Vestibular Rehabilitation: Examination and Treatment in the Acute Setting

10/2021

Chara Booker, PT, DPT, NCSJulie Miller, PT, DPT, NCS, CBISNitin Saini, PT, DPTMichael Tran, PT, DPT

Course Objectives1. The course participants will understand anatomy and physiology

principles that are important for rehabilitation of

the vestibular system, including anatomy of the labyrinth and

otoliths, the triplanar model of the SSC and coplanar pairing.

2. The course participants will recognize the typical presentation of

acute vestibular syndrome (AVS) including BPPV and vestibular

hypofunction.

Course Objectives3. The course participants will identify the components of a bedside

vestibular examination performed in the Acute setting.

4. The course participants will select appropriate, evidence-based

vestibular physical therapy treatments for their patients based on

findings from examination.

Course Objectives5. The course participants will write appropriate “SMART” goals for

patients with acute vestibular syndrome with appropriate

timeframes for the acute setting with focus on appropriate

Referral/Disposition to next level of care and using DME, PRN.

6. The course participants will understand specific challenges to

vestibular treatments in the acute setting, including pharmacology,

polytrauma, and environmental considerations, and develop ways

to overcome them to deliver effective care for their patients.

Course Objectives7. The course participants will understand how to sequence and

incorporate vestibular examination and treatments in the context

of a medically-complex patient (with potentially peripheral

involvement from BPPV, UVH and central involvement concurrently

present) and will move to evaluation considering any needed

additional discharge planning and referral needs.

Inspiration for this Course

• Idea began when PT was covering weekend for Inpatient Rehab Unit

• Met a man who had fallen, developed a SDH and had been in hospital for 10 days with dizziness

• He had bilateral BPPV, PT treated him with bilat Epley CRM, he was discharged 2 days later with disposition to have further treatment in Outpatient department.

Human Balance System

Vestibular System - Anatomy

• SCC – 3, orthogonal

• Otoliths

• Common crus

• Ampulla, cupula

Vestibular System - Anatomy

• Otoconia

Vestibular System - Physiology

Coplanar Pairing

• R Ant SC/L Post SC

• L Ant SC/R Post SC

• R/L Horizontal SCs

Vestibular System - Physiology

Vestibular Ocular

Reflex (VOR)

• Vest End organ

• Vestibular Nuclei

• CN nuclei for 6, 4,3

• Eye muscles move

• Example of VOR w hand

Pathology - BPPV

2 Types of BPPV:

• Canalithiasis

• Cupulolithiasis

Pathology - BPPV

Canalithiasis

BPPV

BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6%Von Brevern et. Al, J Neurol Neurosurg Psychiatry. 2007 Jul; 78(7): 710–715.

Link to article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117684/

Types of BPPV

Of 122 patients, 110 had posterior canal involvement, 10 had horizontal canal involvement, and only 2 had the anterior canal variant.

(90% PC, 8% HC, 2% AC), Korres et. al, Otol Neurotol. 2002 Nov;23(6):926-32.

The incidence of posterior semicircular canal (PC) involvement is between 85% and 95% and lateral semicircular canal (LC) involvement is 5% to 15% of BPPV cases.1 The incidence of anterior semicircular canal (AC) involvement is low (3%). Galgon, A.K. et al. Agreement Between Physical Therapists in Diagnosing Benign Paroxysmal Positional Vertigo. JNPT. 2021; 45: 79-86.

BPPV: Treatment flow from CPG

BPPV: Treatment flow

Unilateral Vestibular Hypofunction (UVH)

Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance.

On the basis of data from the National Health and Nutrition Examination Survey for 2001 to 2004, it is estimated that 35.4% of adults in the United States have vestibular dysfunction requiring medical attention and the incidence increases with age.Hall, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline. JNPT. 2016; 40: 124-155.

Unilateral Vestibular Hypofunction (UVH)

Appropriate treatment is critical because dizziness is a major risk factor for FALLS.

The incidence of falls is greater in individuals with vestibular hypofunction than in healthy individuals of the same age living in the community. Hall, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline. JNPT. 2016; 40: 124-155.

Acute Vestibular Syndrome (AVS).Flow for the Medical diagnosis of AVS at bedside from Zuma e Maia, 2020.

Acute Vestibular Syndrome (AVS).Flow for the Medical diagnosis of AVS at bedside from Edlow, 2018.

Acute Vestibular Syndrome (AVS).Flow for the Medical diagnosis of AVS at bedside from Edlow, 2018.

ATTEST:

A – Associated Symptoms

TT – Timing and Triggers (of dizziness)

ES – Examination Signs (Bedside exam)

T – Additional Testing (orthostatics)

Acute Vestibular Syndrome (AVS)AVS vs spontaneous Episodic Vestibular Syndrome (EVS) vs. Triggered EVS from Edlow, 2018.

Pharmacological Management of Acute VertigoLatest Trends

Clinical Practice Guideline- BPPVBhattacharya et al (2017)

• Vestibular Physical Therapy referral

• Canalith Repositioning Maneuver indicated

• No further imaging/investigations necessary if post testing negative

• No vestibular suppressants indicated

• Exception; use vestibular suppressants if patient not able to tolerate treatment/ vestibular assessment

Acute Peripheral Vestibulopathy

• Unilateral vestibular hypofunction, resulting from varying pathological processes, most common-inflammatory.

• Steroid therapy is debated with no supportive evidence found in recent investigations (Yoo et al. 2017).

• Vestibular suppressants indicated to manage acute symptoms but must be discontinued in 7 days to allow vestibular compensation. (Chabbert, 2016)

• No evidence has been found in support of Antiviral Therapy (Strupp et al. 2004)

• Physical Therapy Clinical practice guideline with research evidence to support VRT in unilateral, bilateral Vestibulopathy (Hall et al, 2016)

Central Vertigo

• Brain Stem or cerebellar stroke

• Invisible Brain stem infarctions have been documented (Tsuyusaki et al. 2014)

• Clinical correlation is warranted

• Vestibular suppressants indicated

• Physical Therapy is indicated

Vestibular Suppressants

• Antihistamines- Meclizine, Cyclizine and promethazine

• Anticholinergics- Scopolamine transcutaneous patch.

• Benzodiazepines- Specially if severe anxiety is associated with vertigo

• Calcium channel antagonists-Cinarazine and flunarzine showing benefit in managing Vestibular Migraine. (Lepcha et al, 2014).

Comparing Vestibular suppressants

• Dornhoffer, Chelonis and Blake (2004) compared effectiveness of Vestibular suppressants in managing over vestibular stimulation in space motion sickness. From most effective to least, scopolamine > promethazine > placebo > meclizine > lorazepam

• Promethazine was found to be more effective in treating Acute vertigo in ED as compared to Lorezapam. (Amini et al. 2014)

Antiemetics

• Onadansetron has been found to be more effective than Promethazine alone to manage Nausea in patients with vertigo (Saberi et al. 2019).

• In addition to being an Antiemetic, Onadansetron may also have vestibulo-protective effect during an excitotoxic neuroinflammatory condition such as Vestibular neuritis resulting in decreased functional limitations (Dyhrfjeld-Johnsen et al. 2013).

Evaluation - History

The importance of a good subjective history interview:

• Components• Vertigo vs.

lightheadedness/presyncope• Duration of dizziness• Frequency of dizziness• Precipitating factors (positional

changes, psychological factors, sound, pressure)

• Concurrent medications• Assists with differential diagnosis

Evaluation - HINTS (and HINTS+) Exam

• Quick exam to differentiate AVS from possible posterior circulation CVA

• Head Impulse, Nystagmus, and Test of Skew tests

• Possible stroke (or central pathology) includes:• NORMAL Head Impulse test• DIRECTION-CHANGING nystagmus• PRESENCE of skew deviation

Evaluation - Diagnostic Maneuvers

• Dix Hallpike• Modified Dix Hallpike• Supine Roll Test• Sit to Supine Test

Evaluation: CRMs

Posterior Canal

• Epley, Semont

Horizontal Canal

• Lempert roll, Gufoni/Appiani, Casani, Vannuchi

Anterior Canal

• Epley, Modified Semont, Yacovino

Outcome Measures

Why Use Outcome Measures?

• Quantify observations is meaningful way• Consistency between therapists• Consistency between settings (acute - IP - OP)• Justification of therapy needs• Easier documentation

Outcome Measures: Balance

• Dynamic Gait Index (DGI) = the highest recommended for dynamic postural stability • Use what you’ve got instead of formal cones (clipboard, pen, cisco phone, extra

supplies in room)• Use anything shoebox shaped (wash basin flipped over, small step stool)• Map out staircases on the floor so you can use whichever is closest to the

patient's room• <19/24 = fall risk

• 4 Square Step Test• Use towels or sheets instead of canes• Perform practice run to ensure understanding• >12 sec = fall risk

Outcome Measures: Other Domains

• Gaze Stabilization: Head Impulse Test*

• Positional: Dix Hallpike*

• *Note this is more diagnostic than traditional outcome measure

• Function/ Participation: Dizziness Handicap Inventory

Barriers to Vestibular Care in the Acute Setting

• Traumatic injuries• vertebral artery screen, neck issues, orthopedic injuries that prevent

maneuvers• Cognitive issues• Acute brain injury• Post-surgical precautions• Vitals• Electrolyte imbalances• Potential for worsening acute status

Barriers to Vestibular Care in the Acute Setting

Other acute disorders may mimic BPPV e.g. migraines, vertebral artery occlusions, tumors, hydrocephalus, psychogenic disorders

Equipment?

• Plinths often not available in the acute care setting• Appropriateness for plinth?

• Time, stability, endurance to transport to gym• Hospital bed modification

• For Dix Hallpike/Epley - two pillows underneath lumbar/thoracic area• Trendelenburg position with bed or tilt table if patient lacks neck extension

• Check for contraindications of back extension with acute injuries

Physical Therapy in ED (Kim et al. 2018)

As the ED patient volumes continue to increase, there is a need for ED initiated Physical Therapy

ED physicians are often unable to complete a detailed evaluation as is needed for Peripheral Vertigo (Chrisholm et al. 2008)

Peripheral Vertigo assessment and treatment by ED PT has potential to decrease length of stay and unnecessary imaging/tests

An effective communication and collaboration with stake holders such as ED physicians, ED administration is necessary

What interventions do we choose ?

SYMPTOMS DIAGNOSIS FUNCTION DIZZINESS OF NON

VESTIBULAR ORIGIN

Positional Vertigo

Impaired Gaze stability

Non-Positional Vertigo

Dizziness

Vertigo

Gait dysfunction

Falls

Bed mobility

Transfers

Gait

Balance

ADLs

Postural Hypotension

Pulmonary pathology

Cardiac conditions

Migraine

Bhattacharya et al. (2017) CPG-BPPV

CRP/CRM group more likely to covert to negative Dix-Hall pike as compared to other groups control, sham, Brandt deroff.

32%- 90% success rate after 1st treatment, 40%-100% after 2nd treatment

No known complications to CRP/CRM other than

• Feeling of falling within 30 min of treatment

• 6-7% chances of canal conversion

• Postural instability for up to 24 hours after treatment

Following are not recommended after diagnoses and successful treatment of BPPV

• Further radiologic imaging

• Vestibular testing

• Post-procedural restrictions

BPPV: Treatment flow from CPG

BPPV: Treatment flow

Treatment of Acute Vestibular Hypofunction

COMPENSATION HABITUATION ADAPTATION SUBSTITUTION

Achieve optimal gaze stability

and postural control in to

restore functional

Independence in all

environmental challenges.

Interventions involve repeated

& graded exposure to stimuli

that facilitates desired rewiring

and neuroplasticity associated

with Vestibulo-ocular and

vestibulo-spinal reflexes.

Achieve decreased severity of

response to a specific

movement or position by

regular and repeated exposure

to the same movement in a

graduated/organized manner.

Biochemical basis may

responsible associated with

decreased neurotransmitter

release.

Achieving decreased severity

of symptoms by altered neural

response involving one or

more sites in the Vestibular

system.

Achieving functional

improvement and decreased

symptom severity by acquiring

alternate strategy.

General Treatment Guidelines for Acute Vestibular Hypofunction (Hall et al. 2016)

NAME OF

INTERVENTION

FREQUENCY TOTAL DAILY

DURATION

REQUIRED

SUPERVISION

Gaze stabilization exercises Upto 3 times a day

Consider tolerance and

symptom severity

Maximum of total 12 minutes

every day

If tolerance is a concern

increase duration gradually

Must complete at least one

supervised session prior to

discharge with home exercise

program

Isolated saccades or pursuit

exercises

Not indicated N/a N/a

Gaze Stabilization Exercises x1

INTERVENTION &

PROGRESSION

MECHANISM

X1 viewing exercise

Progression by using a

metronome

Progression by increasing

postural challenge

a. sitting unsupported

b. standing with optimal BOS

c. Standing narrow BOS

VOR adaption/compensation

Gaze Stabilization Exercises x2

NAME OF

INTERVENTION

MECHANISM

X2 viewing exercise

Progression by using a

metronome

Progression by increasing

postural challenge

a. Sitting unsupported

b. Standing with optimal

BOS

c. Standing narrow BOS

VOR adaption/compensation

Treatment of Acute UVH in ED

• During Acute phase patient likely to be in a lot of distress/anxiety

• Consider severity of symptoms before starting viewing exercises

• Consider recommending Vestibular suppressants to manage acute symptoms.

• In most cases vestibular suppressants must be discontinued 7 days after onset to ensure compensation

• Once diagnosed with Acute UVH and all other pathologies ruled out, education and reassurance about prognosis can be beneficial.

Time Frames

Patients with BPPV, resolved (negative post testing)

• Can go home from ED if no other unrelated medica/surgical needs

• Document pre/post testing and subjective reports

• Document pre/post treatment changes in mobility

• Outcome reports

Patients with Acute UVH

• May go to the floor

• 3-5 days in hospital based on severity

• Likely get put on steroids if inflammatory process suspected

• Document functional/ADL limitations, barriers for safe discharge to support rehab (if needed)

Discharge Disposition

BPPV-IF RESOLVED

AFTER TREATMENT

BPPV- IF NOT

RESOLVED AFTER

TREATMENT

ACUTE UVH THAT IS

NOT RESOLVED

COMPLETELY

ACUTE UVH THAT IS

PARTIALLY RESOLVED

WITH MINIMAL

SYMPTOMS

Home with no follow up

needed if no other barriers

exist

No Assistive device

indicated unless indicated

for another

diagnosis/limitation

No vestibular suppressants

indicated

Home with follow up with

recommendations to follow up

with a specialist

No Assistive device indicated

unless indicated for another

diagnosis/limitation

No Vestibular Suppressants

indicated

Based on mobility and

homeset up any where from

Rehab to Home with Home

health

Assistive device

recommendations to be made

considering symptoms usually

resolve in weeks/days

Vestibular suppressants

usually discontinued 7 days

from onset unless indicated

otherwise

Home with recommendations

to follow up with a vestibular

specialist.

Assistive device

recommendations to be made

considering symptoms usually

resolve in weeks/days

Vestibular suppressants

usually discontinued 7 days

from onset unless indicated

otherwise

Does Physical Therapy work

for these patients?

• Expanding literature supporting Vestibular rehab in vestibular disorders of central and peripheral orgin (Dunlap, Holmberg & Whitney, 2019).

• Canalolith Repositioning Maneuvers can relieve disabling symptoms of BPPV, eliminating need of further imaging (Bhattacharya et al. 2008).

• Corticosteroid therapy and vestibular Rehabilitation therapy have been found to be equally effective in Vestibular Neuritis (Ismail, Morgan & Abdel Rehman, 2018)

• Early intervention can be a game changer in improving outcomes of unilateral vestibular hypofunction (Michael, Laurent & Alain, 2020)

Relevant Practice Patterns

• Pattern 5A: Primary Prevention/Risk Reduction for Loss of

Balance and Falling

• Pattern 5F: Impaired Peripheral Nerve Integrity and Muscle

Performance Associated With Peripheral Nerve Injury

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• Yoo, M. H., Yang, C. J., Kim, S. A., Park, M. J., Ahn, J. H., Chung, J. W., & Park, H. J. (2017). Efficacy of steroid therapy based on symptomatic and functional improvement in patients with vestibular neuritis: a prospective randomized controlled trial. European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery, 274(6), 2443–2451. https://doi-org.akin.css.edu/10.1007/s00405-017-4556-1

Break out into 3 groups for case studies

When return to large group will need:

Brief Summary of discussion from one group member (~3 mins or less)

• Treatment chosen

• Goals for patient

• Discharge Planning/Disposition

Case Study #1: Man Who Hates Movement

Order to see patient for PT evaluation for dizziness, being worked up for CVA

• Came in after fall at home because he was so dizzy, he got up and had to hold onto the wall to make it to the bathroom to vomit, family called 911

• CT was negative, pending MRI

Walk in the room, patient is in bed, doesn’t turn to look at you just keeps looking straight ahead, not happy to see you for PT because he don’t want to get up because he get dizzy and nauseous

• No lights on, blinds drawn

Case Study #1: Man Who Hates Movement

First Part of Exam = mobility basics

• Seems to be doing well with no immediately noticeable balance issues• DGI of 21/24, few points off for head turns

Second Part of Exam = vestibular portion

• Dix Hallpike is negative• HINTS

• + Head Impulse on R• - Direction Changing Nystagmus• + Test of Skew on R

• Symptomatic with smooth pursuits, saccades, gaze conjugation (also noted to have corrective saccades on R)

Case Study #1: Man Who Hates Movement

What tests would you do?

What diagnose(s) does the patient have?

What treatment would you do first?

What is a good (“SMART”) goal for the patient?

Where would you send him next/disposition?

Case Study #2: M.D.

Pt is a 70 yo man who fell at home, hitting his head posteriolaterally. He was admitted from ED after MRI showed he had a small SDH in occipitoparietal region on right. On Neuro floor, he complains of dizziness and is unsteady with walking, needing HH support or to use a RW with CGA to ambulate. He has dizziness with moving in/out of bed and needs to sit at bedside for about 30 secs before he can do a sit to stand or bed to WC transfer. He denies hearing loss or tinnitus. He reports dizziness when he moves his head or turns to quickly.

Case Study #2: M.D.

What tests would you do?

What diagnose(s) does M.D. have?

What treatment would you do first?

What is a good (“SMART”) goal for M.D.?

Where would you send him next/disposition?

Return to Large Group

Brief Summary from one group member (~3 mins or less)

• Treatment chosen

• Goals for pt

• DC planning/Disposition

Questions?

Any Questions?

Chara Booker, PT, DPT, NCS, Herdman-certified Vestibular Rehab specialist

Julie Miller, PT, DPT, NCS, CBIS

Reeves Rehab Center at University Health, San Antonio, TX

Nitin Saini, PT, DPT – Methodist Hospital, San Antonio, TX

Michael Tran, PT, DPT – Dell Seton Medical Center, Austin, TX

Thank You!!

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