Vestibular Rehabilitation & Balance Measures

• CPG measures for balance include:

  • Berg Balance Scale (BBS)
  • Functional Gait Assessment (FGA)
  • Activities-Specific Balance Confidence Scale (ABC scale)
  • 10-Meter Walk Test (10mWT)
  • 6-Minute Walk Test (6MWT)
  • 5 Times Sit to Stand (5TSTS)

• Vestibular rehabilitation goals include:

  • Differentiating subjective complaints of dizziness
  • Understanding common vestibular causes of dizziness and presentations
  • Developing a treatment plan for each diagnosis

Dizziness Categories

• Dizziness is a vague term separated into these basic categories:
  • True vertigo: illusion of movement, feeling that you're moving or the room is moving
  • Unsteadiness: a tendency to fall, especially in darkness
  • Lightheadedness: feeling faint, associated with nonvestibular disorders like hypoglycemia, orthostatic hypotension, or anxiety

Dizziness Statistics and Causes

• Dizziness is a primary complaint in 2.6 million ED visits per year (3.3%) + 2.5% of all primary care visits, totaling 8 million visits per year
• Causes of dizziness include:
  • Otologic: inner ear disorders like BPPV, vestibular neuritis, Meniere's disease
  • Neurologic: CNS issues like migraines, stroke, multiple sclerosis
  • General Medical: systemic conditions like hypotension, anemia, dehydration
  • Psychiatric/Undiagnosed: anxiety, depression, or unexplained functional dizziness

Otologic Dizziness

• Otologic causes of dizziness include:
  • BPPV: 49%
  • Ménière's disease: 18.5%
  • Unilateral Vestibular paresis: 13.5%
  • Bilateral Vestibular paresis: 8%
  • Middle Ear Dysfunction: 6%
  • Fistula: 5%
  • Total n = 119

Neurological Dizziness

• Neurological causes of dizziness include:
  • Stroke and TIA: 35%
  • Vertebrobasilar migraine: 16%
  • Nystagmus: 8%
  • Sensory ataxia: 7%
  • Basal ganglia dysfunction: 4%
  • Cerebellar ataxia: 5%
  • Seizure: 3%
  • Miscellaneous disorders: 22%
  • Total n = 74

Medical Dizziness

• Medical causes of dizziness include:
  • Cardiovascular: 23-43%
    • Hypotension
    • Cardiac arrhythmia
    • Coronary artery disease
  • Infection: 4-40%
  • Medication: 7-12%
  • Hypoglycemia: 4-5%
  • Total n = 40

Persistent Dizziness

• Persistent Postural-Perceptual Dizziness (PPPD) / Chronic subjective dizziness (CSD) includes:

  • Primary symptoms:
    • Persistent postural dizziness without rotational vertigo
    • Worsening when upright and exacerbated by busy environments, illness, and/or stressful events
    • No other identifiable symptom

• Chronic subjective dizziness (CSD) by Staab (2012) leads to Exacerbation by movement but no identifiable vestibular or visual impairment to explain the dizziness, and perception can ↑ or ↓ symptoms

Vestibular System Disorders

• Summary of vestibular system disorders characteristics include:
  • BPPV (Benign paroxysmal positional vertigo):
    • Nystagmus is present
    • Duration is seconds (short)
    • Specific symptoms include acute spinning and (-) head thrust
    • Precipitating action is turning in bed
  • Vestibular Neuritis (acute unilateral vestibular lesion) (UVL):
    • Nystagmus: X
    • Duration is 48-72 hours (2-3 days)
    • Acute onset, motion sensitivity, maybe hearing loss, and (+) head thrust and head shake for specific symptoms
    • Precipitating action: X
  • Ménière's Disease (type of UVL):
    • duration 1–24 hours (acute)
    • fullness of ear, hearing loss, tinnitus and vomiting as specific symptoms
    • very may have high severity presentation
    • precipitating action: X
  • Bilateral Vestibular Disorder:
    • duration: permanent
    • Gait ataxia, oscillopsia, and (+) head thrust as specific symptoms
    • precipitating action is X
  • Fistula:
    • nystagmus: X
    • duration in seconds
    • loud tinnitus as specific symptoms
    • head trauma, sneezing and nose blowing

Functional Implications of Vestibular Disorders

• Functional implications for individuals suffering from vestibular disorders:
  • Limit activities
  • Adopt a rigid head position
  • Develop fear of falling, anxiety, and depression
  • Have difficulty walking
    • on uneven or compliant surfaces
    • in the dark or dimly lit environments
    • in 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

Vestibular Examination

• Vestibular examination includes:
  • Subjective: assess symptoms and their impact on daily life
  • Oculomotor: evaluate eye movements
  • Balance: test stability during standing and walking/movement
  • Function: assess ability to perform daily activities
  • Motion Sensitivity: identify triggers
  • Posture: analyze alignment and postural control
  • ROM: check range of motion in the neck and spine
  • Strength: evaluate muscle strength
  • Coordination: test motor coordination

Subjective Information and Specific Questions

• Subjective information includes:
  • Chief Complaint
  • Onset
  • Duration
  • Frequency
  • Associated Symptoms
  • Provocative positions / situations
  • Remitting positions / situations
  • PMHx, FamHx, SocHx
  • Medications
  • Diagnostic Test Results
• Specific questions to ask:
  • 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 (normal pressure hydrocephalus)

Oculomotor Examination

• Assess ocular motility by having the patient follow your finger

• Nystagmus observations include:

  • Spontaneous: check for involuntary eye movements at rest
  • Gaze Evoked: observe nystagmus when looking in different directions
  • Direction Changing/Alexander's Law: determine if nystagmus changes direction or worsens with gaze toward the fast phase

• Saccades: test rapid, precise eye movements between two targets

• Smooth Pursuit: evaluate the ability to smoothly track a slowly moving object

• Head Thrust (Head Impulse Test): assess vestibulo-ocular reflex (VOR) by observing eye movements during quick head turns

• VOR Cancellation: check the ability to suppress VOR by maintaining gaze on a target while moving the head

• Dynamic Visual Acuity (DVA): test visual acuity during head movement to evaluate VOR function

• Head Shaking Nystagmus: observe for nystagmus after rapid horizontal head shaking, indicating vestibular asymmetry

Nystagmus Details

• Nystagmus details:

  • involuntary, rhythmic, rapid eye movement
  • cardinal sign of vestibular dysfunction
  • latency, plane, direction, and duration are critical factors

• Nystagmus differentiates peripheral versus central disorders

  • Peripheral Disorders:
    • horizontal or rotatory nystagmus
    • unidirectional (always beating in the same direction)
    • fatigues (decreases with time or repeated testing)
    • inhibited by fixation
  • Central Disorders:
    • vertical, horizontal, or torsional
    • bidirectional or multi-directional, not following a consistent pattern
    • persistent and does not fatigue with testing
    • not inhibited by fixation
    • may present with additional neurological signs such as weakness, dysarthria, or ataxia
  • Characteristics include a fast phase movement in one direction and a slow phase in the opposite direction

Examining Spontaneous Nystagmus

• Examining for involuntary eye movements:
  • View eyes looking left, straight, and right.
  • Observe for nystagmus
  • Left beating nystagmus (fast phase to left) worsens when looking to the Left and lessens when looking to the Right

Checking For Gaze Evoked Nystagmus

• Examining nystagmus when the patient looks in different directions:

  • View eyes looking left, straight, and right.
  • Observe for nystagmus
  • Above is Left Gaze evoked nystagmus
  • unilateral vestibular hypofunction if one inner ear is impaired

• Assess nystagmus in the vertical plane:

  • View eyes looking left, straight, and right.
  • Observe for nystagmus
  • Vertical nystagmus is a CENTRAL Finding unless proved otherwise

Direction Changing Nystagmus

• Determine if nystagmus changes direction with gaze:

  • View eyes looking left, straight, and right.
  • Observe for nystagmus
  • Looking to the right, might right beating nystagmus and looking to the left, left beating is a CENTRAL SIGN

• If the nystagmus switches directions in gaze right versus gaze left, then this is suggestive of central pathology

Smooth Pursuits and Saccades Testing

• Smooth pursuits testing:

  • Patient follows your finger as you move it through the pattern
  • Look for quality of the movement
  • Look for "catch up" saccades

• Saccades testing:

  • Patient looks from target to target
  • Significant Overshooting or multiple undershoots is a Central Sign
  • 1 undershoot is normal

Tests

• Head thrust test (Head Impulse Test):
  • Tilt head forward 30 degrees, ask patient to focus on your nose, slowly move head side to side, observing for visual fixation
  • Patient focuses on your nose, then turn their head quickly in a random fashion
  • Look at their eyes to see if they remain stationary on your nose
  • Can ↑ sensitivity by RANDOMIZING the direction of movement
  • But be careful not to exceed patient's comfortable ROM
    • Direction of HEAD MOVEMENT = DIRECTION of Dysfunction
• ↓in fixation with forced LEFT ROTATION = LEFT DYSFUNCTION, + L Head Thrust test

VOR Test

• The VOR must be suppressed during the head movement to keep focused on the target which is moving synchronously with the head

• Unilateral vestibular lesions do not impair VOR cancellation

• unless the spontaneous nystagmus from the lesion is so high that it prevents the eye tracking systems from functioning normally, so impaired VOR cancellation is almost always a sign of cerebellar pathology

• How to perform:

  • Patient's head tilted forward 30 degrees, ask them to focus on your nose.
  • As you step from side to side, keep your patient's head facing you.
  • If patient is normal they will keep their eyes focused.
  • Multiple corrective saccades is positive for cerebellar pathology or ask the subject to clasp hands together and extend their arm with thumbs pointing upward. The head and body/arms rotate together as a single unit 30 degrees to the right and then 30 degrees to the left while the subject maintains gaze on their thumb

• Dynamic visual acuity (DVA) testing: - Patient reads Snellen chart (while in motion) - Gently turn patient's head as they try to read at 1-2 cycle/sec - Assess score the test is positive if there's three or more line difference - (+) can indicate peripheral OR central

• Head shaking test: This test of VOR function is best performed using Frenzel goggles or infrared video goggles because visual fixation must be eliminated for test accuracy

Balance Static and Dynamic Techniques

• Balance static techniques include:

  • Romberg EO/EC/Foam
  • Sharpened Romberg EO/EC/Foam
  • Single Leg Stance

• Dynamic Balance Techniques include

  • Gait with Head Rotation
  • Gait with absent Vision
  • Decreased BOS
  • Singleton's Test (patient may lose balance when turning to affected side)
  • Gait Velocity (normal is approximately 3' per second)
  • Standardized Assessments: Dynamic Gait Index, Berg, Timed Up and Go

• Singleton's test:

  • Patient walks to therapist at normal speed
  • When "at" therapist, patient turns to one side, and assumes the Romberg position with Eyes closed
  • Is suggestive of right vestibular hypofunction if patient loses balacnce when turning to the right
  • not a great test → oversamples

Examing Function By

• Assesing
  • Ambulation (indoors, outdoors, uneven surfaces)
  • Picking objects off floor
  • Stepping over objects
  • Carrying objects (laundry)
  • Cooking
  • Shopping
  • Work
  • Leisure

Examining Motion Sensitivity

• Motion sensitivity is uilateral vestibular hypofunction

• Symptom intensity: subjective scale from 0 to 5 (0 = no symptoms, 5 = severe symptoms)

• Symptom duration: scale from 0-3

  • 5-10 sec = 1 point; 11-30 sec = 2 points; >30 sec = 3 points

• Total score = intensity + duration for each position change

• MSQ is the final score

Balance Clinical Test

• Four test conditions include :

1. firm surface, eyes open
2. firm surface, vision eliminated
3. foam surface, eyes open
4. foam surface, vision eliminated. (the modified CTSIB or mCTSIB) to include only Conditions 1, 2, 4, and 5

• For each condition, it is recommended additional trials be allowed if a patient is unable to stand for 30 seconds, and an average of three trials should be calculated for each condition.
• Domain of the Dizziness Handicap Inventory Number of Questions Areas the questions explore:
  • Domains explore - functional,emotional and physical ability

Other Sensory tests

• Another popular questionnaire that measures the elderly patient's level of confidence in performing common daily activities

• Includes the ability to perform activities without loss of balance and fear of falling

• Self rated based on on 16 functional activities upon which the individual self-rates on a continuum scale of 0% to 100% confident - “0” representing no confidence and “100” representing complete confidence Lower in elderly patients with decreased mobility, and >67%→ risk of falling

Complete sensory examination

• Exams preformed:
  • ROM
  • Strength
  • Sensation
  • Reflex
  • Spasticity
  • Coordination
  • Positionals
  • Function

Central Peripheral test

• Central lesion signs
  • Vertical gaze nystagmus → BS or cerebellum
  • Direction Changing Nystagmus → brainstem
  • Saccades → cortical / central
  • VOR Cancellation → cerebellum
  • Coordination deficits → cerebellum or brainstem
  • Spasticity → motor pathway lesion / corticospinal tract

Tests for Peripheral Versus vs Central Pathology

• For peripheral VS central, onset: -Sudden (and often follows illness) VERSUS Slow, gradual (although sudden and without warning)
• For peripheral VS central, intensity:
  • Severe VERSUS Poorly defined
• For peripheral VS central, duration:
  • Brief, episodic VERSUS Longer, constant
• For peripheral VS central, nausea/diaphoresis:
  • Frequent VERSUS Infrequent
• For peripheral VS central, CNS signs:
  • Absent VERSUS Usually present
• For peripheral VS central, tinnitus/Hearing Loss:
  • Can be present VERSUS Absent
• For peripheral VS central, nystagmus:
  • Torsional/horizontal VERSUS Vertical / direction changing
• For peripheral VS central, nystagmus:
  • Fatigable VERSUS Nonfatigable
• For peripheral VS central, nystagmus:
  • Same direction VERSUS Direction changeing

Causes of Central Lesion

Causes may include:

• Traumatic Brain Injury

• Epilepsy

• Demyelinating diseases such as multiple sclerosis

• Tumors glinoma or meningioma)

• Vascular like CVA or VBI

• Degenerative like Pakinsons

• Central findings in the examination may necessitate further diagnostic imaging if there is no "known” cause of these central findings

Components of the vestibular system

The three components Include

1. Peripheral sensory apparatus (ear)

• Visulal ,Vestibular proprioceptive preceptors of the inner ear

2. Central processor (brain)
3. Mechanism for motor output (nerves)
   • Motor Neurons (controls movments)

Refelxes

• Important reflexes in head movement include Vestibulo-ocular reflex (VOR)

  • stabilizes gaze during head movement, with eye movement due to activation
  • Vestibulospinal reflex (VSR)
  • Cervico-ocular reflex (COR)

• Semicircular canals (SCCs)

  • provide sensory input about head velocity that enables the VOR to generate an eye movement that matches the velocity of the head movement
  • The desired result is that the eye remains still in space during head motion, enabling clear vision

• Hair cells: Specialized hair cells contained in each ampulla and otolith organ

  • biological sensors that convert displacement due to head motion into neural firing Otolith: measures linear acceleration, otoconia on top of hair calls parts of otolith

Tech for testing balance

Other types of balancing test include technology

• Videonystagmography (VNG) ( measures eye movement)

  • peripheral involvement
    • Nystagmus that↓with visual fixation and/or ↑ when visual fixation is removed
  • central lesion: nystagmus does not decrease or abate with visual fixation

• Rotational chair testing - "Gold standard” study for detecting bilateral vestibular loss

• Computerized dynamic posturography Six Conditions of the Sensory Organization Test (SOT) Each condition is 20 sec

Summary on evaluation For Vestibular disorders

Exam used for patients with dizziness, balance issues, or known vestibular disorders

• BPPV, vestibular neuritis
• Exams preformed:
  • Visual Screen
  • visual fields
  • gaze nystagmus
  • saccades
  • head thrust
  • convergence to detect vestibular dysfunction
• Balance exams and strength test is also used to assess patient

Benign Paroxysmal Positional Vertigo

• Pt. will Complain about vertigo spinning
  • Usually patient will know which side is effected

Symptoms include -Usually Abates quickly with movement to move position, could include dissequilibrium

Vertigo is caused by semi circular canals

Testing BPPV

• TEST FOR BPPV – DIX - HALLPIKE

Pt. will start sitting with head rotated 30 degrees towards the side test. Ask is to keep they test the eyes open is as you as you quickly bring then in to supine position with then head extended

• ALTERNATIVE TESTING PATTERN IS IN ALTERNATIVE POSITION FOR POSTERIOR
• Turn the head 45 degreed away from tesing side.
• Observe same symptoms

###Dix test (Hallpike) VS Vertebral Basilar extension.

• If VBI, hold test for 3 sec.
• VBI call be referred to as the "5 Ds and 3s" or diplopia dizziness dysarthria ###Dix Tests or BPPV Hallpike Test
• preform pt. will side
• Hallpike test preform on first to practice speed Rebound Phenomenon
• Complaints happen after to sitting also comman
• make you therapist is supporting the patient for behind 60 seconds for halls pike test

Canalthisa

Otoconis disloge in canals

• When head with move provoking position endolymph move by debris
• in hallpike expect latency or fatigue

Cupuoliasis: Onto coma for this adhered to

• expect

Testing Which semi cirular canal as BPPV

• Canal test RIGHT AND LEFT tests included
• FrenzeLens*
• Special Lens For Test Roll Test for horizontal canal- post
  • Head rapid turn to the neck for rapid test

Nystgamus

• Geotripic will indicate canals

BPPV Agorithym.

• To check right from left side
• to test for canla
• treatment epley manuver is preferreed
  • Semont or liberatotry manual

Epley Maneuver and Semont Maneuver Testing for pt