LEC.16. Vestibular.ppt LEC.16. Vestibular.ppt

LEC.16. Vestibular.ppt

1. Vestibular Rehabilitation:
Evaluation and Treatment
Strategies for Common Vestibular
Disorders
DR.ABDUL RASHAD
ISRA INSTITUTE OF REHABILITATION
SCIENCES

2. Anatomy and
Physiology

3. Anatomy of the Ear

4. 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

5. 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

6. The Labyrinth
•Bony Labyrinth
•Perilymph
•Between bony and Between bony and
membranous labyrinthmembranous labyrinth
•Membranous labyrinthMembranous labyrinth
• Endolymph
•Inside membranous Inside membranous
labyrinthlabyrinth
Parnes, 2003

7. The Labyrinth
•3 Semicircular Canals
•Anterior, Posterior Anterior, Posterior
HorizontalHorizontal
•Cochlea
•Hearing componentHearing component
•Vestibule
•Saccule and UtricleSaccule and Utricle

8. 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)

9. Semicircular Canals
•Hair CellsHair Cells
•Motion SensorsMotion Sensors
•Always sending info Always sending info
to the brain to the brain
•KilociliaKilocilia
•Deflection Towards- ExcitesDeflection Towards- Excites
•Deflection Away- InhibitsDeflection Away- Inhibits

10. Semicircular Canals
•Provides input about
angular head velocity
•Three canals on each side
•Anterior (superior), Anterior (superior),
Posterior (inferior) & Posterior (inferior) &
Horizontal (lateral)Horizontal (lateral)
•90 degree angle from each 90 degree angle from each
otherother
•Horizontal canalHorizontal canal
•30 degree elevation30 degree elevation

11. Semicircular Canals
•Mate on the opposite side
•L ant/R post, R ant/L L ant/R post, R ant/L
postpost
•Each semicircular canal has
a ampulla housing the
sensor organs
•Hair cells covered by Hair cells covered by
the cupulathe cupula
•Both ends terminate in the
utricle

12. The Otoliths
•Utricle (Linear)
•Horizontal MovementsHorizontal Movements
•Head TiltHead Tilt
•Saccule (Linear)
•Up & Down Up & Down
MovementsMovements
•Otoconia “Ear Rocks”
(Calcium Carbonate Crystals)
•Hair Cells
Herdman, 2000

13. Vestibular Occular Reflex
•Allows clear vision through gaze stabilization
•Coordinates eye and head movementsCoordinates eye and head movements
•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 opposite R lat rectus/L med rectus excited and opposite
inhibitedinhibited

14. Causes of Vertigo
Herdman, 2000

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

16. 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-Circular
Canals
Inflammation of the
Vestibular Nerve
Cochlea
Inner Ear

17. Common Disorders
•Vestibular LabyrinthitisVestibular Labyrinthitis
•Viral or bacterial infection of Viral or bacterial infection of
the membranous labyrinththe membranous labyrinth
•Acute onset of hearing loss, Acute onset of hearing loss,
vertigo, nausea/vomitingvertigo, 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
movementsmovements

18. Common Disorders
•Meniere’s DiseaseMeniere’s Disease
•Increased endolymph Increased endolymph
pressurespressures
•EpisodicEpisodic
•Low frequency hearing Low frequency hearing
lossloss
•TinnitusTinnitus
•Can last hours to daysCan last hours to days

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

20. Common Disorders
•CentralCentral
•TBITBI
•CVACVA
•Multiple SclerosisMultiple Sclerosis

21. Vestibular Evaluation
•Subjective componentSubjective component
•Thorough HistoryThorough History
•Dizziness Handicap InventoryDizziness Handicap Inventory
•ABC confidence scaleABC confidence scale

22. 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?

23. 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

24. Vestibular Evaluation
•Other testing optionsOther testing options
•Videonystagmogtaphy (VNG)Videonystagmogtaphy (VNG)
•Caloric TestingCaloric Testing

Test horizontal Test horizontal
semicircular canals semicircular canals
onlyonly

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 flex30 degrees flex

Significant finding 25% or more Significant finding 25% or more
reduction indicates a unilateral weaknessreduction indicates a unilateral weakness

25. Observation Tools
•Frenzel GogglesFrenzel Goggles
•Video Frenzel Video Frenzel
LensesLenses
•Room LightRoom Light

26. 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

27. Berg Balance Scale

28. Timed Up and Go
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 8
70-79 9 9
80-89 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

29. Static Balance Testing
•Modified CTSIB
•Ground-Eyes open and closed
•Foam-Eyes open and closed
•½ Tandem and Tandem
•SLS
•Computerized Dynamic Posturography

31. Computerized Posturogrphy

32. Benign Paroxysmal
Positional Vertigo

33. 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)

34. 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.

35. Causes of BPPV
•“Idiopathic”-50%-70%
•Head injury- 7%-17%
•Viruses
•Vestibular neuritis- 15%Vestibular neuritis- 15%
•Degeneration?

36. BPPV
•NystagmusNystagmus
•Non-voluntary oscillation of the eyeNon-voluntary oscillation of the eye
•Defined fast and slow phases in opposite Defined fast and slow phases in opposite
directiondirection
•Fast phase defines direction of nystagmusFast phase defines direction of nystagmus
•Semicircular canals connected to specific eye Semicircular canals connected to specific eye
muscles, which dictates direction of nystagmusmuscles, which dictates direction of nystagmus
•VideoVideo

37. BPPV – Nystagmus
•Posterior canal
•Up-beating, torsional nystagmus toward involved earUp-beating, torsional nystagmus toward involved ear
•Anterior canal
•Down-beating, torsional nystagmus toward involved earDown-beating, torsional nystagmus toward involved ear
•Horizontal canal
•Lateral, slight torsional nystagmus, greater toward Lateral, slight torsional nystagmus, greater toward
involved earinvolved ear

38. BPPV
•Classic SymptomsClassic Symptoms
•Room spinning, nausea, imbalanceRoom spinning, nausea, imbalance
•Brief episodes of vertigo with changes in head Brief episodes of vertigo with changes in head
position relative to gravityposition relative to gravity
•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

39. Challenges
•Musculoskeletal restrictions
•PainPain

cervical, lumbar, shoulder and hipscervical, lumbar, shoulder and hips
•Fear of falling off table in sidelying when Fear of falling off table in sidelying when
spinningspinning
•Hip replacementsHip replacements
•Use of table/plinth

40. Use of Plinth

41. BPPV – Clinical Exam
•Dix-Hallpike Test
•45 degree cervical 45 degree cervical
rotationrotation
•Align canals with gravityAlign canals with gravity
•Sit to supine with 20 Sit to supine with 20
deg of cervical deg of cervical
extensionextension
•Look for nystagmus and Look for nystagmus and
symptoms of vertigosymptoms of vertigo
•Practice
Herdman, 2000

42. BPPV – Clinical Exam
•Typical NystagmusTypical Nystagmus
•Latency- before nystagmus startsLatency- before nystagmus starts

1-30 seconds1-30 seconds
•DirectionDirection

Mixed up-beating, torsional nystagmus (post.)Mixed up-beating, torsional nystagmus (post.)
•DurationDuration

Less than 1 minuteLess than 1 minute
•Fatigues with repeated testingFatigues with repeated testing

43. BPPV – Clinical Exam
•All you need to know…
•DirectionDirection

The direction of the elicited nystagmus will tell you The direction of the elicited nystagmus will tell you
which canal is involvedwhich canal is involved
•DurationDuration

Will tell you the type of BPPVWill tell you the type of BPPV

44. BPPV – Clinical Exam
•Two types of BPPVTwo types of BPPV
•Canalithiasis (A)Canalithiasis (A)
•Cupulolithiasis (B)Cupulolithiasis (B)

45. 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 minLast less than 1 min

46. BPPV – Cupulolithiasis
•Otoconia are adherent
to the cupula of the
semicircular canal
•Increased density of Increased density of
cupulacupula
•Sensitive to gravitySensitive to gravity
•Persistent-last greater Persistent-last greater
than 1 minthan 1 min
Hain, 2010

47. Repositioning Procedures
Parnes, 2003

48. Patient Response
•Sensation of spinning
•May feel like they will fall of the tableMay feel like they will fall of the table
•Clammy
•Sweating
•Nauseous
•Vomitus

49. Canal Alignment Reminder
•Will treat R post. canal
and L ant. canal the
same way
•Opposite eye
movement
•Post-Up beat/RotPost-Up beat/Rot
•Ant-Down/RotAnt-Down/Rot

50. BPPV Treatment –
Posterior/Anterior Canals
•Canalith Repositioning
Technique
•Starting Position is
Dix-Hallpike
•Nystagmus should be
same direction in all
positions
•Practice

51. 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

52. 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

53. Horizontal Canal BPPV
•Canalithiasis
•Eyes will beat Eyes will beat
geotropicgeotropic
•Cupulolithiasis
•Eyes will beat Eyes will beat
ageotropicageotropic
Parnes, 2003

54. Horizontal Canal BPPV
•Horizontal Canal CRT
•Barbeque RollBarbeque Roll
•Head rotated to Head rotated to
involved side firstinvolved side first
•Roll away from Roll away from
involved sideinvolved side
•Keep head in 30 Keep head in 30
degrees flexiondegrees flexion
Herdman, 2000

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

56. 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.

57. Other Treatment Options
•Brandt-Daroff
•Home CRT
•Balance retraining
•Surgery-canal
plugging

58. Brandt-Daroff Exercises
•3-5 cycles
•3 times per day
•Hold position for 30
seconds after vertigo
stops
Parnes, 2003

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

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

61. Vestibular
Rehabilitation

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

63. 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

64. Vestibular Testing
•Computerized Dynamic
Posturography
•Dynamic Visual Acuity
•Dynamic Gait Index
•Static Balance Testing
•Romberg, Sharpened Romberg, Sharpened
Romberg, SLSRomberg, SLS
•Timed Up and Go