Vestibular Disorders and Treatments

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Vestibular Disorders and Treatments

• Alan Smith, D.C.

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Goals of the lecture

• Be able to identify a possible Vestibular
  Disorder in your patient
• Provide you with low-tech examination procedures
  and vestibular therapy you can do in your office
  starting Monday morning.
• Be able to read a vestibular book and grasp the
  concepts
• If there is time, let you compare your low tech
  findings with the high tech equipment

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What is the Vestibular System?

• The Vestibular System gives us our sense of
  balance and orientation to our world.
• Majority of brain output is to keep our eyes on
  the horizon
• Postural Control involves the behaviorally
  meaningful integration of many different neural
  systems, including those associated with
  cognition. (Nobel Prize Laureate Dr. Eric Kandel)

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Why should we care about the Vestibular System?

• Minor Traumatic Brain Injury can result in
  secondary losses to the Vestibular System.
• Gives the clinician the ability to document
  injuries beyond soft tissue injuries
• Vertigo and balance disorders constitute
  significant public health problems in the United
  States. (Shepard)
• 11 million people seek medical care
• Balance disorders and dizziness are important
  risk factors for falls especially in the elderly
  population.
• Elite athletic performance may be enhanced by
  identifying areas of weakness.
• E.g.. Anterior canal weakness shunt/spurt muscle
  stabilization

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Why Should we care about the Vest system

• 50 of elderly patients admitted for hip
  fractures die within one year (Rubinstein)
• Reduced reaction time is the leading cause of
  falls in the elderly (Tideiksaar)

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Signs and Symptoms of a Vestibular Subluxation

• Vertigo
• Is your world spinning (Peripheral Vest
  System) or are you spinning? (Central problem,
  harder to fix)
• Balance/Gait Problems
• Disequilibrium and Postural instability
• Migraine Headaches
• Tinnitus, Fullness of the ear, hearing loss, drop
  attacks (Menieres Disease

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Signs and Symptoms

• Situational Anxiety and Disorientation
• Dont like walking in malls or going to the
  Supermarket, where walking creates an opt kinetic
  effect
• Slurred Speech, syncope, numbness or tingling in
  the face/extremities,
• Spots before eyes

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Symptoms

• Nausea
• There are some schools of thought that
  Compensated Vertigo may result in
• Fibromyalgia
• Scoliosis
• The more bizarre the patients presentation, the
  more likely the Vestibular System is involved.

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• External world vs. Our Internal representation
  of our world
• As long as there is a one to one relationship
  between the External environment and our Internal
  representation of our environment, we are happy
• When there is not a 11 relationship we have a
  Sensory Mismatch and a possible Vestibular
  Disorder

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• The vestibular system has a resting tone (known
  in neurology circles as the frequency of firing
  of the pre-synaptic and post-synaptic neuronal
  pools) Estimates are the vestibular nuclei fire
  at a million times a second
• When you turn your head say to the left, the left
  vestibular system increases it frequency of
  firing, while the right decreases its frequency
  of firing

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• The brain then makes a mathematical calculation
  in an area called the Neural Integrator
• The brain then says, Hey I must be rotating to
  the left
• The problem arises when the output of the
  vestibular system to the neural integrator, does
  not match what the patient perceives of their
  world.

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• For example, your left vestibular system has
  increased its frequency of firing over your
  right vestibular system due to the fact that the
  right vestibular system had trauma following a
  car accident
• Your brain thinks, Hey, I must be turning to the
  left But in reality, your looking straight
  ahead.
• There is not a 11 relationship between your
  External Environment and your Internal
  Representation of your External Environment. You
  have a Sensory Mismatch thus a possible
  Vestibular Disorder

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What is the big deal about looking at eye
movements?

• The study of eye movements is a source of
  valuable information to both clinicians and basic
  scientists (Zee and Leigh)
• To the neurobiologist, the study of the control
  of eye movements presents a unique opportunity to
  understand the workings of the brain (Zee/Leigh)
• The study of eye movements may contribute to the
  knowledge of motor control in general (Zee/Leigh)

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• The occulomotor system provides a spectacular
  window into the nervous system for both clinician
  and scientists (Nobel Prize Laureate Dr. Eric
  Kandel)
• Much of our understanding of neural processes
  arises from our knowledge of the occulomotor
  system as a microcosm of human behavior (Kandel)

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Examination Findings

• Abnormal Eye Movements
• Smooth Pursuit
• Saccadic eye movements
• Opt kinetic tracking
• Head Tilts/One eye higher than the other
  (Hypertropia)
• Visual Acuity problems
• Audiometric/Tympanometry
• Hearing loss as detected by 512 tuning fork,
  start thinking if the Vestibular System might be
  effected
• Tullio Phenomena Tuning fork placed by the ear,
  causes patient to fall away from the tuning fork

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Examination Findings

• Positioning Tests (look for nystagmus under the
  eyelids, or reproduction of the symptoms.
• Supine
• Roll to one side
• Prone
• Roll to the other side
• Dysdiadochokinesis Alternating Arms Test (Have
  patient catch the raindrops, and drop the
  raindrops as quickly as possible) Look for
  sloppiness in arm movements

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Examination Findings

• Rhomberg Testing/Sharpened Rhomberg
• Head straight ahead-tap both shoulders
• Chin down (tap both shoulders)
• Look back at the ceiling (tap-tap)
• left ear to left shoulder
• right ear to right shoulder (tap-tap)
• Place head in most compromised position (for
  example, left ear to left shoulder, look back at
  ceiling) tap left and tap right shoulder
• Clinical Gem Patient will usually fall away
  from the side of their cortical lesion and into
  the side of their weak cerebellum/vestibular
  system. Remember, whatever side we treat from
  gets registered in the opposite cortex

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Examination Findings

• Fukuda Stepping Test
• 50 or 100 steps, arms outstretched, eyes
  closed, March in place and keep facing the wall
• Abnormal is any deviation greater than 45
  degrees.
• Clinical Gem Patient will march into the side
  of the weak vestibular system

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Examination Findings

• Subjective Visual Vertical
• Go to a hardware store. Purchase a carpenters
  laser light level.
• Place patient in a dark room.
• Move the laser line, that is projected onto the
  wall from an angle from 45 degrees, using the
  floor as a reference point, through a 90 degree
  arc. Tell me when the laser line is straight up
  and down. Turn on the lights, and compare the
  patients line to true vertical.
• Clinical Gem Any thing greater than 2 degrees
  from vertical might be a vestibular problem. The
  line usually tilts in the direction of the weak
  vestibular system

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• Important to tell the patient that their
  condition will wax and wane during the course of
  treatments. They may get worse before they get
  better. You are going to be strengthening a weak
  area, so the body needs to adjust
• You should see results within 7 days of
  treatment. Get a commitment from the patient
  that they will give you 7 days in a row of
  treatments.
• Some clinicians say that the specific exercises
  that will be performed in your office are so
  effective, that if the patient does not respond
  after 7 days, that is pathoneumonic for Multiple
  Sclerosis

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Benign Paroxysmal Positional Vertigo (BPPV)

• Most common cause of episodic vertigo
• Test Have patient turn their head, while seated
  on top of your table. Quickly bring the patients
  head down, 30 degree below horizontal. Wait up
  to 30 to 45 seconds. If positive, you will see
  an upbeating nystagmus under their closed eye
  lids. Any other eye movements, stop the test.
  It is not BPPV.
• Repeat other side

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Epley Maneuver

• Accelerate the patients head, like in the
  previous slide. This is where the therapy
  happens.
• Wait 3 minutes with patient in this head
  position.
• Slowly turn patient head to the opposite side.
  Take a minute to do this rotation.
• Roll patient onto their side, with the head still
  rotated.
• Wait 3 minutes
• Slowly bring the patient up to a seated position,
  with head still turned.

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Epley Cont

• Slowly turn patients head to neutral.
• Place cervical soft collar on patient.
• Tell patient they cannot rotate their neck for
  24-48 hours. They cannot let their head drop
  below 45 degrees
• Reschedule patient in 14 days for reevaluation.
  May need to repeat procedure.
• Give patient home exercises Brandt-Daroff
  Exercises. Show them how to do them in your
  office. These exercises are free in Vestibular
  Rehabilitation Therapy for the Patient with
  Dizziness and Balance Disrders Exercise Protocols
  by Marian Girardi, PhD

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Additional treatment options that are not inDr.
Marian Giradis book

• Use eye movements in a specific plane of a
  canal to inhibit (slow down the offending canal
  on the opposite side. Remember the Push-Pull
  arrangement)
• Right Posterior Canal-Left Anterior Canal are
  together
• Left Posterior Canal and Right Anterior Canal
  are together.
• If one is firing too high, use the other one to
  slow it down.
• E.g.. The right posterior canal will move the
  eyes down and left. So fire the left anterior
  canal by having the patient look from their nose
  and up and to the left

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Additional Treatment Options

• Use chair spins where the patient looks at their
  thumbs while their arms are extended,
• Spin the patient into their weak vestibular side
  90 degrees, wait 10-15 seconds for the inner ear
  fluid to settle down. Keep repeating until the
  patient tells you they have had enough.
  (Ideally, you would have infrared goggles on the
  patient, and as soon as they lost visual fixation
  on their thumbs, you would stop. Or monitor
  their pulse. (Pulse Oximeter). As soon as their
  pulse goes up, stop.

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Prior to adjusting a patient with a vestibular
disorder

• Have patient pick a spot on the ceiling above
  their head and stare at it for 30-60 seconds.
  Then adjust.
• Spin the patient in a rotating chair, while they
  stare at their thumbs with arms extended, 90
  degrees at a time with 10-15 second breaks. Spin
  to the side of their vestibular weakness, then
  adjust.

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• Remember, in patients with chronic balance
  problems, only vestibular rehabilitation has been
  shown to improve balance function and performance
  when compared to medical therapy or general
  exercises (Horak)
• Therapy directed towards a specific diagnosis
  resulted in resolution of symptoms in 85 of
  patients, while general vestibular rehabilitation
  exercises resulted in complete resolution in 64
  (Shepard and Telian)

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• Two patient cases
• Severely impaired
• OSU pitcher

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• Great thanks to Lifetimer for providing the
  tables
• Thanks to Vestibular Technologies for accepting
  my invitation.

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Contact Info

• Alan Smith D.C.
• 709 W 7th Ave
• Eugene, Oregon 97402
• 541-343-1942 Office
• alansmithdc_at_hotmail.com
• I will post new, relevant info on the Oregondcs
  yahoo chat site
• Can ask questions on the site
• Can always contact CAO for my contact info