how to examine, evaluate and treat. I also reviewed and supplied the clinic with the Four Step Square Test and Dynamic Gait Index in order to allow them to implement these outcome assessments into their clinic for individuals with balance/vestibular deficitsTRANSCRIPT
Vestibular RehabilitationAmy E. Rosen, SDPT
“I am dizzy”Vestibular Disorders Association1
◦ Recognizes 19 different types of vestibular disorders“Dizziness” is one of the most common
complaints to physicians by persons over 65 years of age2
Dizziness Definitions1,2
◦ Vertigo: illusion of movement, rotation and/or spinning- either of the self or surrounding objects
◦ Disequilibrium: feeling of being unsteady, loss of balance; often accompanied by spatial disorientation
◦ Presyncope: a feeling of faintness, lightheadedness, or sense of falling; sudden decrease in BP
Balance3
“…a complex process involving the reception and integration of sensory inputs and the planning and execution of movement to achieve a goal requiring upright posture”◦ Ability to control the COG over BOS in a sensory environment
Choice of body movement
Determination of body position
Compare, select & combine senses
Neck Muscle
s
Trunk Muscle
s
Thigh Muscle
s
Ankle Muscle
s
Somato-
sensation
Vestibular
SystemVision
Environmental Interaction
Select & adjust muscle contractile pattern
Generation of body movement
Dizziness and Fall RiskAPTA Fact Sheet4
Those with a vestibular dysfunction & self reported dizziness were 12x more likely to fall (Yuri, 2010)
◦ Pt. with vestibular dysfunction alone was also shown to be at a higher risk for falling
Increased risk of fall & recurrent falls in those reporting dizziness. (Tromp, 2001)
Dizziness when standing correlates with falls & recurrent falls. (Grassfmans, 1996)
Pt. with bilateral vestibular dysfunction were shown to have significant increase in falls compare to general population (Herdman, 2000)
Dizziness & vertigo were found to be the leading cause of falls (Gananca, 2006)◦ Indiivduals who fell due to dizziness/vertigo were more likely to
experience 2 or more falls Those with chronic dizziness were found to be at increased risk
of fall (Tinetti, 2000) Those reporting dizziness 2x more likely to fall (O’Loughlin, 1993)
ANATOMY REVIEW
Image: greymattersjournal.com
Vestibular Labyrinth3
3 Semi- circular canals◦ Anterior, Posterior &
Lateral◦ Angular Accelerations◦ High Frequency
2 Otolith Organs◦ Utricle & Saccule◦ Sensitive to gravity ◦ Linear Accelerations◦ Low Frequency
Processing3
CN 8: Vestibulocochlear Nerve◦ Tonic firing
Deflections toward kinocilium cause depolarization Deflections away from kinocilium cause hyperpolarization
Central Processing◦ CN8 projects information ipsilaterally to 4 Vestibular
nuclei in dorsal Pons & Medulla◦ Vestibular nuclei send output to
Cerebellum to coordinate movements & monitor performance CN3,4,6: contralateral CN6 then projects to Medial
Longitudinal fasciculus (MLF) to contralateral Oculomotor Nucleus
Spinal Cord descending pathways to adjust limbs and trunk to regain balance
Reticular Formation to adjust circulation & breathing for new body position
Through the thalamus to Somatosensory Cortex for conscious perception of orientation & rotation
Without you realizing…3
Motor Output Reflexes◦ Vestibulo-ocular Reflex (VOR)
Allows for stable vision upon head movements Eye movements in opposite direction of head in
1:1 ratio CN3: Oculomotor, CN4: Trochlear, CN6: Abducens
◦ Vestibulo-spinal Reflex (VSR) Stabilize the head and body Lateral & Medial Vestibulospinal Tracts Reticulospinal Tract
Nystagmus◦ Involuntary, rhythmic oscillation of the eyes
characterized by the direction of the fast phase
◦ Can derive from physiologic, pathologic, peripheral &/or central lesions
◦ Can cause reduced visual acuity and vertigo systems
Putting it all together
Image: Reference 1
DISORDERS
General: Vestibular Disorders2,3
Peripheral Central
Nystagmus generally horizontal
Vertigo as severe as nystagmus◦ Response typically fatigues or
habituates
More intense feeling of vertigo
Hearing loss & tinnitus frequent
Long-tract sensory, motor involvement are unusual
Nystagmus can be horizontal, rotatory or vertical; multi-directional
Vertigo relatively mild or absent◦ persistent
Hearing loss & tinnitus rare
Associated sensory, motor, cerebellar, & other CN involvement more common
BPPV1-3,5
Between 17-42% of dizzy patients diagnosed with vertigo
Benign Paroxysmal Positional Vertigo◦ Form of Positional Vertigo
Spinning sensation produced by changes in head position relative to gravity
BPPV- characterized by repeated episodes of positional vertigo◦ Canalithiasis: otoconial debris become free floating in the
endolymph of SCC ◦ Cupulolithiasis: otoconial debris dislodged from otolithic
organs deposits upon cupula of SCC~85% Posterior Canal & 10-15% Horizontal CanalMost common in 5-7th decades of life
◦ Degeneration of cilia during natural agingCharacterized by: acute, discrete episodes of brief
positional vertigo without associated hearing loss◦ Resolution of sx within 60sec.of sustained position
Differential Diagnosis of BPPV5
Peripheral Central
Meniérès DiseaseVestibular neuritisLabyrinthitisSuperior Canal
dehiscence syndrome Post-traumatic vertigo
Migraine-associated dizziness
Vertebrobasilar insufficency
Demyelinating diseases
CNS lesions
Other: Anxiety or panic disorder, cericogenic vertigo, medication side effects, and postural hypotension
Meniérès Disease1-3,5
~10% of Pt. presenting with vertigoChronic disorder due to abnormalities in quantity,
composition &/or pressure of endolymph◦ Mixing of endolymph & perilymph
Characterized by attacks: ◦ Attacks can last 20min- 24hrs◦ Attack frequency: few per week to years between◦ Early Stage: spontaneous & disabling vertigo, fluctuating
hearing loss, ear fullness &/or tinnitus◦ Between Attacks: fatigue, anxiety, LOB, headache, vision
difficulties, vomiting/nausea, neck pain, sound sensitivity◦ Late Stage: hearing loss, tinnitus, constant struggle with
vision and balanceAny age, most common 40-60yoTx: medication, reduce- sodium diet, vestibular
rehab, surgery
Neuritis/Labyrinthitis1-3,5
~41% of Pt. presenting with vertigo Inflammation of inner ear caused by viral or bacterial
infection ◦ Vestibular hypofunction◦ Unilateral or Bilateral ◦ Acute or chronic, lasting several wks.
Neuritis: inflammation of the nerve affecting vestibular ganglion
Labyrinthitis: inflammation of the labyrinth affecting both branches of CN8
Sx: very sudden attacks of severe dizziness, vertigo, nausea and imbalance lasting for hours or even days.◦ Labyrinthitis- tinnitus &/or hearing loss
Secondary conditions:◦ Neuritis: BPPV & Labyrinthlitis: Endolymphatic hydrops
Neuritis/Labyrinthitis1-3,5
Image: http://www.lookfordiagnosis.com/mesh_info.php?term=Neuritis&lang=1
Migraine-Associated Vertigo (MAV)
1-3,5
Migraine is one of the most debilitating chronic disorder in US◦ ~40% of Pts with migraines have a vestibular component
affecting balance &/or dizziness Characterized by migraine with:
◦ Episodic vestibular symptoms Dizziness, motion intolerance, spontaneous vertigo attacks,
diminished eye focus with photosensitivity, LOB and ataxia◦ Sound sensitivity & tinnitus, cervioalgia with muscle
spasms, anxiety, confusion, spatial disorientation◦ No other cause of vertigo
Cause: combinations of vascular events, neuritis of portion of vestibular nerve as result of migraine.◦ Utricle is typically more affected
Difficult to diagnosis◦ Vestibular-evoked myogenic potentials (VEMP) testing◦ Common to also have true BPPV
Cervicogenic Dizziness1-3,5
A clinical syndrome of disequilibrium & disorientation in patients with neck problem, ie. cervical trauma, whiplash, cervical arthritis/denegerative, and others1
Characterized by:◦ Dizziness worse during head movements or after
maintaining one head position for prolonged time◦ Dizziness after the neck pain◦ May be accompanied by headache◦ Dizziness can last minutes-hours◦ Also complain of general imbalance, increasing with head
movementsNo diagnostic test to confirm
◦ Difficult to truly diagnose- rule out other conditionsDizziness typically improves with conservative
treatment of underlying neck issue.
CLINICAL EXAM
What to look for3,5,6
Take thorough history of symptoms◦ Frequency, Duration, Severity & Description of Sensation◦ Current vestibular suppressant medications?
Oculomotor Exam◦ Test VOR
BPPV testingTest for hearing lossCaloric TestingAssess static and dynamic balanceAssess routine postural transitions
◦ Sit-supine, rolling, forward leaning, historyAlso assess for strength, ROM and functional
limitations
Oculomotor Exam3
Gaze nystagmus◦ Gaze at target 20-30° off midline for 20sec (R & L)
Look for nystagmus or change in characteristics of gaze Smooth Pursuit
◦ Tracking H Look for saccadic substitution
Saccades◦ Jump gaze between 2 pts ~12in apart (Vertical & Horizontal)
Look for speed, accuracy and conjugate EOM
Alteration in oculomotor movements indicate central origin of vestibular dysfunction7
◦ Electronystagmograph vs. MRI 83.3% sensitivity & 21.2% specificity Severe alterations: 71.4% sensitivity & 50% specifity
MAV: saccadic eye motion testing generally normal1
Testing VOR2,3
Head Trust (Impulse) test◦ Visual fixation on a target◦ Rapid, passive rotation to one side
Perform slowly first & ensure adequate Cspine ROM
◦ Look for loss of fixation with saccadic reacquisition Test function of ipsilateral ear to thrust
Head Shaking test◦ Seated, with head tilted 30°, head shake @20Hz
for 20 seconds◦ Look for nystagmus after head shake
Peripheral Origin: fast phase of nystagmus toward stronger/intact labyrinth
Central Origin: prolonged nystagmus, dysconjugate nystagmus, or vertical nystagmus after horizontal stimulus
Testing for Posterior BPPV3,
5Hallpike- Dix
◦ Head turned 45° to one side
◦ Quickly from seated position to supine, head 20° below horizontal
◦ Observe for latency, direction & duration of nystagmus Latency: 5-20sec Direction: mixed torsional
& vertical components with fast phase (upper pole) toward dependent ear
Duration: should resolve within 60seconds
◦ Sit up & repeat contralateral ear, if necessary.
Testing for Horizontal BPPV3,5
Pagnini-McClure Maneuver ◦aka: Supine Roll Test
Pt. supine with head in neutral Quickly rotate head 90° to one side
Observe for nystagmus Head returned to neutral then quickly rotated 90° to
other side Observe for nystagmus
◦ In most cases, Geotropic nystagmus is produced Fast component toward the ground Less common Apogeotropic nystagmus is toward upper
ear
◦Affected ear is thought to be the one to which the side of rotation produced the more intense nystagmus/vertigo
Exclusions for BPPV testing5
Pt with physical limitations including:◦Cervical stenosis◦Serve kyphoscoliosis◦Limited cervical ROM◦Down syndrome◦Severe rheumatoid arthritis◦Cervical radiculopathies◦Paget’s disease◦Morbid obesity◦Ankylosing spondylitis◦Low back dysfunction◦Spinal cord injuries
Tests for hearing loss2,3
Rinne Test◦ Place vibrating tuning fork (512Hz) against Pt’s
mastoid bone, ask Pt to tell you when sound is no longer heard
◦ Once sound is no longer heard, place still vibrating tuning fork 1-2 cm from the auditory canal, ask Pt to tell if they are able to hear tuning fork Normal Hearing: Air conduction should be greater than bone
conduction
Weber Test◦ Place tuning fork (256Hz) in the middle of the Pt’s
forehead, equidistant from each ear.◦ Pt asked to report which ear the sound is heard louder
Normal Hearing: Equal in both
Caloric Testing2, 3, 8
To evaluate integrity of unilateral vestibular apparatus. ◦ Determine unilateral vestibular hypofunction, ie neuritis/labrynthitis
Performed irrigation to external auditory canal in supine with head elevated 30°◦ Cold & warm water for 30secs◦ 5mins between each condition
Normal: COWS◦ Cold opposite, Warm same
Cooling- increase, Warming- decrease in the specific gravity of the endolymph
Measure time of onset of nystagmus from beginning irrigation, duration & direction of each side under each condition◦ Approx. 20% different is considered significantly abnormal◦ Ask Pt about sensation, intensity and any differences they experience
80% accurate at diagnosing nerve damage as a cause of vertigo◦ Electronystagmograph
Central origin dizziness/vertigo◦ Also used in testing for brainstem lesions. Bilateral hyper- or hypo-
reflectivity
Outcome Measures3
Dynamic Gait Index9
◦ Time to Administer <10min◦ Assess ability to modify
balance while walking in the presence of external demands
◦ Vestibular disorders, geriatrics, PD, post-stroke, brain injury & MS
≤19/24 increased fall risk◦ Pt. with vestibular disorders
scoring ≤19/24 are 2.58 times more likely to have a fall in last 6 months
Excellent test-retest reliability (ICC= 0.86)
Four Square Step Test10
◦ Time to Administer <5min
◦ Active stepping for Functional Tasks
◦ Vestibular disorders, geriatrics, PD, post-stroke & transtibial amp.
Increased Risk of Falls◦ Vestibular: >12s◦ Geriatric: >15s◦ Acute Stroke: >15s
Excellent test-retest reliability (ICC= 0.93)
Helpful Tools for Assessment3,5
Frenzel Goggles◦ Video or optical◦ Enlarge (and record)
oculomotor function◦ Help monitor performance
& oculomotor function during testing (Nystagmus)
Gordon College: Center for Balance, Mobility, and Wellness (Wenham, MA)
http://www.interacoustics.es/com_en/Pages/Product/BalanceSystems/_index.htm?prodid=57249
“Balance Master” Computerized Dynamic
Posturography 6 conditions Pt. relative reliance on
visual, vestibular, and somatosensory inputs
INTERVENTION
Treating the “Dizzy” Patient2,3,5,6
Vestibular Rehabilitation◦ Goals:
to help retrain the ability of the body and brain to process balance information1
to allow free head movement without dizziness, especially during gait6
Enhace gaze stability, postural stability, improve dizziness/vertigo & activities of daily living
◦ Canalith repositioning exercises (CRP), postural control exercises, fall prevention training, relaxation training, strength conditioning exercises, functional skills retraining, education and…
Habituation◦ Retrain brain to manage offending stimuli◦ Conditioning
Adaptation ◦ Active head movements to compensate for retinal slip
Substitution◦ Visual and somatosensory systems to compensation
Treating Posterior BPPV3,5
Epley maneuver Pt in upright position with head turned 45° toward affected ear Rapidly laid back to supine head-hanging position, held 20-30sec Head turned 90° toward unaffected side, held 20sec Head turned further 90° (switch Pt to s/l facing floor), held 20-30sec Bring Pt to upright sitting position
◦ Most researched and most effective in short and long term treatment◦ Canal switch occurs in 6-7% of those treated with CRP
Semont’s maneuver Pt in upright position with head turned 45° away from affected ear Rapidly moved to s/l position, looking up at ceiling, held 30sec Rapidly move to opposite s/l position, looking at table, held 30s Bring Pt to upright sitting position
◦ Less researched than Epley maneuver and possibly less effective long term Brandt- Daroff Exercises
◦ Overall less effective but good for HEP as Habituation Exercises◦ Self-administered CRP appeared to be more effective, 64% improvement,
than self-treatment with Brandt-Daroff exercises, 23% improvement . (Radtke, 1999)
Effectiveness of Posterior Canal BPPV treated with Epley Maneuver5
Treating Horizontal BPPV3,5
Lempert Roll Maneuver◦ ~75% effective in treating Lateral BPPV
Begin supine, turn head slowly toward unaffected side Maintain each step for 15sec. Complete maneuver, Pt brought to upright with head bowed
30°
http://www.tinnitusjournal.com/detalhe_artigo.asp?id=483
Therapeutic Intervention2,3,5,6
Pt’s with BPPV◦ Evaluate & Treat, if positive, prior to beginning other treatment◦ Should be re-evaluated after 1month from initial CPR◦ Discuss safety and possible reoccurrence
Challenge the systems◦ Reduce influence of dominant sensory systems, strengthen the weak
Visual Somatosensory Vestibular
Gaze stabilization◦ Most common exercises for peripheral vestibular hypofunction
Work at tolerable level of dizziness◦ Increase in symptoms should last no longer than 20mins following
treatment Frequency & Duration of treatment are dependent on Pt. &
symptoms◦ 2-3 times per week to 1 time every 2-3 weeks◦ 1-2 weeks to several months
Activities3,6
Get Creative & Consider Real-Life Function◦ Gaze stabilization: active head and eye movements
Adjust for distance, speed & frequency, plane of movement, BOS, posture, surface, etc.
◦ Static stance EC/EO, change surfaces, change BOS, vary combinations
◦ Walking head turns, change speed, change direction, change surface, change BOS, navigate
obstacles, etc.
◦ Manipulate BOS for functional activities◦ Reaching out of BOS◦ Vary surfaces
Foam, Trampoline, Dyna Discs, balance boards, BOS Transfers from one surface to another- stepping stones
◦ Physioballs for sitting balance Add EC, add bouncing, add feet on foam
◦ Hurdles◦ Cones◦ Obstacle Course
Do Not forget general strengthening, stretching & conditioning for functional activities.
Effectiveness of Vestibular Rehab11
Systematic Review of 71 articles dated until 2006 Strong evidence for vestibular rehab
◦ Vestibular hypofunction: Neuritis/Labyrinthitis◦ Multisensory dizziness◦ Meniérès Disease
Moderately strong evidence◦ After vestibular surgery
Insufficient evidence◦ BPPV◦ PPV◦ Neurological causes of dizziness◦ Dizziness from whiplash-associated disorder◦ Migraine- associated dizziness
STRONG EVIDENCE: VESTIBULAR REHAB FOR VESTIBULAR DISORDERS
Practice Makes PerfectOculomotor testingVOR testingBPPV testingOutcome Measures
◦Dynamic Gait Index◦Four Square Step Test
Instructional Exercises
Any Questions?
Vestibular Rehabilitation
Gordon College: Center for Balance, Mobility & Wellness (Wenham, MA)
References1. Vestibular Disorders Association. Understanding Vestibular Disorders. Available at:
http://vestibular.org/understanding-vestibular-disorder/types-vestibular-disorders
2. Reeves AG, Swenson RS. Disorders of the Nervous System. Dartmouth Medical School. Chapter 6, 14. Copyright 2008. Available at: http://www.dartmouth.edu/~dons/.
3. Umphred DA, Lazaro RT, Roller ML, Burton GU. Umphred’s Neurological Rehabilitation, Sixth Ed. Chapter 22. Elsevier, Inc. Copyright 2013.
4. Bloom M. Research Studies that Associate Dizziness and Falls: Fact Sheet. APTA, Section of Neurology. Available at: http://www.neuropt.org/docs/vsig-physician-fact-sheets/research-studies-that-associate-dizziness-and-falls.pdf?sfvrsn=2
5. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. Otolaryngology-Head and Neck Surgery 2008; 139, S47-S81
6. Hoffer M, Balaban C, Whitney S, Sparto P. Principles of vestibular physical therapy rehabilitation. Neurorehabilitation [serial online]. July 2011;29(2):157-166. Available from: CINAHL Complete,
7. Tirelli G, Rigo S, Bullo F, Meneguzzi C, Gregori D, Gatto A. Saccades and smooth pursuit eye movements in central vertigo. Acta Otorhinolaryngologica Italica: Organo Ufficiale Della Società Italiana Di Otorinolaringologia E Chirurgia Cervico-Facciale [serial online]. April 2011;31(2):96-102. Available from: MEDLINE
8. MedlinePlus. Caloric Stimulation. Last modified: 2/26/14. Available at: www.nlm.nih.gov/medlineplus/ency/article/003429.htm
9. Rehabilitation Measures Database. Rehab Measures: Dynamic Gait Index. Last modified 1/30/14. Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=898
10. Rehabilitation Measures Database. Rehab Measures: Four Step Square Test. Last modified: 1/31/14. Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900
11. Hansson EE. Vestibular rehabilitation-For whom and how? A systematic review. Advances in Physiotherapy. 2007; 9: 106-116