Whitney Huryta-Vestibular Rehabilitation in the Acute...

VestibularRehabilitationintheacutesetting

Presentationby:WhitneyWilson,SPT

LearningObjectives

• Attheendofthepresentationyouwillbeableto:– Brieflydescribetheanatomyandphysiologyofthevestibularsystem

– Understandtheroleofvestibularsysteminbalanceandposture

– Describeterminologyrelatedtodizziness– PerformbasicPTexamforPtwithdizziness– DetermineifaPthasBPPVandutilizetheEply maneuver– Prescribevestibularrehabilitationincludingadaptation,habituationexercises

Arewethereyet?

• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture

• Terminologyrelatedtodizziness

• PTexam• BPPVandtheEplymaneuver

• Vestibularrehabilitation

AnatomyandPhysiologyofVestibularSystem1,2

Labyrinth

Organof

hearing

Vestibule

3canals

SemicircularCanals1,2

Angularacceleration

OtolithOrgans:UtricleandSaccule1,2

Staticandlinear

acceleration

VestibularProjectionPathways1,2

PhysiologyoftheVestibularSystem1,2

• 1.VestibularOcularReflex(VOR)– Stabilizationofgazeduringheadmotion

• 2.Vestibulospinal Reflex(VSR)– Posturalresponsestoheadmovementforstabilizationofthebody

• 3.Vestibulo-collic reflex(VCR)– Stabilizationoftheneckmminrelationtoheadmovements

VSR4

• MaintainsEquilibriumandcenterofgravity

PhysiologyoftheVestibularSystem:VCR2

MedialVestibularNucleus

MLF

Arewethereyet?



• PTexam• BPPVandtheEply maneuver• Vestibularrehabilitation

PurposeoftheVestibularSystem4

• Sensory– Perceptionofmotionandorientation• Angularacceleration• Linearacceleration• Positioninrelationtogravity

• Motor– Controlofeyemovementtopermitclearvisualimageofsurroundings

–Maintenanceofequilibriumandpositioninrelationtogravity

VestibularSystemRolesinBalanceandPosturalControl2,4

• Vestibularmechanismscontrolneck,trunkandhipmmactivationinordertostabilizethehead

Somatosensorymoreresponsible:• Firm,big

surface• Slow,lowamp

perturbation• Mmrecruited

distal-prox• Headinphase

withhips

Vestibularsystemmoreresponsible:• Unstable,small

surface• Fast,largeamp

perturbation• Mmrecruited

prox-distal• Headoutof

phasewithhips

Arewethereyet?


• Terminologyrelatedtodizziness• PTexam• BPPVandtheEply maneuver• Vestibularrehabilitation

Terminology:Whatdoyoumeandizzy?!

– Dizziness4,6:• Distortionofspatialawareness

– 4Maintypes1,2,4:• 1.Vertigo• 2.Imbalance/Disequilibrium• 3.Lightheadedness/presyncope• 4.Other(psychiatric,hyperventilation,encephalopathies,multisensory,etc.)

Thisbeingsaid…Typeofdizzinessisleastreliablefactor,butwemustworkwithwhatwe’vegot,right?

Vertigo1,4,5

• anillusionofmovement(selforsurroundings)– rotation ismostcommon– canalsobetranslational(rising)orstaticreorientation (tilting)

• BPPV• earinfections• viralneurolabyrinthitis• Meniere’sdisease(orendolymphatichydrops)

Imbalance/Disequilibrium1,4

• “dizzyinyourheadorinyourfeet?”

• Vestibularloss• Proprioceptiveorsomatosensoryloss

• Motorandcerebellarlesions

Lightheadedness/Presyncope4

Lightheaded

OrthostaticChangesofposition Spontaneous

ArrhythmiaOrthostaticHypotension:• Dehydration

• AdverseeffectofCVmed

• CardiacDysfunction

Arewethereyet?





Meclizine4 =CNSdepressant

• Neg.impactonVest.Rehabprogram2/2preventionof

centraladaptation• Dec.Nystagmusandvertigo

responsetotesting

PTevaluationfora“dizzy”Pt1,4

• History• Dizzinessinventory/questionnaire• Medications• Vision/GazeStabilityTesting• VOR/VORcancellation• Positionaltesting• Posturalcontrolassessment/BalanceAssessment

History1,4

• Typeofdizziness• Spontaneousv.motioninduced

• Duration• Frequency• Provocativefactors• Auditorycomplaints• Falls

Red Flags4

• Declineinhearing• Dysarthria• Discoordination• Diplopia• Decreasedmentationandurinaryincontinence• Declineinstrength/weight• Decreasedconsciousness• DysfunctionattributabletoCNdysfunction

D’s

Medications1

Nystagmus1,7

+DixHallPike

• Namedbyfastphase• Peripheralnystagmus:– fast=awayfromlesion– alwaystosamesidenomatterwheregaze

• Centralnystagmus:– Changesdirections

PTEvaluation1,4,7

• Eyemovement- “H”– Smoothpursuits– Extraoccular eyemovement– Endrangenystagmus

• Convergence• Saccades• VOR• VORcancellation• Headthrust

Practice

HeadThrustTest1,4,7

• TestshighfrequencyVOR• Normal:Ptsgazeshouldremainfixedonexaminer’snose• Abnormal:

– Hypoactive:correctivesaccadeindirectionoppositeheadthrust=diminishedipsi VOR

– Hyperactive:correctivesaccadeindirectionofheadthrust=centralvestibulardysfunction

• Sensitivityismaximizedwhen:– Unpredictableheadthrustsareperformed– Velocity>180deg/sec

HeadThrustVideo

Practice

PeripheralorCentral8?

BalanceAssessment1,4

• Rhomberg/SharpenedRhomberg• FunctionalReach• BergBalanceScale• Tinetti BalanceandGait

Assessment• Timed“UpandGo”test• DynamicGaitIndex• PhysicalPerformanceTest• ClinicalTestofSensory

InteractioninBalance(CTSIB)• BalanceMaster

Otherstoconsider:• Gaitspeed• 5xSTSor30secSTS

• TUG• FunctionalReach

Arewethereyet?• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture• Terminologyrelatedtodizziness• PTexam• BPPVandtheEply maneuver• Vestibularrehabilitation

Alternativecausesofpositionaldizziness/nystagmus

• Migrainous positionalvertigo

• Orthostatichypotension• Peripheralvestibularhypofunction

• phobia

• MS• TumororCVAnearcerebellarvermis

• Superiorcanaldehiscence

• VestibularParoxysmia/vascularcompressionof8thnerve

BenignParoxysmalPositionalVertigo4,9,10

• CommonComplaints:– Rolling– Reachingtofloor,ceilingortopshelf

– Washinghair– Workingundercar– Changinglightbulb– Dentalchair– Diagnosticproceduresinvolvingheadposition

Cupulolithiasis4,9,10

• Otoconia adheretocupulaofaffectedsemicircularcanal

• Canalbecomesgravitysensitive(notnormalfx)

• Characteristics:– Immediateonsetvertigoandnystagmus

– Sx duration:longlasting,graduallydecaysoveraperiodofminutes

Canalithiasis4,9,10

• Freefloatingotoconiawithinthesemicircularcanal=abnormalendolymphaticflowinaffectedcanal

• Characteristics:– Latencyrange:1-40sec– Nystagmusandvertigo

followinglatency(5-45sec)– Reversalofnystagmus– Temporarilyfatigueswith

repetition

TestingManeuvers:PosteriorBPPV• DixHallpike4,9,10

Video• Sidelying11

Video

EyemovementsforBPPV

• PosteriorCanalBPPV- Canalithiasis– Torsionipsi totheeardownandupbeat

• HorizontalCanalBPPV- Canalithiasis– Horizontalgeotrophic (towardtheground)

• HorizontalCanalBPPV- Cupulothiasis– Horizontalageotrophic (awayfromtheground)

• AnteriorCanalBPPV(rare)- Canalith orCupulo– Torsiontotheaffectedsideanddownbeat

TreatmentforBPPV:Eply’s4,9,10,12

PostManeuverInstructions4

• SleepinRecliner– Slightlyelevateheadendofbed:wedge/extrapillow

– Sleeponunaffectedsidetoreducerecurrence(shingeno 2012)

• Education:ItcanreoccursoteachPthowtoself-diagnose

Arewethereyet?• Anatomyandphysiology• Roleofvestibularsysteminbalanceandposture




GazeStabilizationExercises4,7

VORx1&x2

HabituationExercises13

BalanceExercises7

LearningObjectives

• Attheendofthepresentationyouwillbeableto:– Brieflydescribetheanatomyandphysiologyofthevestibularsystem

– Understandtheroleofvestibularsysteminbalanceandposture

– Describeterminologyrelatedtodizziness– PerformbasicPTexamforPtwithdizziness– DetermineifaPthasBPPVandutilizetheEply maneuver– Prescribevestibularrehabilitationincludingadaptation,habituationexercises

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Yes!We’reThere!AnyQuestions?!

References1. McCulloch K. Vestibular Dysfunction: Physical Therapy Intervention. 2016.2. Kernick. Modulation of Movement by the Cerebellum Part 2. 2016.3. Bajandas FKline L. Neuro-Ophthalmology Review Manual. Thorofare, NJ: Slack Inc.; 1988:Figure 4-6 Horizontal eye movement pathways.4. Walter J. Vestibular Rehabilitation Therapy: Practical Management of the Patient with Dizziness and Balance Dysfunction. 2014.5. Furman JCass S. Balance Disorders. Philadelphia: F.A. Davis; 1996.6. Drachman D. A 69-Year-Old Man With Chronic Dizziness. JAMA. 1998;280(24):2111. doi:10.1001/jama.280.24.2111.7. Otoneurology Index. Dizziness-and-balancecom. 2016. Available at: http://www.dizziness-and-balance.com. Accessed June 14, 2016.8. namrata. Nystagmus. Slidesharenet. 2016. Available at: http://www.slideshare.net/namratagupta96780/nystagmus-namrata. Accessed June 14, 2016.9. Wahlgren APalombaro K. Evidence-Based Physical Therapy for BPPV Using the International Classification of Functioning, Disability and Health Model. Journal of Geriatric Physical Therapy. 2012;35(4):200-205. doi:10.1519/jpt.0b013e318247a243.10. BHATTACHARYYA N, BAUGH R, ORVIDAS L et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology - Head and Neck Surgery. 2008;139(5):S47-S81. doi:10.1016/j.otohns.2008.08.022.11. Cohen H. Side-Lying as an Alternative to the Dix-Hallpike Test of the Posterior Canal. Otology & Neurotology. 2004;25(2):130-134. doi:10.1097/00129492-200403000-00008.12. Helminski J, Zee D, Janssen I, Hain T. Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review. Physical Therapy. 2010;90(5):663-678. doi:10.2522/ptj.20090071.13. Clendaniel R. The Effects of Habituation and Gaze Stability Exercises in the Treatment of Unilateral Vestibular Hypofunction: A Preliminary Results. Journal of Neurologic Physical Therapy. 2010;34(2):111-116. doi:10.1097/npt.0b013e3181deca01.

Whitney Huryta-Vestibular Rehabilitation in the Acute...

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