Vestibular disorders and rehabilitation

this video summerises and best effort to get the physiotherapeutic content on vestibular rehabilitation

1. Vestibular disorders and rehabilitation Ruchika gupta BPT,MPT,CNMT

2. Vestibular disorders The vestibular system includes the parts of the inner ear and brain that process the sensory information involved with controlling balance and eye movements. If disease or injury damages these these processing areas , vestibular disorders can result.

3. Types Acoustic neuroma Age-related diziness and imbalance Autoimmune inner ear disease Benign paroxysmal positional vertigo Bilateral vestibular hypofunction CANVAS syndrome Cervicogenic dizziness Cholesteatoma Concussion Enlarged Vestibular A queduct Syndrome General Vestibulopathy Labyrinthitis and vestibular neuritis Mal De De’barquement Migraine Associated Vertigo Menier’s disease Neurotoxicity Otosclerosis Ototoxicity Pediatric vestibular disorders Perilymph Fistula Persistent Postural Perceptual Dizziness (PPPD) Secondary Endolymphatic hydrops (SEH) Superior Semicircular Canal Dehiscence Tinnitus Vestibular Hyperacusis Vertibrobasilar Insufficiency

4. BENIGN PAROXYSMAL POSITIONAL VERTIGO Benign Paroxysmal Positional Vertigo (or BPPV) is the most common cause of vertigo, which is a false sensation of spinning. 1 Benign  – it is not life-threatening Paroxysmal  – it comes in sudden, brief spells Positional  – it gets triggered by certain head positions or movements Vertigo  – a false sense of rotational movement

5. WHO IS AFFECTED BPPV is fairly common, with an estimated incidence of 107 per 100,000 per year ( Froehling DA, 1991) and a lifetime prevalence of 2.4 percent (von Brevern M, 2007). It is thought to be extremely rare in children but can affect adults of any age, especially seniors. The vast majority of cases occur for no apparent reason, with many people describing that they simply went to get out of bed one morning and the room started to spin. However associations have been made with trauma, migraine, inner ear infection or disease, diabetes, osteoporosis, intubation (presumably due to prolonged time lying in bed) and reduced blood flow. There may also be a correlation with one’s preferred sleep side ( Shigeno K, et al.2012). 

6. DIAGNOSIS Normal medical imaging (e.g. an MRI) is not effective in diagnosing BPPV, because it does not show the crystals that have moved into the semi-circular canals. However, when someone with BPPV has their head moved into a position that makes the dislodged crystals move within a canal, the error signals cause the eyes to move in a very specific pattern, called “ nystagmus ”. Tests like the Dix- Hallpike or Roll Tests involve moving the head into specific orientations, which allow gravity to move the dislodged crystals and trigger the vertigo while the practitioner watches for the tell-tale eye movements, or nystagmus .

7. TYPES OF BPVV There are two types of BPPV: one where the loose crystals can move freely in the fluid of the canal ( canalithiasis ), and, more rarely, one where the crystals are thought to be ‘hung up’ on the bundle of nerves that sense the fluid movement ( cupulolithiasis ). With canalithiasis , it takes less than a minute for the crystals to stop moving after a particular change in head position has triggered a spin. Once the crystals stop moving, the fluid movement settles and the nystagmus and vertigo stop. With cupulolithiasis , the crystals stuck on the bundle of sensory nerves will make the nystagmus and vertigo last longer, until the head is moved out of the offending position. It is important to make this distinction, as the treatment is different for each variant.

8. How to diagnose which canal is involved Differential Diagnosis of BPPV To formulate a physical therapy differential diagnosis, a thorough history and neurologic examination is performed to identify BPPV from other potential causes of positional vertigo such as orthostatic hypotension, low spinal fluid pressure, and brainstem or cerebellar dysfunction. Cervical spine and vertebral artery screening tests should be included prior to positional testing to identify limitations and potential contraindications to performing the positional tests. Once the cervical spine and vertebral artery are cleared, positional testing is performed. The AAO-HNS describes the diagnosis of posterior semicircular when two conditions are present: (1) the patient reports a history of vertigo associated with changes in head position and (2) the Dix- Hallpike test provokes the characteristic nystagmus described for this condition. The nystagmus described for posterior canal BPPV is up-beating and torsional with the fast phase beating toward the side being tested.The standard recommendation to diagnosis HC BPPV for entrylevel physical therapists and specialists in vestibular rehabilitation continues to be a single positional test, the Supine Roll Test

9. When a therapist cannot determine side of involvement they may take longer to apply the most appropriate canalith repositioning maneuver (CRM) and patients will require more physical therapy sessions and experiences longer durations of active BPPV before symptoms are resolved. In the Supine Roll Test (SRT) the patient lies in supine with neck flexed 30 degrees to align the horizontal canals into the gravitational field. The head is then quickly rotated 90 degrees to the right and the eyes are observed for either geotropic (towards the ground) or apogeotropic (away from the ground) nystagmus . The head is then brought back to facing upward, and then quickly rotated to the left 90 degrees. Because of the relationship of the two HCs to gravity in supine, when otoconia are present,nystagmus will be provoked on both the right and left rotations and the direction (geotropic or apogeotropic ) will be the same in each head rotation. There will be a greater response when otoconia move toward the ampulla ( ampulopetal ) and the system is excited than when they are displaced away from the ampulla ( ampullofugal ) and the system is inhibited. Head Pitch Test (HPT) or Bow and Lean Test (BLT), may further differentiate between sides of involvement. The upward pitch (or lean) creates a horizontal nystagmus away from the side of involvement in the geotropic form and toward the side of involvement in the apogeotropic form. The downward pitch (Bow) creates a horizontal nystagmus towards the side of involvement in the geotropic and away from the side of involvement in the apogeotropic form.

10. The right Dix- Hallpike position used to elicit nystagmus for diagnosis. The patient is moved from a seated to a supine position with her head turned 45 degrees to the right and held for 30 seconds.

11. Head Shaking Induced Nystagmus (HSIN) may be an additional sign to localize side. The Head Shake Test involves rotating the head in upright several times at ~2Hz and then observing for nystagmus1

12. 10 reasons why a PT should treat BPPV Anne K. Galgon , PT, PhD, NCS Vestibular SIG Vice Chair Here are my TOP TEN REASONS 1) Physical therapists can evaluate and treat gait and balance deficits that are concurrent or result from BPPV. 2) Physical Therapists will address functional changes in bed mobility, transfers and ambulation that are concurrent or result from BPPV 3) Physical Therapists spend more time with each patient than most other health professionals. 4) Physical Therapists will schedule a patient quickly and at a frequency which addresses an individual's BPPV in a timely fashion. 5) Physical Therapists can address residual movement sensitivity that may present after nystagmus is resolved. 6) Physical Therapists can provide the most appropriate education (knowledge of the disorder, recognizing signs and symptoms, treatment options, self management). 7) The physical therapists' optimal goal is self management of the condition. 8) Physical Therapists develop rapport with their patient that will help reduce anxiety and intensity of symptoms associated with BPPV during examination and intervention. 9) Physical Therapists have the knowledge and skills to examine for BPPV, make appropriate diagnosis and clinical decisions for intervention. 10) Physical Therapists have the knowledge and skill to consider other physical, emotional and medical conditions when examining and treating individual patients with BPPV.

13. TREATMENT Though many people are given medication for BPPV, there is no evidence to support its use in treatment of this condition (Fife TD, et al., 2008). In extremely rare circumstances, surgical options are considered. However, fortunately, in the vast majority of cases, BPPV can be corrected mechanically. Canalith Repositioning Maneuvers : The maneuvers make use of gravity to guide the crystals back to the chamber where they are supposed to be via a very specific series of head movements Liberatory Maneuver : In the case of cupulolithiasis , they would utilize rapid head movement in the plane of the affected canal to try to dislodge the ‘hung-up’ crystals first. and then guide them out as described above. Epley maneuver Additionally, before testing or treating for BPPV, the healthcare provider should perform a careful neurological scan, evaluation of the neck, and other safety-related investigations to determine if certain elements of the procedure need to be modified or avoided. It is possible to have more than one canal involved, especially after trauma, in which case your vestibular therapist would typically have to correct them one at a time.

14. POSTERIOR CANAL

15. HORIZONTAL CANAL

16. ANTERIOR CANAL

17. liberatory Anterior canal

18. Epley maneuver

19. refrences Practice guidelines for BPPV- APTA newsletter Vestibular disorders association.