7 Vestibular Rehabilitation

Question 1

Sensory components of balance

Answer 1

Vision- to cortex, BG, ventrolateral thalamus, back to cortex
Vestibular- to brainstem/cerebellum, BG, ventrolateral thalamus, cortex
Somatosensory- to SC through DCML, to brainstem/cerebellum, etc.

Question 2

Sensory processing occurs…

Answer 2

At vestibular nuclear complex and cerebellum

Question 3

Two otolith organs

Answer 3

Respond to gravity and linear acceleration, send afferent information to vestibular ganglion
Utricle- horizontal
Saccule- vertical

Question 4

Structure of semi-circular canals

Answer 4

Ampulla houses sensory hair cells, hair cells project into gelatinous mass (cupula), movement in plane of canal causes endolymph to push against cupula

Question 5

Superior vestibular nerve innervates…

Answer 5

Anterior SCC, horizontal SCC, utricle

Question 6

Inferior vestibular nerve innervates…

Answer 6

Posterior SCC, saccule

Question 7

Vestibular nuclear complex projections

Answer 7

Spinal cord, cerebellum, nuclei of CN III, IV, VI for control of eye, head, and body movements

Question 8

Vestibular nuclear complex components

Answer 8

Superior and medial nuclei- control gaze
Lateral (Deiter’s) nucleus- postural reflexed
Inferior nucleus- integration of vestibular and motor signals

Question 9

Roles of vestibulocerebellum

Answer 9

Adaptation
Compensation for motor deficits
Motor learning
Regulation of balance and eye movements

Question 10

Vestibular nuclear complex pathways

Answer 10

To thalamus and cortex- sensation and perception of head movement
Vestibulospinal pathways- motor commands to muscles of neck, upper torso, lower limbs to maintain balance and posture
Vestibulo-ocular pathways- to CN III, IV, VI for VOR

Question 11

VOR

Answer 11

Maintains steady image on retina for high frequency head movements
VOR gain should be 1

Question 12

Cervico-ocular reflex

Answer 12

Like VOR but slower speeds
Cervical proprioception drives eye movement
Used in presence of vestibular dysfunction

Question 13

Other sources of dizziness (not central or peripheral vestibular)

Answer 13

Diabetes, hypoglycemia, infection, meds, emotional/psychological, hypotension, arrhythmias, multi-factorial fallers

Question 14

Etiology and epidemiology of BPPV

Answer 14

Idiopathic in 50-70%, recurrence rate 27-41%, incidence increases with each decade of life

Question 15

Clinical presentation of BPPV

Answer 15

Brief vertigo with position changes/head movements
<60 seconds for canalithiasis, >60 for cupulo
Latency of seconds
Nystagmus
Symptoms fatigue with repetition
Nystagmus quick beat towards involved side with Dix-Hallpike

Question 16

Horizontal canal BPPV

Answer 16

Geotropic- canal affecting most symptomatic side
Ageotropic- if more than one minute, cupulo affecting least symptomatic; if less than one minute, canal affecting least symptomatic

Question 17

Treating BPPV

Answer 17

Epley maneuver- posterior or anterior canalithiasis
Liberatory (Semont)- anterior or posterior cupulo
BBQ roll- horizontal canalithiasis
Modified Liberatory (Semont)- horizontal cupulo

Question 18

Vestibular neuritis/labrynthitis presentation

Answer 18

Secondary to viral infection, neuritis = CN VIII, labrynth- endolymph fluids
Acute- severe vertigo and nausea lasting days, horizontal gaze-evoked nystagmus, abnormal VOR, impaired DVA
Sub-acute- prolonged disequilibrium without true vertigo, inadequate VOR, postural instability, gait, falls, deconditioning, CN VIII dysfunction

Question 19

Vestibular neuritis/labyrnthitis treatment

Answer 19

Vesibular depressants in acute phase only

Vestibular rehab improves 80% of patients

Question 20

Meniere’s disease presntation

Answer 20

Over-accumulation of endolymph in inner ear causes abnormal firing of hair cells
Episodic exacerbations (vertigo) minutes to hours with full recovery, but over time get permanent damage and unilateral hypofunction
Rotary vertigo, low-tone sensorineuronal hearing loss, tinnitus, aural fullness, nausea and vomiting
Chronic- imbalance, dizziness with head turns

Question 21

Meniere’s disease treatment

Answer 21

Vestibular sedatives, anti-emetics (diazepam), intra-tympanic gentamycin
Endolymphatic sac surgery or ablative surgery for intractable symptoms
Low salt diet, avoidance of caffeine

Question 22

Vestibular schwannoma/ acoustic neuroma

Answer 22

Variable presentation

Dizziness, disequilibrium, unilateral hearing loss, tinnitus, +CN signs (V, VII, VIII)

Question 23

Trauma/skull fracture

Answer 23

Temporal bone fractures result in variable symptoms

Question 24

Perilymphatic fistula

Answer 24

Tear or deficit in small and/or round windows separating middle and inner ears allowing fluid to leak to air-filled middle ear
Changes in pressure (altitude, increased CSF pressure from lifting, bending, cough/sneeze) stimulate balance and/or hearing strucures
Aural fullness, fluctuating hearing, dizziness w/o true vertigo, motion sensitivity
Treatment- repair if symptoms don’t resolve

Question 25

Superior canal dehiscence

Answer 25

Opening in temporal bone overlying superior SCC from developmental abnormality (1-2%) Vertigo and oscillopsia from loud noises and/or maneuvers that change middle ear of intracranial pressure (coughing/sneezing, straining) Autophony, hypersensitivity to bone-conducted sounds, apparent conductive hearing loss Avoid stimuli if possible, surgery for severe cases

Question 26

Bilateral hypofunction diagnoses

Answer 26

``` Otoxic meds Idiopathic vestibular loss Bilateral Meniere's Trauma Autoimmune disease (RA, psoriasis) Meningitis Neurofibromatosis type 2 ```

Question 27

Ototoxic meds

Answer 27

Gentamicin affects hair cells- irreversible damage

Question 28

Symptoms of bilateral hypofunction

Answer 28

Oscillopsia during head movement Instability of gait Disequilibrium No vertigo!

Question 29

Central dysfunction signs

Answer 29

``` Constant symptoms Nystagmus not suppressed by visual fixation Pure vertical nystagmus Impairments in smooth pursuits/saccades Impaired VOR cancellation ```

Question 30

Vertiginous migraine

Answer 30

Vascular origin, about 25% of those with migraine have vertigo Can occur with or without headache Symptoms seconds to days Treatment- trigger avoidance, migraine preventative meds, vestibular rehab PT- VOR exercises, COR reflex, depth perception, sensory integration for balance, gait, aerobic exercise

Question 31

Concussion

Answer 31

Anxiety, cognitive problems, depression, fatigue, HA, irritability, photo/phono-sensitive, sleep disturbances Dizziness, imbalance, visual disturbances 23-81% of people have dizziness in first few days PT- VOR exercises, static standing balance, gait exercises, cervical spine interventions

Question 32

Multiple sclerosis

Answer 32

Plaques in brainstem, visual pathways, cerebellum can cause vestibular symptoms 34.7-50.9% of those with MS have brainstem and cerebellum lesions Peripheral vestibulopathy in up to 85% of those with MS PT- can improve fatigue, balance, disability by DHI

Question 33

Cervicogenic dizziness

Answer 33

Non-specific sensation of altered orientation in space and disequilibrium from abnormal afferent activity from neck Mis-match of proprioceptive and vestibular input Symptoms- unsteadiness, imbalance, light-headed, disorientation minutes to hours; neck pain, HA, jaw pain, tinnitus

Question 34

Electronystagmography/ videonystagmography

Answer 34

Caloric test- gold standard Irrigate external canal with cold or warm water/air and watch nystagmus Cold = away from irrigated ear Warm = toward irrigated ear

Question 35

Sinusoidal harmonic acceleration test

Answer 35

Rotary chair test VOR measured during rotation of body in dark Assesses horizontal canal and/or superior vestibular nerve Identifies central impairment, bilateral vestibular dysfunction, and central compensation

Question 36

Vestibular evoked myogenic potential (VEMP)

Answer 36

Tones in ears while evoking responses from specific muscles Cervical VEMP- saccule and inferior nerve Ocular VEMP- utricle and superior nerve

Question 37

Oculomotor exam components

Answer 37

``` Alignment- tropia, phoria, exo-, eso- ROM Convergence Nystagmus (spontaneous, gaze-holding)- unable to suppress with visual fixation in central dysfunction Smooth pursuit, saccadic movement Head impulse test VOR cancellation DVA (>2 line drop can indicate deficit) ```

Question 38

Dizziness handicap inventory

Answer 38

0-100 (higher number is greater handicap) 0-30 mild 31-60 moderate 61-100 severe handicap

Question 39

Sensory organization test

Answer 39

1- fixed support and surround/ EO 2- fixed support and surround/ EC 3- fixed support, responsive surround/ EO 4- responsive support, fixed surround/ EO 5- responsive support, fixed surround/ EC 6- responsive support and surround/ EO

Question 40

Clinical test of sensory interaction and balance

Answer 40

``` 1- firm EO 2- firm EC 3- firm visual conflict 4- foam EO 5- foam EC 6- foam visual conflict ```

Question 41

Modified CTSIB

Answer 41

1- firm EO 2- firm EC 3- foam EO 4- foam EC

Question 42

Motion sensitivity quotient

Answer 42

``` 16 changes of head or body position 0 (no dizziness) to 5 (severe) Duration- 1 (5-10 sec), 2 (11-30 sec), 3 (>30 sec) 0-10%- mild 11-30%- moderate 31-100%- severe motion sensitivity ```

Question 43

Adaptation

Answer 43

Induce CNS plasticity by creating error signal (retinal slip) to change VOR gain VORx1, VORx2 For unilateral hypofunction, bilateral if residual function, central if appropriate Can add visual stimulation, duration/rate up to 2 Hz for 2 minutes

Question 44

Substitution

Answer 44

Use alternative strategies- saccadic movements dissociated from head movement Pts may need AD for somatosensory input For bilateral hypofunction, central

Question 45

Habituation

Answer 45

Desensitization to provocative stimuli via repetitive exposure Visual vertigo- exposure to optokinetic stimulation can help in cases where over-reliance on visual input creates symptoms in visual/vestibular conflict For unilateral hypofunction and central vestibular dysfunction

Question 46

Rehab effects for bilateral hypofunction

Answer 46

Adaptation, gait, and balance activities Significantly improves DVA similar to unilateral hypofunction Age not a factor in recovery Recovery in approximately 5 weeks of exercise