Vestibular Rehabilitation Goals

• Differentiate subjective complaints of dizziness, such as vestibular versus cardiac issues.
• Understand common vestibular causes of dizziness and their presentation.
• Develop treatment plans for each diagnosis based on presented case studies.

What is Dizziness?

• Dizziness is a vague term, roughly separated into three basic categories. -True Vertigo: An illusion of movement, either of self or the environment. -Unsteadiness: A tendency to fall, especially in darkness. -Lightheadedness: Feeling faint, possibly with loss of consciousness, often associated with nonvestibular disorders like hypoglycemia, orthostatic hypotension, and anxiety.

Importance of addressing Dizziness

• Dizziness accounts for 2.6 million ED visits yearly, or 3.3% of all visits.
• Dizziness is the primary complaint in 2.5% of all primary care visits, totaling 8 million/year.
• Causes of dizziness can be categorized as otologic, neurologic, general medical, or psychiatric/undiagnosed

Causes of Otologic Dizziness

• Benign Paroxysmal Positional Vertigo (BPPV) is the cause of otologic dizziness in 49% of cases.
• Ménière's disease is the cause of otologic dizziness in 18.5% of cases.
• Unilateral Vestibular Paresis is the cause of otologic dizziness in 13.5% of cases.
• Bilateral Vestibular Paresis is the cause of otologic dizziness in 8% of cases.
• Middle Ear Dysfunction is the cause of otologic dizziness in 6% of cases.
• Fistula is the cause of otologic dizziness in 5% of cases.
• The data sample size is 119 patients.

Causes of Neurological Dizziness

• Stroke and Transient Ischemic Attack (TIA) is the cause of neurological dizziness in 35% of cases.
• Vertebrobasilar migraine is the cause of neurological dizziness in 16% of cases.
• Nystagmus is the cause of neurological dizziness in 8% of cases.
• Sensory ataxia is the cause of neurological dizziness in 7% of cases.
• Basal ganglia dysfunction is the cause of neurological dizziness in 4% of cases.
• Cerebellar ataxia is the cause of neurological dizziness in 5% of cases.
• Seizure is the cause of neurological dizziness in 3% of cases.
• Miscellaneous disorders is the cause of neurological dizziness in 22% of cases.
• The sample size is 74 patients.

Causes of Medical Dizziness

• Cardiovascular issues such as hypotension, cardiac arrhythmia, and coronary artery disease account for 23-43% of medical dizziness.
• Infection accounts for 4-40% of medical dizziness.
• Medication accounts for 7-12% of medical dizziness.
• Hypoglycemia accounts for 4-5% of medical dizziness.
• The sample size is 40 patients.

Persistent Postural-Perceptual Dizziness (PPPD)

• Primary symptoms include persistent postural dizziness without rotational vertigo, which is worse when upright and exacerbated by busy environments, illness, or stressful events.
• PPPD has no other identifiable cause of the person's symptoms.
• Also known as Chronic Subjective Dizziness (CSD), PPPD was renamed by Staab in 2012.
• PPPD is exacerbated by movement, but has no identifiable vestibular or visual impairment to explain the dizziness.

Summary of Vestibular System Disorders

• BPPV is characterized by positive nystagmus, seconds of duration, acute spinning symptoms, and turning in bed as the precipitating action.
• Vestibular Neuritis is characterized by negative nystagmus, 48-72 hours of duration, acute onset motion sensitive symptoms, and no clear precipitating action.
• Meniere's Disease is characterized by positive nystagmus, 1-24 hours (acute) of duration, fullness of ear, hearing loss, tinnitus, vomiting symptoms, and no clear precipitating action.
• Bilateral Vestibular Disorder is characterized by negative nystagmus, permanent duration, gait ataxia, oscillopsia symptoms, and no clear precipitating action.
• Fistula is characterized by negative nystagmus, seconds of duration, loud tinnitus symptoms, and head trauma/sneezing/nose-blowing as precipitating action

Functional Implications of Vestibular Disorders

• Individuals limit their activities due to their condition.
• They adopt a rigid head position to minimize movement-related symptoms.
• Individuals may develop a fear of falling, anxiety, and even depression.
• Have difficulty walking on uneven or compliant surfaces like carpet or grass.
• Have difficulty walking in the dark, dimly lit environments, or wide-open spaces.
• Tend to limit head movements and avoid busy visual environments.
• Adopt a wide base of support and frequently hold onto walls or nearby objects for support.

Examination Components for Vestibular Disorders

• Subjective assessment
• Oculomotor examination
• Balance assessment (static and dynamic)
• Functional assessment
• Motion sensitivity testing
• Assessment of posture
• Range of Motion (ROM) assessment
• Strength testing
• Coordination assessment

Subjective Examinations

• Chief Complaint
• Onset
• Duration
• Frequency
• Associated Symptoms
• Provocative positions / situations
• Remitting positions / situations
• PMHx, FamHx, SocHx
• Medications
• Diagnostic Test Results

Specific Questions for Dizziness

• Oscillopsia
• Headaches
• Positioning Symptoms
• Motion Sensitivity
• Issues in Dark, busy environments
• Exertion induced (vertigo with strain may suggest a fistula)
• Coordination issues
• Incontinence / memory loss suggests normal pressure hydrocephalus

Oculomotor Examination

• Assessing ocular motility (simple ROM of eyes)
• Evaluating nystagmus, look for spontaneous or gaze evoked, and note direction changes or following of Alexander's Law
• Saccades
• Smooth Pursuit
• Head Thrust
• VOR Cancellation
• Dynamic Visual Acuity (DVA)
• Head Shaking Nystagmus

Nystagmus

• Nystagmus is an involuntary, rhythmic, rapid eye movement and considered the cardinal sign of vestibular dysfunction.
• Critical factors for observation are latency, plane, direction, and duration.
• It is critical in differentiating peripheral vs central disorders.
• Nystagmus includes a fast phase movement in one direction and a slow phase in the opposite direction, named based on the fast phase.
• A patient with acute unilateral vestibular lesion (UVL) may have right-beating nystagmus, moving quickly to the right horizontally, then slowly to the left each cycle.

Nystagmus Observation

• Observe eyes looking left, straight, and right to assess for nystagmus.
• Left beating nystagmus (fast phase to left) worsens when looking to the Left and lessens when looking to the Right.
• Left Gaze evoked nystagmus, where eyes look left, is present.
• Vertical nystagmus indicates a CENTRAL finding until proved otherwise.
• Direction Changing nystagmus during right gaze indicates right beating nystagmus, and during left gaze indicates left beating. This is a CENTRAL SIGN.
• Nystagmus switching directions in gaze r/l (right versus left) is suggestive of central pathology.

Smooth Pursuits Test

• Observe patient following your finger as it moves through a pattern.
• Look for quality of movement and if there are "catch up" saccades.

Saccades Test

• Observe patient's eye movement as they look from target to target.
• Overshooting or multiple movements are Central Signs. 1 undershoot can be considered normal.

Head Thrust Test

• Tilt head forward 30 degrees, ask patient to focus on your nose, slowly move head from side to side, while looking at visual fixation.
• Patient focuses on your nose, then turns their head quickly in a random fashion (about 20 degrees).
• Observe the patient's eyes to see if they remain stationary.
• Highly specific (95%), but not highly sensitive (38%), meaning that the test misses many positives, but doesn't falsely identify normals.
• Can increase sensitivity by RANDOMIZING the direction of movement, but be careful not to exceed patient's comfortable ROM.
• HEAD MOVEMENT direction = Dysfunction direction. Decrease in fixation with forced LEFT ROTATION = LEFT DYSFUNCTION, + L Head Thrust test, a test of the PERIPHERAL SYSTEM.

VOR Cancellation

• The VOR must be suppressed during head movement to stay focused on a target moving synchronously with the head.
• Unilateral vestibular lesions do not impair VOR cancellation unless the spontaneous nystagmus prevents eye tracking systems from functioning normally, so impaired VOR cancellation is a sign of cerebellar pathology. This has a higher demand for smooth pursuits.
• Patient's head is tilted forward 30 degrees, and they focus on your nose; as you step from side to side, keep the patient's head facing you with their eyes remaining focused.
• Ask the subject to clasp hands together, extend arms, with thumbs pointing upward; the head and body/arms rotate as a single unit 30 degrees to the right and then 30 degrees to the left; subject maintains gaze on their thumb.

Dynamic Visual Acuity (DVA)

• Patient reads Snellen chart and assesses score.
• Gently turn patient's head as they try to read at 1-2 cycle/sec.
• A positive test result is a "3 or more" line difference.

Head Shaking Test

• The head shaking test is best performed using Frenzel goggles, or infrared video goggles, eliminating visual fixation for test accuracy.
• Observe eye movements in darkness for 10 seconds to obtain a baseline (Hain, 2007); then close eyes with their neck placed at 30 degrees of flexion.
• Shake the head in rotation vigorously at 2 Hz left and right, around 30-45 degrees for 20-30 cycles, stop after 20 cycles, and ask the patient to open eyes while you observe and document nystagmus.
• Normal people or people with bilateral vestibular loss will have no nystagmus.
• Unilateral vestibular hypofunction or loss cases will exhibit nystagmus that will beat (fast component) toward the intact side.

Balance Assessment

• Static balance: Look at Romberg EO/EC/Foam, Sharpened Romberg EO/EC/Foam, and Single Leg Stance.
• Results will vary with patient's ability to visually fixate.
• Dynamic balance: Observe gait w/ head rotation or absent vision, and note decreased base of support.
• Look at Singleton's Test where patient may lose balance when turning to affected side.
• Evaluate Gait Velocity with normal approximately 3' per second.
• Utilize standardized assessments like Dynamic Gait Index, Berg, Timed Up and Go.

Singleton's Test

• Patient walks towards the therapist at a normal speed.
• When arriving to therapist, the patient turns to one side, and assumes the Romberg position with eyes closed.
• This is assessed 2x, 1x turning to patient's right, and 1x turning to the patient's left.
• If patient loses balance when turning to right, but not left, this is suggestive of right vestibular hypofunction.

Functional Assessment

• Ambulation in varying environments in- or outdoors and on uneven terrain.
• Picking objects off the floor
• Stepping over objects
• Carrying objects (laundry)
• Cooking
• Shopping
• Work
• Leisure

Motion Sensitivity Testing

• The scale of symptom intensity of subjective patient reports ranges from 0-5 (0 = no symptoms, 5 = severe symptoms).
• Symptom duration scale ranges from 0-3 (5-10 sec = 1 point; 11-30 sec = 2 points; >30 sec = 3 points).
• Total score which is intensity plus duration for each position change.
• MSQ (motion sensitivity quotient) = (#Positons × Total Score) / 20.48.
• Abbott: 0-10% = mild; 11-30% = moderate; 31-100% = severe.

Clinical Test of Sensory Interaction for Balance (CTSIB)

• The Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) has four test conditions: -Condition #1: firm surface, eyes open -Condition #2: firm surface, vision eliminated -Condition #4: foam surface, eyes open -Condition #5: foam surface, vision eliminated.

Dizziness Handicap Inventory (DHI)

• The DHI has functionality, emotional, and physical domains -The Functional domain encompasses 9 questions with a max of 36 points, and looks at the impact of the condition (restrict travel, getting into or out of bed, restriting social activity, reading difficulties, avoidance of heights, doing strenuous housework or yardwork, walking alone, walking around home in the dark, and interference with job/household responsibilities -The Emotional domain encompasses 9 questions with a max of 36 points, and examines feelings of frustration, fear of leaving home without someone else, embarassment in front of others, wondering if people think they're intoxicated, difficulties concentrating, fear staying home alone, and feeling handicapped, stressed on relationships, depressed? -The Physical domain encompasses 7 questions with a max of 28 points, and looks at particular movements that cause dizziness (looking up, supermarket aisle, strenuous activities, quick movements of head, turning, walking down sidewalk, and bending over).
• Scoring indicates 100 points total, with the score indicating handicap due to dizziness (0 = none).
• A total score >18 has 94% specificity for BPPV; while minimal clinically important difference for DHI is 11 points.
• In patients with vestibular dysfunction, mean is Mean 32.7 ± S.D. 21.9 (Jacobson, 1990) – Scored 4 for YES, 2 for SOMETIMES, and 0 for NO.

Activities-Specific Balance Confidence Scale (ABC)

• The Activities-specific Balance Confidence (ABC) scale measures the patient's level of confidence in performing daily activities without loss of balance/fear of falling.
• The ABC consists of 16 functional activities to self-rate on scale, and 0%-100% indicates confidence from no to complete confidence.
• ABC score shown to be lower in elderly patients with decreased mobility with high correlation within DHI for patients above 65 years of age (Duracinsky, 2007).
• Scores less than 67% suggests a risk of falling and classification of people with 84% fall rate.

Complete Examination

• ROM
• Strength
• Sensation
• Reflex
• Spasticity
• Coordination
• Positionals
• Function

Differentiating Central and Peripheral Lesion

• Central lesion is characterized by vertical gaze nystagmus, saccades, VOR cancellation, direction changing nystagmus, coordination deficits, and/or spasticity.

Vertigo Characteristics, Central vs Peripheral Pathology

• Peripheral vertigo is usually sudden, follows an illness/event, severe intensity, has short bursts, involves nausea/ diaphoresis, and absences CNS (central nervous system) signs, presence of tinnitus/hearing loss, torsional/horizontal nystagmus, fatigable nystagmus, and has a fixed direction, even with changing head position (excluding horizontal BPPV).
• Central vertigo is slow, gradual although it may suddenly appear and does not follow warning signs, sometimes associated with medications, poorly defined intensity, longer more constant , with no nausea/diaphoresis, presents CNS, absences of tinnitus/hearing loss, vertical nystagmus, non-fatigability nystagmus, changing direction, without changing head direction.

Types of Central Lesions

• Traumatic Brain Injury (Concussion, mTBI)
• Epilepsy
• Demyelinating diseases
• Tumors
• Vascular injury (including CVA, VBI)
• Degenerative changes

Components of the Vestibular System

• Three Components: -Peripheral sensory apparatus as visual, vestibular, proprioceptive cues -Central processor including the cerebellum, vestibular complex. -The mechanisms to motor output for eye and positional movements.

Key Ocular Reflexes

• Vestibulo-ocular reflex (VOR) helps to stabilize gaze during head movements with eye movement due to activation of the vestibular system.
• Vestibulospinal reflex (VSR) generates compensatory body movements to maintain head and postural stability, which prevents falls.
• Cervico-ocular reflex (COR) is an ocular stabilization reflex that is elicited by rotation of the neck.
• COR works in conjunction with VOR to stabilize gaze, and at slower speeds than the VOR.

Semicircular Canals (SCCs)

• Semicircular canals, or SCCs, provide sensory input relating to head velocity, which enables VOR to generate matching eye movement of the head to improve clear vision.

Hair Cells

• Specialized hair cells in each ampulla and otolith organ are biological sensors that convert displacement to head movements as neural firing.

Otoliths

• Otoliths measure linear acceleration and otoconia are on top of hair cells, within parts of otoliths.
• Saccule is a structure that measures vertical forces.
• Utricle is a structure that measures horizontal forces.

Videonystagmography (VNG)

• Systems offer more advanced diagnostic information
• Measures eye movement under a variety of test conditions with an infrared camera system mounted in goggle set.
• Allows playback of video to review test findings (Pietwiewicz, 2012).
• Nystagmus that decreases in visual fixation and/or increases when visual fixation is removed is more indicative of peripheral involvement.
• If nystagmus does not decrease or abate with visual fixation, there is a suspected central lesion.

Rotational Chair Testing

• It is the “gold standard" study for detecting bilateral vestibular loss, however it is expensive, and has very few facilities have access.
• Patients with an inner ear disorder become less dizzy, comparing to people with normal ears.

Computerized Dynamic Posturography (CDP)

• Evaluated with sensory organization testing with each condition having three 20 second trials. -Condition 1: Eyes open; stable floor (baseline condition) -Condition 2: Eyes closed; stable floor (visual input is eliminated; patient must rely on somatosensory and vestibular cues) -Condition 3: Eyes open; moveable visual screen; stable floor (vision is inaccurate/unhelpful; patient must rely on somatosensory and vestibular cues) -Condition 4: Eyes open; unstable, movable floor (somatosensory information is not helpful, patients with visual acuity impairment will have difficulty) -Condition 5: Eyes closed; unstable floor (with visual input eliminated, and proprioception inaccurate, the vestibular input is essential) -Condition 6: Eyes open; moveable visual screen; unstable floor (vision and proprioception are inaccurate/unhelpful; patients who are unable to ignore inaccurate sensory information will have difficulty standing)

Comprehensive Vestibular Evaluation

• Who is this appropriate for?
• Visual Screen (visual fields, gaze nystagmus, saccades, head thrust, convergence)
• Assessment of Coordination by having patient perform finger to nose, toe tapping.
• Performing MMT in sitting if any deficits need to assess s/l hip abduction, prone hip extension.
• Static balance tests as romberg EO/EC and Foam EO/ EC, to check for pt's visual ability to fixate
• Dynamic balance
• Gait and or stairs.
• Completing Hallpike maneuver, as well as assessing for pt's motion sensitivity, or if testing was deferred for pt.

Benign Paroxysmal Positional Vertigo (BPPV) -

• Presentation involves complaints of vertigo (room spinning) with static positioning.
• Initial episode may occur rolling for the snooze alarm or retrieving object from shelf.
• Patient knows which positions are involved and avoids them.
• Symptoms usually abate quickly moving away from the provoked positions.
• Patient may report disequilibria and decreased balance secondary to poor usage of vestibular cues for balance

BPPV pt Presentation

• Vertigo when placed in the hallpike position (affected ear 30 degrees below horizontal) ,torsional nystagmus
• Vertigo caused by excitation of semicircular canal (SSC) (now more sensitive.)
• BPPV occurs in anterior, horizontal SSC and patient reports vertigo over past months or years.

Test for BPPV - Dix-Hallpike Test

• Begin by having Patient start in long sit, with head rotated 30 degrees towards side to test.
• Ask the patient to keep their eyes open as you quickly bring them into a supine position with their head extended 10-20 degrees.

Alternative Testing Position

• Turn the patient's head 45 degrees away from the testing side.
• If testing the right canal, turn head 45 degrees to the left; and then guide the patient into a side-lying position to the side being tested (e.g., down to the right to test the right canal). Observe for similar symptoms as in Dix-Hallpike test (nystagmus).

Verterbral Basilar Insufficiency

• Dix - Hallpike test is done at 30 degrees rotation and 10-20 degrees extension while VBI test is done at full extension and full rotation
• To assess for VBI hold 30 seconds in each direction and have patient perform VBI sit
• Assess 5 Ds and 3 Ns: diplopia, dizziness, dysarthria, drop attacks, dysphasia, nausea, numbness (unilateral), nystagmus (vertical nystagmus)
• Patient is said to positive for VBI if according to New England Medical Center Posterior Circulation Registry (over 400 patients) 1% present with only a single symptom

Dix - Hallpike Test

• Do the hillpike on the UNAFFECTED( good side) to practice technique.

BPPV - Canalithiasis and Cupulolithiasis

• Canlithiasis- otoconia get stuck in the semicircular canals( posterior usually), becomes free floating- endolymphatic movement by debris that move the cupula, in hallpike with latency and fatigue.
• Cupolithiasis otoconia adhere to cupula expect immediate nystagmus no fatigue
• cupula (ampulla, gravity-sensitive)expect immediate nystagmus not fatigue Use Semont-Liberatory maneuveror pt could have stroke.

Canal/Diagnosis Chart

• In Anterior canal, contralateral side*, down beat, pt side straight,worse in supine.
• .In Hotizontal, (Roll Test),Ageotropic / away (earth) -Cupulolithiasis worse on both sides.
• ,Geotropic / towards ground (earth). Horizontal Canalithiasis roll worsens both sides

Frenzel Lenses

• Special magnifying lenses, within goggles, make observation of nystagmuses easier by increasing what can therapist can see of pt eye

Roll Test Positional

• Position the patient in supine and flex the patient's neck to 30 degrees.
• Quickly turn the head to one side and hold the position for up to 60 seconds while observing nystagmus and symptoms.
• Return the head to midline for 30 seconds, then repeat the test on the other side.
  Nystagmus will be geotropic (beating towards the ground or undermost ear) indicates canalithiasis
• if nystagmus is ageotropic, (beating away from the ground -Cupulolithiasis

BPPV Treatment

• Epley- MOST OFTEN used for posterior Canalithiasis which has latency, fatigue
• Semont(LIBERATORY)- posterior Cupulolithiasis NO latency &HORIZONTAL canal, horizontal nystagmus
• BBQ(log roll)- Best for horizontal canal, horizontal nystagmus ( horizontal canalithiasis)
• Brandt's Exercises for those who are getting better motion

Home Modifications

• Patient must sit up the next 48.
• Patient must issue some soft tissue neck collar.
• Pt must not try to bring on the vertigo
• Pt must not lie on the vertigo side
• Pt should note perform up and down movement for the neck.*.
• most facilities are NOT using these mods bc need called to question

Brandt's Exercises

• These help pt with residual/motion type symptoms & are useful when 50-75% better
• This a habituation technique and is done 3x a day for 5 cycles.

* Post Estimate length of stay is based on patient's ability to respond and/or prognosis

• Respond quickly to few , Generally once a treatment a week has shown to symptoms greatly decrease , above +75%
• 15% have recurrence at 1 year and 50% have recurrence at 5 years Postural instability may also related and associated/ or found, when with BPPV Prognosis can show 80% rate that pt will lose and or be less likely to develop it again.
• Hypofunction- unilateral

###Hypofunction - unilateral* Vestibular Neuritis is an inner ear infection that is typically caused by a virus - Sudden onset that follows along with any other illness or very stressful event Hours are the likely length the vertigo may last May experience Nausea May have No amount of hearing loss - Will say had single moment 95% of those who had it will say imbalance and had dizz from pt moving around and head movements.

Vestibular Labyrinthitis

Has same issues seen in with Vestibular Neuritis and with loss of hearing

Acoustic Neuroma

Nerve sheath tumor is found near internal auditory/ or brain stem. often and can be assoc with, neurofibromatois-2

Ménière's Disease

episodes/progressive- the Vertigo along tinnitus, hearing loss

• Mismatch causes Dizz with movement - motion
• pt 1 or 2 percent of weakness at vestibular
• 5 D -double v- Dizz- dysarthria- drop dyphasia and nausea- N- Numbness

Unilateral Hypofunction -

• Mismatch right is diff then Brain- dizz in motion

• 50 % weakness- vestibular when turning to one side the brain has 100degree and 50-50 • The decreased part TEST pt head the other

Cases of Vestibular Nueritis

• Infection with clear 1-2 weeks and decomp. Limiting CNS be SEN to vestib input and VRT is needed to go back into WITHOUT worsening pt ( 1 minute ru

Hypo Px

• Full return with full pre morbid activities as their body can in other system to compensate stay is 1-2 months • CPG - Px and and dx with other issues

Bilateral Vestibular Hypofunction Characteristics

Otoxicity damage the cells so cant get the signal and often antibiotic

• UNSTEADINES S wide step dizz absent and pt sees jumbling on the floor from seeing object move

B hypo Function characteristics

• pt in both impaired and Pt had has prob balancing the body the envirMove/ key part-
• Head thust - dynamic Visual Acuity Gait rotation.

EVAL

•Pt - function and remain benefit ,exercise for for Pt then exercise substitution for visual and som to stay balanced -Known comp diabetics periph nero - visual

• Either comp greatly will decrease pt determine there.

Compensate RESTORE

• Process/ how - process

Compensation and Treatment for Vestibulars

• to help so that the rest of the systems take over where the others lack to ensur safety and increase ability to maintain
• assist devices- LE strategy- how - reach Mod Pt home to minimize and fall

Prognosis With Balance Issues :

• Incomplete is easier - driving will be harder -

Px

• With some work need recover -decrease
• pt with another other involvement and need more function less stay

Menieres disease

deability unilateral, tympnaums, and many other hearing loss Typically pt have 3 days can be ambulatory / or to help -but there is often that loss- later pt may experience drop attacks*

• is seen 30-50 y.o*

Menieres disease

in part the trans structural exac - calm the meds/ while they try pt has normal vestibular systems - and pt wont likely be a part of pre op - M* pt is having other issues and med should stop -salt -

Ménière's Diseas Pt will need salt cut down.

• salt/ and med to decrease how much, and other factors as drink or etc For surgical - intra - ablates or abt to then the side- then that makes pt to have vestibular and Rehab

Migraines-

• High 18% for females 6%- men and 4 children with I year
• Headache not linked to D.

treat ment mign

• treat factors, stop if you know. /if per month consider for meds /if many

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• no strain but soft,

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