Vestibular Resources

Badaracco C, Sylos Labini F, Meli A, De Angelis E, Tufarelli D. Vestibular rehabilitation outcomes in chronic vertiginous patients through computerized dynamic visual acuity and gaze stabilization test. Otol & Neurotology 2007; 28: 809-813.

Badke MB, Pyle GM, Shea T, Miedaner J. Outcomes in vestibular ablative procedures. Otol & Neurotology 2002; 23: 504-509.

Bar-Kochba E, Scimone MT, Estrada JB, Franck C. Strain and rate-dependent neuronal injury in a 3D in

vitro compression model of traumatic brain injury 2016. Scientific Reports (6):30550. Becker-Bense et al., Vestibular compensation in acute unilateral medullary infarction. Neurology 80,

2013; 1103-1109

. Black FO, Angel CR, Pesznecker SC, Gianna C. Outcome analysis of individualized vestibular rehabilitation protocols. Am J Otol 2000; 21: 543-551.

Brown KE, Whitney SL, Wrisley DM, Furman JM. Physical therapy outcomes for persons with bilateral vestibular loss. The Laryngoscope 2001; 111: 1812-1817.

Calder JH, Jacobson GP. Acquired bilateral peripheral vestibular system impairment: Rehabilitative options and potential outcomes. J Am Acad Audiol 2000; 11: 514-521. Cawthorne T. The Physiological basis for head exercises. J Chartered Soc Physiother 1944; 30-106.

Cohen, HS. Assessment of functional outcomes in patients with vestibular disorders after rehabilitation. NeuroRehabil 2011; 29: 173-178. Cohen HS. Vestibular rehabilitation reduces functional disability. Otolaryngol Head Neck Surg 1992; 107 (5): 638-643. Cohen HS, Kimball KT, Adams AS. Application of vestibular disorders activities of daily living scale. Laryngoscope 2000; 110: 1204-1209. Cooksey FS. Rehabilitation and vestibular injuries. Pro R Soc Med 1946; 39: 273. Dispenza F, Kulamarva, MS, Stefano, A. Comparison of repositioning maneuvers for benign paroxysmal positional vertigo of posterior semicircular canals: advantages of hybrid maneuver. American Journal of Otolaryngology.2012 Sep-Oct;33(5):528-32 Enticott JC, O’Leary SJ, Briggs RJS. Effects of vestibulo-ocular reflex exercises on vestibular compensation after vestibular schwannoma surgery. Otol & Neurotology 2005; 26: 265-269. Ellis A, Schone C, Vibert D, Caversaccio M, Mast, F. Cognitive rehabilitation in bilateral vestibular patients: a computational perspective. Frontiers in Neurology. 2018 Apr 27; 9:286. Gans, RE. (1996). Vestibular Rehabilitation: Protocols and Programs. AIB Education Foundation Press. Gans RE. Vestibular Rehabilitation: Protocols and Programs. San Diego: Singular Publishing Group 1996.

Gates GA. Clinimetrics of Meniere’s Disease. The Laryngoscope 2000; 110 (3): 8-11. Ghai S, Ghar I, Eiffenbert A. Effects of dual tasks and dual-task training on postural stability: a systematic review and meta-analysis. Clinical Intervention Aging: 2017 Mar 23; 12: 557-577. Gottschall KR, Moore RJ, Hoffer ME. Vestibular rehabilitation for migraine-associated dizziness. Int Tinn J 2005; 11(1): 81-84. Hall CD, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An evidence-based clinical practice guideline. JNPT 2016: 40: 124-156 Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: Review of indications, mechanisms, and key exercises. J Clin Neurol 2011; 7: 184-196.

Herdman, SJ, Blatt PJ, Ventuto P, Tusa RJ. Quantitative dynamic visual acuity test (DVA): Clinica utility in diagnosis (abstract). Phys Ther 1998; 78: S23. Herdman SJ. Therapy: Rehabilitation. In: Goebel JA; ed. practical management of the dizzy patient. Philadelphia, PA: Lippincott, William & Wilkins 2001; 327-344.

Hillman EJ, Bloomberg JJ, McDonald PV, Cohen HS,. Dynamic visual acuity while walking in normals and labyrinthine-deficient patients. J of Vestibular Rehabilitation 1999; 9 (1): 49-57.

Horak FB, Jones-Rycewicz C, Black FO, Shumway-Cook A. Effects of vestibular rehabilitation on dizziness and imbalance. Otolaryngol Head Neck Surg 1992; 106: 175-180.

Huxhold O, Li S, Schmiedek F, Lindenberger U. Dual-tasking postural control: Aging and the effects of cognitive demand in conjunction with focus of attention. Brain Research Bulletin 2006 Apr 14;69(3):294-305. Jacobson GP, Newman CW. The development of Dizziness Handicap Inventory. Arch Otolaryngol 1990; 116: 424-427. Kramer P, Shelhamer M, Zee DS. Short-term vestibulo-ocular adaptation: Influence of context. Otolaryngol Head Neck Surg 1998; 119 (1): 60-64.

Liao W-L, Sung P-Y, Chui W-F, Chang T-P. Vestibular rehabilitation therapy in a patient with chronic vestibulopathy of Ramsay Hunt Syndrome. Am J Phys Med Rehabil 2011; 90(10): 851-855. Lisberger S. Physiologic basis for motor learning in the vestibulo-ocular reflex. Otolaryngol Head Neck Surg 1998; 119 (1): 43-48.

Magnusson M, Karlberg M, Tjernstrom F. ‘PREHAB’: Vestibular prehabilitation to ameloriate the effect of a sudden vestibular loss. NeuroRehabil 2011; 29: 153-156.

Meldrum D, Glennon A, Herdman S, Murray D, McConn-Walsh R. Virtual reality rehabilitation of balance: Assessment of the usability of the Nintendo Wii® Fit Plus. Disabil and Rehabil: Assistive Technology 2012; 7(3): 205-210.

Meldrum D, Herdman S, Moloney R, Murray D, Duffy D, Malone K, French H, Hone S, Conroy R, McConn-Walsh R. Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait and balance impairment in adults with unilateral peripheral vestibular loss: a randomized controlled trial. BMC ENT Disorders 2012; 12(3): 1-8.

Morris AE, Lutman ME, Yardley L. Measuring outcome from vestibular rehabilitation, part II: Refinement and validation of a new self-report measure. Int J Audiol 2009; 48:24-37.

National Institute on Deafness and Other Communication Disorders, U.S. Dept. of Health and Human Services, National Institutes of Health. The National Strategic Research Plan 1995; 97- 3217, 77-110. Oghalai J, Manolidis S, Barth J, Stewart, M, Jenkins H. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngology-Head and Neck Surgery 2000; 122:630-634 O’Leary DP, Davis-O’Leary LL. High frequency autorotation testing of the vestibulo-ocular reflex. Neurol Clin North Am 1990; 8: 297-312. Omara A, Mosaad DM, Mohamed A, Abd El Raoof, NA. Epley repositioning maneuver versus Gans repositioning maneuver on positional instability in elderly patients with benign paroxysmal positional vertigo. Egyptian Journal of Otolaryngology 2017, 33 (2): 518-522. Powell LE, Myers AM. The Activities-specific Balance Confidence Scale. J Gerontol A Biol Sci Med Sci 1995; 50: M28-M34. Roberts RA, Gans, RE. Nonmedical Management of Positional Vertigo. Balance Function Assessment and Management; 2008. Roberts RA, Gans RE. Background, Technique, Interpretation, and Usefulness of Positional/Positioning Testing. Balance Function Assessment and Management: 2008. Roberts RA, Gans RE. Comparison of horizontal and vertical dynamic visual acuity in patients with vestibular dysfunction and non-vestibular dizziness. J Am Acad Audiol 2007; 18: 236-244. Roberts RA, Gans RE, Johnson, EL. Computerized dynamic visual acuity with volitional head movements in patients with vestibular dysfunction. Ann Otol Rhinol Laryngol 2006; 115 (9): 658- 666. Roberts RA, Gans RE, DeBoodt Treatment of benign paroxysmal positional vertigo: necessity of post-maneuver restrictions. Journal of American Academy of Audiology 2005, 16: 356-357. Saberi, A, Nemati S, Sabnan S, Mollahoseini F. A safe repositioning maneuver for the management of benign paroxysmal positional vertigo: Gans vs Epley maneuver; a randomized comparative trial. Eur Arch Otorhinolaryngology. 2017 Aug;274(8):2973-297.

Schubert MC, Herdman SJ, Tusa RJ. Vertical dynamic visual acuity in normal subjects and patients with vestibular hypofunction. Otol & Neurotol 2002; 23: 372-377. Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg 1995; 112: 173-182. Shepard NT, Telian SA, Smith-Wheelock M. Habituation and balance retraining therapy; a retrospective review. Neurol Clin 1990; 8: 458-475. Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: suggestions from the field. Phys Ther 1986; 66: 1548-1550. Shumway-Cook A, Horak FB. Rehabilitation strategies for patients with vestibular deficits. Neurol Clin 1990; 8: 441-457. Shumway-Cook A, Horak FB. Vestibular Rehabilitation: An exercise approach to managing symptoms of vestibular dysfunction. Seminars in Hearing 1989; 10: 196-204.

Spinks S, Gans RE. Cervical and vertebral artery issues. Balance Disorders in Children and Adults: Evaluation and Treatment 2018. Staab, JP. Behavioral aspects of vestibular rehabilitation. NeuroRehab 2011; 29: 179-183. Staab et al, Diagnostic criteria for persistent postural-perceptual dizziness (PPPD); Consensus document of the committee for the classification of vestibular disorders of the bar. Journal of Vestibular Research 2017; 27:191-208 Sugaya N, Arai M, Goto F. Changes in cognitive function in patients with intractable dizziness following vestibular rehabilitation. Scientific Reports 2018; 8: Article number 9984. Tee LH, Chee NWC. Vestibular rehabilitation therapy for the dizzy patient. Ann Acad Med 2005; 34(4): 289-294. Venosa AR, Bittar RS. Vestibular rehabilitation exercises in acute vertigo. The Laryngoscope 2007; 117: 1482-1487. Ware JE. How to Score the Revised MOS Short Form Health Scales (SF-36). Boston: The Health Institute, New England Medical Center Hospitals. 1988. Whitney SL, Sparto PJ, Brown KE, Furman JM, Jacobson JL, Redfern MS. The potential use of virtual reality in vestibular rehabilitation: Preliminary findings with the BNAVE. J Neurol Phys Ther 2002; 26 (2): 72-78. Whitney SL, Wrisley DM, Brown KE, Furman JM. Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with a history of migraine. The Laryngoscope 2000; 110: 1528-1534. Whitney SL, Wrisley DM, Marchetti GF, Furman JM. The effect of age on vestibular rehabilitation outcomes. The Laryngoscope 2002; 112: 1785-1790.

Wrisley DM, Whitney SL, Furman JM. Vestibular rehabilitation outcomes in patients with a history of migraine. Otol & Neurotology 2002; 23: 483-487.

Terminology

ABR / BAER auditory brainstem response

AC anterior canal

BOS base of support

BPPV benign paroxysmal positional vertigo

BRT balance retraining therapy

BVD bilateral vestibular dysfunction

CDP computerized dynamic posturography

CDVAT computerized dynamic visual acuity test

COG center of gravity

CRM canalith repositioning maneuvers

CTSIB clinical test of sensory integration of balance

cVEMP cervical vestibular evoked myogenic potentials

EcoG/ECochG electrocochleography

Gans SOP sensory organization performance

GRM Gans repositioning maneuver

HC horizontal canal

KRC kinetic rotary chair

LOS limits of stability

MDDS mal de debarquement syndrome

mTBI (mild) traumatic brain injury

OAE otoacoustic emissions

OPK / OKN optokinetics

PC posterior canal

ROM range of motion

SCDS superior canal dehiscence syndrome

SLM Semont liberatory maneuver

SNHL sensorineural hearing loss

UVD unilateral vestibular dysfunction

VCR vestibular collic reflex

vHIT video head impulse test

VNG videonystagmography

VOR vestibular ocular reflex

VRT vestibular rehabilitation therapy

VSR vestibular spinal reflex

GLOSSARY OF TERMS Balance Control movements of the center of mass relative to stability limits

in order to maintain equilibrium. BPPV Benign Paroxysmal Vertigo – A benign disorder of the labyrinth of

the inner ear characterized by paroxysmal vertigo and Nystagmus only when the head is in a certain direction. The diagnosis is made at bedside by moving patient from the sitting position to recumbency with head tilted down 30 degrees over end of table and 30 degrees to one side. This causes a paroxysm of vertigo. This test is called the HALLPIKE MANEUVER. The episodes may last less than a minute, but may recur for months.

Center of Mass Point at which object pivots in equilibrium. Cupulolithiasis Disease of calculi in the cupulo of the posterior canal of the inner

ear. The condition may be associated with positional vertigo. Dysequilibrium Refers to unsteadiness, imbalance, or loss of equilibrium often is

accompanied by spatial disorientation. Endolymphatic Hydrops Dilation due to an accumulation of fluid in the labyrinth space of

the ear. Equilibrium State of balance. Condition in which contending forces are equal. Gait Manner of walking. Gaze Stabilization Keeps images stable on the retina while head is moving, facilitated

by vestibular ocular reflex: used when walking, keeps horizon stable during heel-strike, or reading lines of print.

Kinetic Consisting of motion; forces acting on the body during movement

and the interactions of sequence of motion with respect to time and forces present.

Labyrinth The inner ear, made up of the vestibule, cochlea and canals. Advancing the Study of Human Equilibrium

Meniere’s Disease A disorder of the inner ear that causes episodes of vertigo, Tinnitus (a feeling of fullness or pressure in the ear), and fluctuating hearing loss.

Neuromuscular Concerning both nerves and muscles. Nystagmus Involuntary, alternating rapid and slow movements of eyeballs. Otitis Media Inflammation of the middle ear. Otoliths Calcium carbonate crystals found in the utricle and saccule of inner

ear. Orthostatic Hypotension Decrease in blood pressure upon assuming erect posture. Perception of Motion Being able to distinguish between body movement and

environment moving. Postural Stability Feedback from visual, vestibular and somato-sensory (muscles,

joints) that helps the body accommodate changes in movement. Proprioception The awareness of posture, movement, and changes in equilibrium

and the knowledge of position, weight, and resistance of objects in relation to the body.

Romberg’s Sign Inability to maintain body balance when the eyes are shut and the

feet close together. The sign is positive if the patient sways and falls when the eyes are closed.

Somato-sensory Touch, joint and muscle receptors. Vertigo True vertigo is the sensation of moving around in space or of

having objects move about the person and is a result of a disturbance of equilibratory apparatus.

Vestibular Neuronitis Inflammation or degenerative inflammation of nerve cells. Vestibular Rehabilitation An alternative form of exercise treatment designed to decrease

dizziness, increase balance function and increase activity levels.

Advancing the Study of Human Equilibrium

Review of Audiology, Vestibular and Electrophysiology Tests Audiology Testing Audiology tests can provide information about hearing, middle ear function, cochlear hair cell function and several neural aspects of the hearing-balance system. Although there are many ear related conditions, which cause hearing loss along with vertigo, there are many that do not. So, the presence of an accompanying hearing loss with the vertigo symptoms may help differentiate certain ear disease-disorders from one another. For example, Meniere’s disease and labyrinthitis typically has both hearing loss and vertigo, whereas vestibular neuronitis and BPPV only have the symptom of vertigo Audiology testing often includes: Pure tone (air and bone) and word discrimination tests as well as Immittance Audiometry which evaluates middle and inner ear and some neurological pathways. Otoacoustic Emissions is a relatively new test that looks at the outer hair cell function within the inner ear (cochlea). Brainstem Auditory Evoked Response (BAER) tests the neural conductivity of the hearing and balance nerve (CN VIII). Sensory Organization Performance Test (SOP) A combination of the Romberg, CTSIB and Fukuda Stepping Tests provide qualitative information on whether an equilibrium dysfunction exists, whether it is CNS or peripheral and also serves as an indicator of impact on balance function. Whether the patient surface or visually dependent gives insight into the status of the vestibular system. Recovery of function post treatment may also be documented. Computerized Dynamic Visual Acuity Test (CDVAT) This tests for oscillopsia. Oscillopsia is a breakdown in gaze stabilization during active head movement caused by peripheral or central vestibular disorders. The abnormal vestibulo-ocular reflex (VOR) function of as little as 3 degrees can change vision from 20/20 to 20/200 simple head movements. The vision test is conducted while the patient produces horizontal and then vertical head movement of 2.5 cycles per second. This is in the low-mid range of normal active head movement. The test indicates the function problem caused by the vestibular dysfunction and can be used as a baseline to latter compare improvement post Vestibular Rehabilitation Therapy (VRT) to document the treatment efficacy. Vestibular Autorotation Testing VOR function gain and phase is quantitatively analyzed using this active rotation test for both horizontal and vertical head movements over a frequency range of approximately 2-8 cycles per second. This indicates the direction of head movement, which is most dysfunctional as well as the frequency (speed) of head movement. The patient is required only to look straight ahead while moving their head to an auditory cuing signal. This test as those mentioned above provides diagnostic as well as outcome measurements. This test can be obtained through passive tests like the Rotary Chair, in which the patient simply sits while being harmonically accelerated or active tests, in which the person volitionally moves their head to an auditory cue.

Videonystagmography (VNG) The most enduring and commonly used test of vestibular function is the VNG. The latest technology utilizes infrared video cameras recording the movement of each eye. Prior to this technology, the test was called ENG, as it was a recording of the corneoretinal potential. The test is comprised of subsets, which test the following: Dix-Hallpike- tests for BPPB-PC Oculo motor tests- saccadic, pendular and optokinetic pursuit are tests, which provide diagnostic information about the central vestibular and neuropthamologic systems connections within the brain. Gaze testing- tests for the presence of spontaneous nystagmus. High frequency headshake test- dynamically provokes nystagmus in some cases if the patient has an uncompensated or non-stabilized unilateral vestibular dysfunction. Positional testing- documents the presence of static positional nystagmus. Findings are used for differential diagnosis of HC-BPPV and other peripheral type causes vs. CNS lesions. Caloric tests- Thermal convection of inner ear fluids are created by irrigating each ear with warm and cool air, which is above and below body temperature. The test may also be performed with water. The reactivity or responsiveness of each of the respective ear’s horizontal semicircular canals is calculated through a measurement of the patient’s induced nystagmus. A difference of 25% or more in the total nystagmus of the two ears indicates a “caloric weakness” a finding usually attributed to a peripheral or central dysfunction. In some disorders, both ear’s responses are depressed. Vestibular-Evoked Myogenic Potentials (VEMPs) Introduction Vestibular-evoked myogenic potential testing (VEMPs) is based on the reflex, which occurs between the otolith system (specifically the saccule), and the sternocleidomastoid muscle (SCM). The vestibulo-collic reflex (VCR) has been well studied in animals and humans. The benefit of VEMPs is there is no other vestibular function test, which provides information regarding the saccule or its innervation by the inferior branch of the vestibular nerve. As the VCR is a classic reflex arc with a sensory, CNS, and motor output component, it has been used to provide information regarding both the integrity of the saccule and inferior vestibular nerve, as well as the reflex arc through the brainstem. This has provided information on both otologic and neurologic conditions. In the literature, you will see VEMPs reported in studies with patients ranging from otologic conditions such as Meniere’s, superior canal dehiscence syndrome to neurological disorders such as multiple sclerosis (MS).

Definitions of Vestibular Disorders T. Oma Hester, MD and Herbert Silverstein, MD, FACS

Meniere’s Disease: an inner ear disorder characterized by episodic vertigo attacks, sensorineural hearing loss, Tinnitus, and pressure or fullness in the involved ear. Initially the hearing loss involves the lower frequencies and fluctuates, usually worsening with each attack. The attacks are characterized by true vertigo, usually with nausea and vomiting lasting hours in duration. Histopathologically, this disorder is felt to be due to dilation of the Endolymphatic spaces (Hydrops) with ruptures and healing of the membranous labyrinth. Variants of the disease do occur, including dizziness without associated auditory symptoms. Vestibular Neuronitis: presents as a sudden episode of vertigo without hearing loss in an otherwise healthy person. The disorder can occur as a single attack or can present as multiple attacks. It occurs more often in spring and early summer and, as a result, is often associated with an upper respiratory infection, developing two to three weeks afterward. The onset of vertigo is sudden and typically associated with nausea and vomiting and can last for a period of days with gradual improvement over the following weeks. The disorder is often followed by episodes of benign positional vertigo. Benign Positional Vertigo: felt to be the most common type of peripheral vertigo. This disorder can be seen following head injury, vestibular Neuronitis, stapes surgery, Meniere’s disease, or can present alone. The disorder is felt to be related to an abnormality in the association of the otoconia to the cupula within the membranous labyrinth resulting in abnormal responses to endolymphatic movement with head motion. Symptoms are typically associated therefore with head movement such as rolling over or getting in or out of bed. The associated vertigo is brief lasting only seconds in duration and can be seen as an acute form only or in an intermittent or chronic form. Acoustic Neuroma: more appropriately known as a vestibular neurinoma, this is a benign neoplasm that typically arises from the vestibular portion of the eighth cranial nerve. The lesion grows slowly and causes a progressive sensorineural hearing loss. Because of a gradual destruction of vestibular function on the involved side, patients do not typically present with complaints of dizziness. Labyrinthine Infarction: leads to a sudden profound loss in auditory and vestibular function and typically occurs in older patients. This phenomenon can be seen in younger patients with atheroscelortic vascular disease or hypercoagulation disorders. Episodic vertigo may herald a complete occlusion in the form of a type of transient ischemic attack. After complete occlusion, the acute vertigo that ensues will subside often leaving the patient with some residual unsteadiness and dysequilibrium over the next several months while vestibular compensation occurs..

Perilymphatic Fistula: represents an abnormal communication between the perilymphatic space of the inner ear and the air containing space of the middle ear. The existence and pathophysiology of this disorder is still heavily debated. Nevertheless, there is evidence to support such an occurrence in association with head trauma or barotraumatic injuries. This problem can also occur after stapes surgery and spontaneous fistula are believed to exist. Patients typically present with fluctuating progressive sensorineural hearing loss, episodic vertigo, and Tinnitus. Labyrinthitis: is an inflammatory process occurring within the membranous labyrinth, which may have a bacterial or viral etiology. Viral infections produce symptoms of dizziness similar to vestibular Neuronitis except that there is cochlear dysfunction as well. Congenital measles, rubella and cytomegalovirus infections frequently cause no vestibular symptoms. Bacterial labyrinthitis can present in a supparative form with direct involvement of the membranous labyrinth by the pathogen or in a serous form. The serous form is often seen with acute otitis media when diffusion of bacterial toxins across the round window membrane occur.