Vestibular Rehabilitation for Dizziness and Balance Disorders

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Vestibular Rehabilitation for Dizziness and
Balance Disorders

• Spalding Rehabilitation Hospital
• Vicki Council, PT
• Karin J. George, MS PT

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Life is Good
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Objectives

• Be familiar with the anatomy and physiology of
  the vestibular system
• Have a basic understanding of the assessments for
  vertigo and balance
• Be familiar with the treatment strategies to
  address vestibular and balance disorders

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Vestibular Rehabilitation

• Evaluation to discover deficits and details
  regarding symptoms
• Develop program with goal of retraining the brain
  to recognize and process signals from the
  vestibular system in coordination with the visual
  and proprioceptive systems.

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A Need for Intervention

• 4 (8 million) of American adults report having
  a chronic balance problem. An additional 1.1
  (2.4 million) report chronic problems with
  dizziness alone.
• Overall, the cost of medical care for patients
  with balance disorders exceeds 1 billion/year in
  the United States.
• Though BPPV is seen by most as the most common
  vestibular disorder, only 8 receive effective
  tx.

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Definitions

• Dizziness
• Light headedness
• Feeling faint
• Unsteady
• Dysequilibrium

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Definitions

• Vertigo
• A specific spinning sensation
• An illusion of motion
• The feeling that you or your environment is moving

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Definitions

• Imbalance
• Stumbling, difficulty walking straight or turning
  a corner
• Clumsiness or difficulty with coordination
• Tendency to fall

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Balance Systems

• Sensory
• Visual - eyes orient
• Vestibular - inner ear system that registers the
  head and movement in space
• 3 components
• Gaze stabilization
• Postural Control
• Perception of movement
• Proprioceptive - involves the joint and muscle
  receptors that let us know where we are in space

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Balance Systems

• Motor
• Strength
• Coordination
• Cardiorespiratory/endurance
• ROM
• Reaction time

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Anatomy and Physiology of the Inner Ear
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Anatomy and Physiology of the Inner Ear

• Bony Labyrinth Houses the membranous labyrinth.
  Filled with perilymph fluid (similar to CSF).
• Membranous Labyrinth Consists of the otolith
  organs and semi-circular canals. Filled with
  endolymph (similar to intracellular fluid).

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Membranous Labyrinth

• Otolith Organs
• Utricle Responsible for horizontal translation
  of the head and head tilt
• Saccule Responsible for vertical translation of
  the head.
• Combined, they sense linear acceleration and
  static tilt of the head with respect to the
  gravitational axis.
• Maculae Sensory receptor for the otolith
  organs. A gelatinous matrix surrounds the
  hair cells. Otoconia are embedded on top of the
  maculae in the otolithic membrane..

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Membranous Labyrinth

• Semi-circular Canals (SSC)
• Three fluid filled loops responsible for sensory
  input related to head velocity and angular
  acceleration.
• Enables the VOR to generate eye movements to
  match head movements, resulting in clear vision
  during head movement.
• Cristae sensory structure for the SSC that sense
  angular movement
• Cupula gelatinous mass surrounding the hair
  cells of the cristae in the SSC.

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Membranous Labyrinth

• Hair Cells
• Endolymph fluid within the SSC and otolith organs
  move the hair cells according to head movement.
• The direction of deflection of the hair cells
  tells the brain how the head is moving.
• Resting Vestibular Tone Firing rate 100
  spikes/sec at rest, increases on ipsilateral
  side and decreases on contralateral side related
  to head movement.

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Anatomy and Physiology of the Inner Ear
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Central Processing

• Electrical activity generated from the inner ear
  travels to
• Vestibular nuclei in the brainstem
• Cerebellum
• Emetic center in the brainstem

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Dizziness Diagnosis

• Unilateral Peripheral Vestibular Loss
• Nystagmus
• Falling/loss of balance to affected side
• Possible Cerebellar Dysfunction
• True Vertigo
• Bilateral Peripheral Vestibular Loss
• Usually no vertigo
• Oscillopsia
• Ataxia
• Imbalance

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Dizziness Diagnosis

• Related to specific health issues
• Vestibular Neuritis
• Viral Labyrinthitis
• CVA
• Acoustic neuroma
• Ototoxicity

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Vestibular Pathologies Seen in Head Injury

• Endolymphatic hydrops or post-traumatic
  Menieres disease
• Vestibular migraine
• Labyrinthine concussion
• Perilymphatic fistula
• Brainstem injury

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Dizziness Diagnosis

• Duration of Spells
• Seconds BPPV
• Orthostatic Hypotension
• Minutes Migraines
• TIAs
• Hours/Days Menieres Disease
• Hydrops

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ENT Testing

• Hearing Test
• Videonystagmography (VNG)- test of lateral
  semi-circular canal
• Vestibular evoked myogenic potentials (VEMP)-test
  of otolithic function
• Electrocochleography (ECoG)- test for
  endolymphatic hydrops (Menieres disease)
• Platform Posturography- Assesses use of all
  sensor systems-visual, vestibular, somatosensory

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Vestibular Evaluation

• Subjective
• Dizziness
• What makes it better, worse, duration, frequency,
  intensity
• Falls
• Dizziness Handicap Index
• History including test results/medications

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Vestibular Evaluation

• Objective
• Vision and eye/head coordination
• Eye movement range
• Smooth pursuits
• End point nystagmus
• Gaze evoked nystagmus
• Saccades
• Skew eye deviation
• Spontaneous nystagmus
• VOR Cancellation
• Visual/Vestibular Ocular Interaction Reflex

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Vestibular Evaluation

• Vertiginous Positions/movements requires that
  the patient be placed in 16 positions monitoring
  level of dizziness, nystagmus and length of time
  of dizziness.
• Hallpike assesses BPPV

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Dix Hallpike Position
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Vestibular Evaluation

• Strength
• ROM
• Joint position sense
• Sensation
• Gait

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Vestibular Evaluation

• Balance Tests
• BERG
• Dynamic Gait
• Balance Evaluation-Systems Test (BEST)
• Balance Master(sensory organization test)

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Smart Balance Master
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Smart Balance Master

• Sensory Organization Test
• Force plate system
• Moving surround
• Uses 3 senses for postural control-vestibular,
  visual, somatosensory.
• Looks at the ability to differentiate the
  differences in accurate inputs, choose the most
  useful input, and perceive the correct position
  in space.

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Red Flags

• Sudden loss of hearing or fluctuation in hearing
• Pressure and fullness to point of pain/discomfort
• Fluid from ears
• Severe ringing in ears
• Other undiagnosed central signs

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Medications

• Anticholinergics Antihistamines
• Meclizine
• Antivert
• Phenergan
• Benzodiazepines
• Valium
• Klonapin
• Ativan

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Vestibular Treatment

• Central Compensation
• Adaptive Plasticity
• Central Sensory Substitution
• Tonic Rebalancing
• Habituation

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Treatment

• Symptom driven
• Head/eye movements
• Position progression
• Support surface
• Eyes open/closed
• Environment
• Manual Interventions
• Canalith Repositioning (BPPV)

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Vestibular Treatment

• Rehab strategies
• Retraining
• Habituation
• Adaptation
• Compensation

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Vestibular Treatment

• Motor Learning
• HEP based on deficits
• Education
• Manual Interventions
• Referrals to other providers

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Time Frames

• Simple
• 3-4 sessions
• Complex-involving multiple systems
• 6-18 months
• Patient compliance
• 6 to 18 months

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Team Role

• Know general signs and symptoms
• Gather information and refer patient to
  appropriate specialists
• Repeat education to patient and family
• VEDA (Vestibular Disorders Association)

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Conclusion