Vestibular Rehabilitation: Evaluation and

Treatment Strategies for Common

Vestibular DisordersBurt DeWeese, PT, MCMTRebound Physical Therapy

Vestibular Rehab Specialistburt@reboundphysicaltherapy.com

Background• Graduate of Kansas State University,

1999• Master’s in Physical Therapy from Mayo

School of Health Sciences, Rochester, MN, 2002• Completed APTA Competency Based

Certification Course: Vestibular Rehabilitation-Emory University, 2004• Working toward manual therapy

certification through NAIOMT – will complete level III this year• Clinical Director at Rebound Physical

Therapy, Topeka, KS

Objectives• Describe the anatomy and physiology of the

vestibular system.

• Describe the pathophysiology of common vestibular disorders.

• Complete and interview and examination of a person with vestibular dysfunction.

• Identify appropriate standardized assessment tools for use in vestibular rehabilitation.

• Demonstrate skill in performing the occulomotor exam.

• Demonstrate skill in differentiating between types of BPPV.

• Identify appropriate treatment intervention with patients with vestibular disorders.

Anatomy and Physiology

Anatomy of the Ear

Anatomy of the Ear• The External Ear• External auditory canal• Ends at the tympanic membrane

• The Middle Ear• Space between the tympanic membrane

and the inner ear• Contains the malleus, incus and stapes• Transmits sound into waves inside the

cochlea• Filled with air

Anatomy of the Ear• The Inner Ear• Contains sensory organs for hearing and

balance• Bony labyrinth within the temporal bone• Central portion is names the vestibule

• Saccule and Utricle• Cochlea is anterior and vestibular

portion post• Tissue layers: bony labyrinth, perilymph,

membranous labyrinth, endolymph

The Labyrinth•Bony Labyrinth• Perilymph• Between bony Between bony

and membranous and membranous labyrinthlabyrinth

• Membranous Membranous labyrinthlabyrinth

• Endolymph• Inside Inside

membranous membranous labyrinthlabyrinth

Parnes, 2003

The Labyrinth• 3 Semicircular

Canals• Anterior, Anterior,

Posterior Posterior HorizontalHorizontal

• Cochlea• Hearing Hearing

componentcomponent• Vestibule• Saccule and Saccule and

UtricleUtricle

The Hair Cell• Found in cochlea, semicircular canals,

saccule and utricle• Send in information to the

vestibularcochlear system• “Hair” of the hair cell consists of:• Sterocilia (40-70 in one hair cell)Sterocilia (40-70 in one hair cell)• Kinocilium (1 per hair cell)Kinocilium (1 per hair cell)

Semicircular Canals

• Hair CellsHair Cells• Motion SensorsMotion Sensors• Always sending info Always sending info

to the brain to the brain

• KilociliaKilocilia• Deflection Towards- Deflection Towards-

ExcitesExcites• Deflection Away- Deflection Away-

InhibitsInhibits

Semicircular Canals• Provides input about

angular head velocity• Three canals on

each side• Anterior (superior), Anterior (superior),

Posterior (inferior) Posterior (inferior) & Horizontal & Horizontal (lateral)(lateral)

• 90 degree angle 90 degree angle from each otherfrom each other

• Horizontal canalHorizontal canal• 30 degree elevation30 degree elevation

Semicircular Canals• Mate on the opposite

side• L ant/R post, R L ant/R post, R

ant/L postant/L post• Each semicircular

canal has a ampulla housing the sensor organs• Hair cells covered Hair cells covered

by the cupulaby the cupula• Both ends terminate

in the utricle

The Otoliths• Utricle (Linear)• Horizontal Horizontal

MovementsMovements• Head TiltHead Tilt

• Saccule (Linear)• Up & Down Up & Down

MovementsMovements• Otoconia “Ear Rocks”

(Calcium Carbonate Crystals)• Hair Cells Herdman,

2000

Vestibular Occular Reflex

• Allows clear vision through gaze stabilization• Coordinates eye and head Coordinates eye and head

movementsmovements• Sensory stimulation sends info to the

brainstem region that controls eye movement• Example: Head left, eyes turn right

while focusing on an object• R lat rectus/L med rectus excited and R lat rectus/L med rectus excited and

opposite inhibitedopposite inhibited

Causes of Vertigo

Herdman, 2000

Causes of Vertigo• BPPV• Vestibular Neuritis• Labyrinthitis• Meniere's Disease• Bilateral Vestibular Loss• Cervicogenic Dizziness

Common Disorders

• Vestibular NeuritisVestibular Neuritis• SymptomsSymptoms• Sudden onset of vertigoSudden onset of vertigo• Nausea/vomitingNausea/vomiting• ImbalanceImbalance• Sensitivity to motionSensitivity to motion

• Last hours to daysLast hours to days• CCan result in chronic dysequilibriuman result in chronic dysequilibrium• Caused by viral infectionCaused by viral infection• TreatmentTreatment

Semi-CircularCanals

Inflammation of theVestibular Nerve

Cochlea

Inner Ear

Common Disorders

• Vestibular LabyrinthitisVestibular Labyrinthitis• Viral or bacterial infection of Viral or bacterial infection of

the membranous labyrinth the membranous labyrinth• Acute onset of hearing loss, Acute onset of hearing loss,

vertigo, nausea/vomiting vertigo, nausea/vomiting• Can last 1-4 daysCan last 1-4 days• Will demonstrate Will demonstrate

imbalance and imbalance and sensitivity to head sensitivity to head movements movements

Common Disorders• Meniere’s DiseaseMeniere’s Disease• Increased endolymph Increased endolymph

pressurespressures• EpisodicEpisodic• Low frequency Low frequency

hearing losshearing loss• TinnitusTinnitus• Can last hours to daysCan last hours to days

Common Disorders• Fear of Falling• Disuse Dysequilibrium• Orthostatic Hypotension• Cervicogenic Dizziness• Anxiety

Common Disorders

• CentralCentral• TBITBI• CVACVA• Multiple SclerosisMultiple Sclerosis

Vestibular Evaluation

• Subjective componentSubjective component• Thorough HistoryThorough History• Dizziness Handicap InventoryDizziness Handicap Inventory• ABC confidence scaleABC confidence scale

Common Questions• Tell me about your symptoms.• When did your symptoms begin?• How long did/does your symptoms last?• Are your current symptoms better, worse or the same?• Can you rate the severity of your symptoms 0-10/10?• Do your symptoms increase with positional changes or

certain movements?• Do you have difficulty with keeping objects in focus?• Do you have ear fullness, pressure, ringing or hearing

loss?• Do you have a history of these symptoms?• Have you had any falls or unsteadiness?• Currently what meds are you taking?

Dizziness Handicap Inventory

Vestibular Evaluation• Bedside ExamBedside Exam• OcculomotorOcculomotor

Smooth PursuitSmooth Pursuit SaccadesSaccades VORVOR VOR cancellationVOR cancellation Head Thrust/Head ShakeHead Thrust/Head Shake

• Upper and lower extremity screenUpper and lower extremity screen• Cervical screen-may choose to do firstCervical screen-may choose to do first

Vestibular Evaluation• Other testing optionsOther testing options• Videonystagmogtaphy (VNG)Videonystagmogtaphy (VNG)• Caloric TestingCaloric Testing

Test horizontal Test horizontal semicircular canals semicircular canals only only

External auditory canal is External auditory canal is irrigated with warm and irrigated with warm and cold water with head in cold water with head in 30 degrees flex 30 degrees flex

Significant finding 25% or more Significant finding 25% or more reduction indicates a unilateral reduction indicates a unilateral weaknessweakness

Observation Tools

• Frenzel GogglesFrenzel Goggles• Video Frenzel Video Frenzel

LensesLenses• Room LightRoom Light

Vestibular Evaluation

• Functional TestingFunctional Testing• Dynamic Gait Index-videosDynamic Gait Index-videos• Berg Balance ScaleBerg Balance Scale• Timed Up and GoTimed Up and Go• Static Balance TestingStatic Balance Testing

Eyes Open/Eyes ClosedEyes Open/Eyes Closed Head turnsHead turns Firm and FoamFirm and Foam

Dynamic Gait Index

Dynamic Gait Index• Video

Berg Balance Scale

Timed Up and Go• Video

Timed Up and Go (secs) (7,12,14)Back against chair, arms on armrests –get up and walk at comfortable place to line 3 meters away, return to chair and sit down; repeat, take average

Age Male Female(years)60-69 8 870-79 9 980-89 10 10

Time < 10 seconds is normal

11-20 seconds is normal for frail elderly

>14 seconds indicates risk for falls

>20 seconds indicates impaired

functional mobility

>30 seconds indicates dependency in

most ADL and mobility skills

Static Balance Testing

•Modified CTSIB•Ground-Eyes open and closed• Foam-Eyes open and closed•½ Tandem and Tandem• SLS•Computerized Dynamic Posturography

Computerized Posturogrphy

Benign Paroxysmal Positional Vertigo

BPPV Statistics•BPPV is the most common cause of vertigo in patients with vestibular disorders (Bath et al, 2000)•About 20% of all dizziness is due to BPPV (Hain, 2010)•About 50% of all dizziness in older people is due to BPPV (Hain, 2010)

BPPV Defined•Benign- It does not signify anything life-threatening. Not malignant.• Paroxysmal- Refers to the fact that the episodes are brief and self-limited – "paroxysm" means "attack."• Positional-Change in position provokes symptoms.•Vertigo-Room spinning sensation.

Causes of BPPV•“Idiopathic”-50%-70%•Head injury- 7%-17%•Viruses

•Vestibular neuritis- 15%Vestibular neuritis- 15%

•Degeneration?

BPPV

• NystagmusNystagmus• Non-voluntary oscillation of the eyeNon-voluntary oscillation of the eye• Defined fast and slow phases in Defined fast and slow phases in

opposite directionopposite direction• Fast phase defines direction of Fast phase defines direction of

nystagmusnystagmus• Semicircular canals connected to Semicircular canals connected to

specific eye muscles, which dictates specific eye muscles, which dictates direction of nystagmusdirection of nystagmus

• VideoVideo

BPPV – Nystagmus• Posterior canal• Up-beating, torsional nystagmus toward Up-beating, torsional nystagmus toward

involved earinvolved ear• http://youtu.be/siL3MTNUIQI

•Anterior canal• Down-beating, torsional nystagmus toward Down-beating, torsional nystagmus toward

involved earinvolved ear

•Horizontal canal• Lateral, slight torsional nystagmus, greater Lateral, slight torsional nystagmus, greater

toward involved eartoward involved ear• http://youtu.be/MtmkD5rDU0o

Occurrence Rates

• PercentagesPercentages• Posterior canal- 92% occurrencePosterior canal- 92% occurrence• Horizontal canal- 6% occurrenceHorizontal canal- 6% occurrence• Anterior canal- 2% occurrenceAnterior canal- 2% occurrence

• Once patient has had BPPV, re-Once patient has had BPPV, re-occurrence rate is about 25-30%occurrence rate is about 25-30%

BPPV

• Classic SymptomsClassic Symptoms• Room spinning, nausea, imbalanceRoom spinning, nausea, imbalance• Brief episodes of vertigo with Brief episodes of vertigo with

changes in head position relative to changes in head position relative to gravitygravity

• Lying down in bedLying down in bed Sitting up from lying downSitting up from lying down Rolling over in bedRolling over in bed Bending overBending over Looking up- Top Shelf SyndromeLooking up- Top Shelf Syndrome

Challenges•Musculoskeletal restrictions• PainPain

cervical, lumbar, shoulder and hipscervical, lumbar, shoulder and hips

• Fear of falling off table in sidelying Fear of falling off table in sidelying when spinningwhen spinning

• Hip replacementsHip replacements

•Use of table/plinth

Use of Plinth

BPPV – Clinical Exam•Dix-Hallpike Test• 45 degree cervical 45 degree cervical

rotationrotation• Align canals with Align canals with

gravitygravity• Sit to supine with Sit to supine with

20 deg of cervical 20 deg of cervical extensionextension

• Look for Look for nystagmus and nystagmus and symptoms of symptoms of vertigovertigo

• Practice

Herdman, 2000

BPPV – Clinical Exam

• Typical NystagmusTypical Nystagmus• Latency- before nystagmus startsLatency- before nystagmus starts

1-30 seconds1-30 seconds

• DirectionDirection Mixed up-beating, torsional nystagmus Mixed up-beating, torsional nystagmus

(post.)(post.)

• DurationDuration Less than 1 minuteLess than 1 minute

• Fatigues with repeated testingFatigues with repeated testing

BPPV – Clinical Exam•All you need to know…• DirectionDirection

The direction of the elicited nystagmus The direction of the elicited nystagmus will tell you which canal is involvedwill tell you which canal is involved

• DurationDuration Will tell you the type of BPPVWill tell you the type of BPPV

BPPV – Clinical Exam

• Two types of BPPVTwo types of BPPV• Canalithiasis (A)Canalithiasis (A)• Cupulolithiasis (B)Cupulolithiasis (B)

BPPV – Canalithiasis•Otoconia are freely moving in the canals• Fall to the lowest point in canal• Induces flow of endolymph•Deflection of cupula• Fatiguing Nystagmus• Last less than 1 Last less than 1

minmin

BPPV – Canalithiasis• Video Animation• http://youtu.be/IHfU2cA7eRo

BPPV – Cupulolithiasis

•Otoconia are adherent to the cupula of the semicircular canal• Increased Increased

density of density of cupulacupula

• Sensitive to Sensitive to gravitygravity

• Persistent-last Persistent-last greater than 1 greater than 1 minmin

Hain, 2010

Repositioning Procedures

Parnes, 2003

Patient Response• Sensation of spinning• May feel like they will fall of the May feel like they will fall of the

tabletable

•Clammy• Sweating•Nauseous•Vomitus

Canal Alignment Reminder

•Will treat R post. canal and L ant. canal the same way•Opposite eye movement• Post-Up Post-Up

beat/Rotbeat/Rot• Ant-Down/RotAnt-Down/Rot

BPPV Treatment –Posterior/Anterior

Canals•Canalith Repositioning Technique• Starting Position is Dix-Hallpike•Nystagmus should be same direction in all positions

• Practice

Liberatory or Semont Maneuver

•Used for Cuplulolithiasis• Posterior and Anterior Canal•Rotate head 45 degrees away from affected side•Quick movements to jar otoconia loose

Parnes, 2003

Case Study• 74 yo female with past medical history of

BPPV• Slipped and fell at home• Hit her head on the floor• Admitted to hospital for 2 days• Patient self report of BPPV• Dizziness with getting in bed and rolling

to the left• Patient positive for Left Posterior Canal

BPPV• Treatment-Left CRT

Case Study• 68 yo male with sudden onset of

dizziness• Increased with rolling over in bed and

looking up• Mild imbalance in Romberg eyes closed

position• Positive R Dix-Hallpike with persistent

upbeating and R torsional nystagmus

Case Study•All other evaluation info was negative• Treatment• Semont Maneuver performedSemont Maneuver performed• Then performed CRT for post canal Then performed CRT for post canal

BPPV, once otoconia are dislodged BPPV, once otoconia are dislodged from cupulafrom cupula

• Symptoms were resolved after one Symptoms were resolved after one visitvisit

Horizontal Canal BPPV

•How do you test? Roll Test•Head in 30 degrees flexion•Rotate head either direction•Nystagmus will be lateral• Treat the side with greater symptoms

Herdman, 2003

Horizontal Canal BPPV

•Canalithiasis• Eyes will beat Eyes will beat

geotropicgeotropic

•Cupulolithiasis• Eyes will beat Eyes will beat

ageotropicageotropic

Parnes, 2003

Horizontal Canal BPPV

•Horizontal Canal CRT• Barbeque RollBarbeque Roll• Head rotated to Head rotated to

involved side involved side firstfirst

• Roll away from Roll away from involved sideinvolved side

• Keep head in 30 Keep head in 30 degrees flexiondegrees flexion Herdman,

2000

BPPV – Flow Chart

Horizontal Canal BPPV

•HC- Semont maneuver•Used for Cuplulolithiasis•Horizontal Canal•Head in neutral position•Quick movements to jar otoconia loose• Then perform CRT

BPPV Treatment• Post-Treatment Instructions- typically 24 hours• Avoid lying down until you go to bed.Avoid lying down until you go to bed.• Avoid up and down head movements.Avoid up and down head movements.• Prop head up at night with pillows.Prop head up at night with pillows.• Avoid sleeping on affected side.Avoid sleeping on affected side.

•Debate

Other Treatment Options

•Brandt-Daroff•Home CRT•Balance retraining• Surgery-canal plugging

Brandt-Daroff Exercises

• 3-5 cycles• 3 times per day•Hold position for 30 seconds after vertigo stops

Parnes, 2003

Home CRT• Same as CRT• Place pillow under shoulders• Tip head over pillow and rest on mattress

Balance Re-training• Progress toward balance activities if the patient continues to have imbalance.•Will discuss balance activities in the Vestibular Rehabilitation section.

Vestibular Rehabilitation

Output of CNS•Vestibulo-Ocular Reflex (VOR)• Allows clear vision while the head is Allows clear vision while the head is

in motion.in motion.

•Vestibulo-Spinal Reflex (VSR)• Generates compensatory body Generates compensatory body

movement in order to maintain movement in order to maintain head and postural stability. head and postural stability.

• Prevents FallsPrevents Falls

Vestibular Function Testing

•Video Infrared Recording• Eye Movements and

Head Shake• BPPV

•Caloric Testing•Head and Eye Movements• Saccades, Smooth,

Pursuit, Head Thrust, Slow VOR

Vestibular Testing•Computerized Dynamic Posturography•Dynamic Visual Acuity•Dynamic Gait Index• Static Balance Testing• Romberg, Romberg,

Sharpened Sharpened Romberg, SLSRomberg, SLS

• Timed Up and Go

Treatment Theory

Treatment Theory for Dysfunctions

•Compensation• Response to Response to permanentpermanent vestibular vestibular

lesion.lesion.• Goals- approximate normal gaze Goals- approximate normal gaze

stability and postural control.stability and postural control.• CNS changes to optimize function.CNS changes to optimize function.• Visual input important.Visual input important.

•Mechanism for Compensation- Habituation

Treatment Theory•Habituation• Long-term reduction of a response to Long-term reduction of a response to

a noxious stimulus.a noxious stimulus.• Repeated movements of provocative Repeated movements of provocative

stimulus.stimulus.• Patients who move more, improve Patients who move more, improve

more.more.• Need to provoke symptoms to reduce Need to provoke symptoms to reduce

symptoms.symptoms.• Examples (MSQ)Examples (MSQ)

Treatment Theory•Adaptation • Long term changes in neuronal Long term changes in neuronal

responses.responses.• GoalsGoals

Decrease retinal slip- gaze stabilization.Decrease retinal slip- gaze stabilization. Improve postural stability.Improve postural stability. Decrease symptoms.Decrease symptoms. Decrease sensitivity.Decrease sensitivity. Increase balance and function.Increase balance and function.

Treatment Exercises•Based on Models of VOR• Retinal Slip and Head MovementsRetinal Slip and Head Movements

•Main Exercises• x1 and x2 Viewing Exercises x1 and x2 Viewing Exercises

Viewing Exercises

Treatment Exercises•Guidelines• Target Seen ClearlyTarget Seen Clearly• Head Movement +/- 30 degreesHead Movement +/- 30 degrees• SmoothSmooth• ContinuousContinuous• Pushes Upper LimitPushes Upper Limit

Treatment Exercises• Progression• Duration: 1-2 minutesDuration: 1-2 minutes• Frequency: 3-5x/dayFrequency: 3-5x/day• Target Size: SmallTarget Size: Small• Position of Head: Level, Slightly Position of Head: Level, Slightly

DownDown• Position of Patient: Sit, StandPosition of Patient: Sit, Stand• Target Distance: Near, Far Target Distance: Near, Far • Compliant vs. Non-Compliant Compliant vs. Non-Compliant

Surface Surface

Treatment Exercises•Active Head Movements b/t 2 Targets•Remembered Target•Walking Fwd/Bwd with Head Turns•Bean Bag Toss (1 & 2)• 180 & 360 Degree Turns•Ball Against Wall•Walk in Circle with Ball Toss

Treatment Exercises• Sit to Stand with head turns•Wobble board with head turns•Hurdles with ball toss•Obstacle course• Stairs

Balance Re-training•Romberg•½ Romberg• Full Romberg

•On ground and on foam•Add head turns

Home Exercise Program

•All the previous discussed exercises•Can modify as needed•Can create any exercise incorporating head and eye movements• Include balance activities.Include balance activities.

Billing• PT evaluation- 97001•Neuromuscular Re-ed-97112•Canalith Repositioning-95992• One unit per dayOne unit per day

• Therapeutic Activity-97530

Treatment Frequency• 1-3 times per week•Can take up to 8-12 weeks•Most often 4 weeks length of treatment•BPPV only: 1-3 visits• If BPPV and neuritis• Treat BPPV first, once resolved, treat Treat BPPV first, once resolved, treat

neuritis and balance disordersneuritis and balance disorders

Any Questions?

Bibliography• Herdman, Susan. Vestibular Rehabilitation.

Philadelphia: F.A. Davis Company, 2000.• Parnes LS, Agrawal SK, Atlas J. Diagnosis and

management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003; 169:7 681-693.• http://www.dizziness-and-balance.com/disorder

s/bppv/bppv.html. Timothy Hain, MD. Benign Paroxysmal Positional Vertigo. July 19, 2010.• Vestibular Rehabilitation: A Competency Based

Course. Emory University. Atlanta, Georgia.

Thank You!