An Introduction to Vestibular

Rehabilitation

Jennifer Fay, PT, DPT, NCS

Neurologic Clinical Specialist

Vestibular Rehabilitation

Rusk Institute

NYU Langone Medical Center

Objectives: •Describe Vestibular System Function, Anatomy

and physiology

•Identify evaluation components

•Identify common causes of dizziness

•Demonstrate Vestibular treatment and exercises

•BPPV testing and treatment.

•Considerations for Concussion

© Jennifer Fay, PT, DPT, NCS

Vestibular Anatomy

and Physiology

Anatomy

© Jennifer Fay, PT, DPT, NCS

Semicircular Canals

•Filled with endolymph with a density slightly greater

than water and moves freely within each canal in

response to the direction of head rotation.

(Schubert MC 2004)

•Act in pairs.

•Each semicircular canal is sensitive to motion in

the plane of that canal.

Semicircular Canals

Detect changes in angular

acceleration of the head in

three dimensional planes.

A) Lateral (Horizontal) Canal

B) Anterior Canal

C) Posterior Canal

Perpendicular Alignment

© Jennifer Fay, PT, DPT, NCS

Semicircular Canal

Utricle and

Saccule

•Detects

changes in

linear

acceleration

Detects head

position relative

to gravitational

forces

Vestibular Processing

Input:

Vision

Vestibular

Somatosensory

Primary Processor:

Cerebellum

OUTPUT:

Postural Control

VESTIBULAR SPINAL REFLEX (VSR)

OUTPUT:

Oculomotor

VESTIBULAR OCULAR REFLEX (VOR)

Interpretation Process:

Vestibular Nuclear Complex

© Jennifer Fay, PT, DPT, NCS

Vision Somatosensory

Vestibular

BALANCE

Neuroanatomy

• Vestibular nerve transmits

afferent signals from the

labyrinths along its course

through the internal auditory

canal.

• Superior vestibular nerve

innervates the lateral and

anterior SCC as well as the

utricle.

• The inferior vestibular nerve

innervates the posterior SCC

and the saccule. (Naito Y

1995)

Vestibular ocular reflex

© Jennifer Fay, PT, DPT, NCS

Vestibulo-occular reflex •As the head is rotated to the left,

the left vestibular nerve is

stimulated.

•The right vestibular nerve is

inhibited.

•This results in an excitation of

the right abducens nerve fibers

innervating the right lateral rectus

muscle and the left oculomotor

nerve fibers innervating the left

medial rectus muscle.

Vestibular spinal reflex

© Jennifer Fay, PT, DPT, NCS

Medial

Vestibulo-spinal

tract Medial Vestibulospinal tract mediates

head righting in response to

semicircular canal input, and ongoing

postural changes.

Lateral

Vestibulospinal

Tract Lateral vestibulospinal tract receives

majority of its input from otoliths and

the cerebellum.

Generates antigravity postural control,

or protective extension in the lower

extremities in response to head

position changes.

Nystagmus

•The vestibular system is a balanced system.

•Effects of activity from one vestibular organ are balanced by

effects from the other.

•A vestibular imbalance will cause overstimulation on one

side and slow tonic deviation of the eyes away from that

side.

•The tonic nature of the movement induced by the vestibular

system causes this slow movement followed by a rapid or

saccadic return to be repeated over and over.

•**Nystagmus will always beat to the side of increased

neural activity**

•Named relative to the fast phase relative to the patient.

Peripheral Causes of Dizziness

•Benign Paroxysmal Positional Vertigo

•Vestibular neuritis/labyrinthitis

•Meniere’s Disease

•Ototoxicity (chemotherapy/IV antibiotics)

•Acoustic Neuroma

Central Causes of Dizziness

•Concussion

•Cerebrovascular disorders

•Migraine

•Multiple sclerosis

•Epilepsy

•Craniocervical junction disorders

•Neoplastic: primary, metastatic or paraneoplastic

•Inherited ataxias

•Pyschogenic

•Neurodegenerative disorders: parkinsonism, normal

pressure hydrocephalus

Concussion

•43 working definitions of concussion. Only one is evidence

based.

43rd Working Definition of Concussion

Concussion is:

• A change in brain function following a force to the

head,which may be accompanied by temporary loss of

consciousness, but is identified in awake individuals,with

measures of neurologic and cognitive dysfunction.

© Jennifer Fay, PT, DPT, NCS

Risk Factors for More Complicated Recovery

•Age

•Younger athletes had more complicated recovery

•Migraine History and Symptoms

•Prior history of migraine or migraine symptoms

post concussion

•History of Learning Disability

•Repetitive Concussion

•Gender

•Females had longer recovery

Dizziness following Concussion

•Prevalence Reported to occur in 23% to 81% of cases in first days after injury (Alsalaheen et al 2010)

•55% of concussed athletes report dizziness as an early symptom (Lovell 2004) •32% of 141 patients with mild TBI report dizziness after 5 years.

Aural Symptoms

•Ringing, pressure, fullness or hearing changes

•Patients with mixed central and peripheral vestibular

dysfunction recover more slowly and incompletely. (Brown

2006)

•Could also have labyrinthine concussion.

•Warrants referral to Otology or Neuro-otology

Postural Control

•43% of athletes report

balance dysfunction

following sports related

concussion. (Lowell

2004)

•May resolve more

quickly than other

symptoms following

concussion. (Catena

2011)

Space and Motion Sensitivity

•Problems •Walking in supermarket or

crowded places?

•Heights?

•Wide open spaces?

•Clinical Assessments: •VOR Cancellation

•SOT (conditions 3,6)

•DHI Items 4 and 12

•Increased dizziness with

surround moving

Vestibular Evaluation

© Jennifer Fay, PT, DPT, NCS

Subjective History

•Specific Questions

•Aural Symptoms

•Hearing loss, fullness

•Positioning Symptoms

•BPPV

•Motion Sensitivity

•Head

•Visual

•Balance

•Headaches-migraines?

•Photophobia and phonophobia

•Nausea/vomiting

•History of Concussion or ever hit their head?

Characterizations of Symptoms

•Temporal course:

•paroxysmal lasting seconds, minutes, hours, days, weeks

•OR continuous with exacerbation lasting seconds minutes, hours,

days, weeks

•Type of dizziness: vertigo, imbalance, lightheadedness, falls,

disorientation

•Nausea & vomiting, headaches, any of the “Ds”=diplopia, dysphagia,

dysarthria, dysmetria, asymmetric muscle weakness

•Onset of symptoms-spontaneous OR head motion or visual motion

provoked

•Hearing-involvement in the auditory system e.g. tinnitus, aural fullness,

progressive or fluctuant hearing loss

Clinical Exam:

•Oculomotor exam in room light

•Ocular motility (ROM)

•Convergence

•Nystagmus

•Saccades

•Smooth Pursuit

•VOR

•Head Thrust Test

•Dynamic Visual Acuity

Clinical Exam

•Oculomotor exam with vision blocked (frenzels or infrared)

•Spontaneous and gaze evoked nystagmus

•Post head shaking nystagmus

•BPPV

•Dix-Hallpike

•Balance Exam:

•Romberg

•EO, EC, Foam EO, Foam EC

•Sharpened Romberg EO, EC

•Ambulation

•Ambulation with Head Rotation

•Dynamic Gait Index/Functional Gait Assessment

•BESS Test for concussion

SPONTANEOUS NYSTAGMUS

GAZE HOLDING NYSTAGMUS

RAPID HEAD THRUST

DYNAMIC VISUAL ACUITY

Balance Testing

© Jennifer Fay, PT, DPT, NCS

POSTUROGRAPHY

• Sensory Organization Test

Functional Gait Assessment

•Modification of the Dynamic Gait Index developed to improve reliability

and decrease the ceiling effect.

•Added gait with narrow base of support, ambulating backwards, and gait

with eyes closed.

© Jennifer Fay, PT, DPT, NCS

Ambulation with Head Turns

© Jennifer Fay, PT, DPT, NCS

TREATMENT

Principles of Treatment

•Habituation

•Adaptation –retinal slip

•Substitution

Habituation

•Asymmetry in labyrinth function results in “sensory

mismatch”.

•Repeated exposure to a provocative stimulus will

result in a reduction in the pathological response to

that treatment.

Adaptation

•Refers to long term changes that occur in response

of the vestibular system to input.

•In acute injury the gain of the VOR is reduced (eye

movement velocity is less than head movement

velocity).

•Resulting in retinal slip (blurred vision)

•Retinal slip causes an error signal resulting in a

change in the gain of the VOR.

Substitution

•Compensation for lack of vestibular function

through use of visual and somatosensory systems.

© Jennifer Fay, PT, DPT, NCS

Gaze Stability/VOR

•Have the patient focus on one letter and turn their

head as fast as they can while keeping letter in

focus and still.

•Progression:

•Duration

•Velocity

•Position

•Target distance

•Background

•Frequency

Vestibular-Ocular Reflex (VOR)

© Jennifer Fay, PT, DPT, NCS

Sensory Organization and Postural Control

•Static and Dynamic

Balance training: •Decreasing base of

support

•Perturbing visual and

somatosensory cues

•Head rotation

•Changing direction

•Stair climbing

•Dual task •Cognitive

•Manual

© Jennifer Fay, PT, DPT, NCS

100, 97, 94, 91

Recovery Depends On

•Central verses Peripheral

•Unilateral verses Bilateral

•Age

•Time from onset

•Comorbidities

•Use of medications (meclizine, antivert)

Vestibular Treatment

•Systematic monitoring throughout session of

symptoms

•Incorporate ocular motor training when needed

and/or make referrals

•Proceed at a slower rate with central injuries than

with peripheral injuries (“less is more”)

LAB

• Practice VOR

• Practice Sharpened Romberg with Eyes Closed

© Jennifer Fay, PT, DPT, NCS

Benign Paroxysmal

Positional Vertigo (BPPV)

BPPV

•Most common vestibular disorder in adults (Bhattacharyya,

Baugh et al. 2008)

•Most common cause of vertigo resulting from head trauma

(Fife and Giza 2013)

•“BPPV should always be considered in patients with head trauma

with complaints of positional vertigo.” (Fife and Giza 2013)

•Recurrence rates similar to idiopathic BPPV

Liu 2012:

•May take more maneuvers to achieve success

•More likely to be bilateral occurring in 25% vs 2% in idiopathic

•35% of patients with post-traumatic bppv were cured after one

maneuver vs. 85% in idiopathic bppv.

Benign Paroxysmal Positioning Vertigo (BPPV)

•Classic symptom:

•Brief (typically <1minute) episodes of vertigo

associated with changes in head position relative

to gravity

•Lying down-rising from horizontal orientation

•Rolling over in bed

•Bending over

•Looking up

© 2003 Canadian Medical Association; Association medicale canadienne. Published by Canadian Medical Association.

2

(Parnes, Agrawal et al. 2003)

Fig. 4 : Left inner ear. Depiction of canalithiasis of the posterior canal and cupulolithiasis of the lateral canal. Photo: Christine Kenney

DIX-HALLPIKE TEST

Canalithiasis

Dix-Hallpike Test

•45 degrees cervical rotation

•Sit to supine with 20 degrees cervical extension

•Look for nystagmus and symptoms of vertigo

•Latency

•Direction

•Duration

•Fatigues

Left Dix-Hallpike Test

Clinical Exam

Canal Right Left

Posterior Up & Right Torsion Up & Left Torsion

Anterior Down & Right Torsion Down & Left Torsion

Horizontal

Cupulolithiasis

Canalithiasis

Left ageotropic (to the

sky)

Right geotropic (to the

floor)

Right ageotropic

Left geotropic

Left Posterior Canalithiasis Nystagmus

© Jennifer Fay, PT, DPT, NCS

Treatment

•Epley or Canal repositioning Maneuver

•Each position is held for 30 sec-2 min

•Designed to treat canalithiasis

•Semont Maneuver

•Designed to treat cupulolithiasis

Right Canal Repositioning Maneuver

© Jennifer Fay, PT, DPT, NCS

References:

• Bhattacharyya, N., R. F. Baugh, L. Orvidas, D. Barrs, L. J. Bronston, S. Cass, A. A. Chalian, A. L. Desmond, J. M. Earll, T. D. Fife, D. C. Fuller, J. O. Judge, N. R. Mann, R. M. Rosenfeld, L. T. Schuring, R. W. Steiner, S. L. Whitney, J. Haidari, O.-H. American Academy of and F. Neck Surgery (2008). "Clinical practice guideline: benign paroxysmal positional vertigo." Otolaryngol Head Neck Surg 139(5 Suppl 4): S47-81.

• Froehling, D. A., M. D. Silverstein, D. N. Mohr, C. W. Beatty, K. P. Offord and D. J. Ballard (1991). "Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota." Mayo Clin Proc 66(6): 596-601.

• Froehling DA, S. M., Mohr DN, Beatty CW (1994). "Does this dizzy patient have a serious form of vertigo?" JAMA: Journal of the American Medical Association 271(5): 385-388.

• Goldberg JM, F. C. (1971). "Physiology of peripheral neurons innervating semicircular canals of the squirrel monkey, I: resting discharge and response to constant angular accelerations. ." Journal of Neurophysiology 34: 141-153.

• Herdman SJ, H. C., Delaune W (2011). "Variables Associated with Outcome in Patients with Unilateral Vestibular Hypofunction." Neurorehabilitation and Neural Repair 26(2): 151-162.

• Krebs D.E., G. K. M., Riley P.O, Parker S.W. (1993). "Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction-Preliminary report. ." Otolaryngology-Head and Neck Surgery 109: 735-741.

• Lysakowski A, M. L., Fernandez C, Goldberg JM. (1995). "Physiological identification of morphologically distinct afferent classes innervating the cristae ampullares of the squirrel monkey. ." Journal of Neurophysiology 73: 1270-1281.

• M, N. (1988). "Vestibular Habituation Training: Specificity of Adequate Exercise." Archives Otolaryngology Head Neck Surgery 114: 883-886.

• Naito Y, N. A., Lee WS, et al. (1995). "Projections of the individual vestibular end-organs in the brain stem of the squirrel monkey. ." Hearing Research 87: 141-155.

• Schubert MC, M. L. (2004). "Vestibulo-ocular Physiology Underlying Vestibular Hypofunction." Physical Therapy 84(4): 373-385. • TC, H. (2011). "Neurophysiology of vestibular rehabilitation " NeuroRehabilitation 29: 127-141. • Whitney SL, S. P. (2011). "Principles of vestibular physical therapy rehabilitation " NeuroRehabilitation 29: 157-166. • Fife, T. D. and C. Giza (2013). "Posttraumatic vertigo and dizziness." Semin Neurol 33(3): 238-243. • Valovich McLeod, T. C. and T. D. Hale (2015). "Vestibular and balance issues following sport-related concussion." Brain Inj 29(2):

175-184. • Gurley, J. M., B. D. Hujsak and J. L. Kelly (2013). "Vestibular rehabilitation following mild traumatic brain injury."

NeuroRehabilitation 32(3): 519-528. • Lei-Rivera, L., J. Sutera, J. A. Galatioto, B. D. Hujsak and J. M. Gurley (2013). "Special tools for the assessment of balance and

dizziness in individuals with mild traumatic brain injury." NeuroRehabilitation 32(3): 463-472.