Post on 12-Jan-2017
Vestibular Physical Therapy in the Inpatient SettingA brief introduction and helpful tips for diagnosis, treatment, and proper referral
Nathan Dugan, PT, DPT Kalispell Regional Medical CenterJanuary 20, 2016
Objectives
● Overview of the vestibular system○ Anatomy and physiology○ Vestibular disorders
● History taking● Screening● Oculomotor/vestibular assessment
○ Tests and measures○ Outcome measures
● BPPV diagnosis and treatment● Outpatient vestibular therapy● Practical portion
Vestibular Anatomy and Physiology
Vestibular AnatomyBony Labyrinth
● 3 semicircular canals (SCCs), cochlea, vestibule (central chamber)
Membranous Labyrinth● Suspended within bony labyrinth by
perilymphatic fluid● Contains 5 sensory organs
○ Membranous portions of SCCs
○ Otolith organs■ Utricle■ Saccule
Vestibular Anatomy
Hair Cells
● Contained in each ampulla and otolith organ, convert displacement of the head into neural firing
Vestibular Anatomy
Semicircular Canals
● Register angular rotations and velocity of the head● Anterior, posterior, and horizontal
○ Arranged perpendicularly to each other, form coplanar pairs
● Each coplanar pair forms a push-pull relationship○ Why is this important?
Vestibular Anatomy
Otolith Organs
● Register forces related to linear acceleration (linear head motion/tilt)● Saccule
○ Vertical○ Senses anterior-posterior and occipital-caudal motion
● Utricle○ Horizontal○ Senses anterior-posterior and interaural motion
Vestibular Reflexes
Vestibulo-ocular Reflex (VOR)
● Acts to maintain stable vision during head motion● With head turn to the left
○ Firing rate from hair cells in left increase, right decrease○ Excitatory impulses transmitted to ipsilateral medial rectus/contralateral lateral rectus○ Inhibitory impulses transmitted to antagonists○ If retinal image motion is >2 deg/sec, firing rate is modified - VOR IS TRAINABLE
Vestibulospinal Reflex (VSR)
Vestibulocollic Reflex (VCR)
Cervical Reflexes
Cervico-ocular Reflex (COR)
● Interacts with VOR● Eye movements driven by neck proprioceptors● Facilitated when vestibular apparatus is injured, however it is rare that COR
has any clinical significance
Cervicospinal Reflex (CSR)
● Acts when body is rotated on stable head
Cervicocollic Reflex (CCR)
Vestibular DisordersTypical clinical presentations of common disorders
Vestibular Disorders - Clinical PresentationBenign Paroxysmal Positional Vertigo (BPPV)
● Vertigo lasting 30 seconds to 2 minutes○ Disappears even if offending head position
is maintained○ Usually self-limiting and resolves
spontaneously within 6-12 months● Brought about by assuming specific head
postures● Common in elderly, any age group after
mild head trauma, F > M● Very specific nystagmus patterns
depending on canal involvement● HEARING LOSS, TINNITUS, AURAL
FULLNESS NOT SEEN WITH BPPV
Vestibular Neuritis
● Sudden onset vertigo lasting 48-72 hours○ Exacerbated by head movement○ Associated with horizontal - rotatory
nystagmus, postural imbalance, nausea○ Normal balance returns in ~6 weeks
● Often preceded by a viral infection of upper respiratory or GI tract (up to 2 weeks)
● Age of onset: 30-60 years○ Female peak: 40s○ Male peak: 60s
Vestibular Disorders - Clinical PresentationMeniere’s Disease/Endolymphatic Hydrops
● Episodic in nature, over many years● AURAL FULLNESS, HEARING LOSS,
TINNITUS○ Accompanied by vertigo, imbalance,
nystagmus, nausea, vomiting○ Vertigo persists from 30 minutes to 24
hours○ Patient generally ambulatory within 72
hours● Hearing generally returns but will
eventually fail to return as disease progresses
● Usually burns itself out● Age of onset: 40-60 years
Perilymphatic Fistula/Superior SCC Dehiscence
● Patient generally has a history of trauma, may report a “pop”
● May lead to episodic vertigo and sensorineural hearing loss
● Tullio phenomenon○ Vestibular symptoms caused by auditory
stimuli● Rest generally alleviates symptoms
○ Sneezing, nose blowing may precipitate
Vestibular Disorders - Clinical PresentationVestibular Migraine
● Migraine is a common cause of vertigo and disequilibrium
● Question about headaches and migraines to determine a link with vestibular symptoms
● Greater incidence of motion sickness associated with migraine
Mal de Debarquement Syndrome
● Defined by prolonged/inappropriate sensations of movement after exposure to motion
● Occurs after activity such as boat trip, airplane travel, train travel, etc
● Persistence of symptoms for >/= 1 month● Find relief when moving
History TakingWhat is important to know?
History Taking
● The MOST IMPORTANT part of the initial evaluation○ Devote some time to this area
● Clinical symptoms will likely begin to lead you to a diagnosis
● This is a big part of what separates a good vestibular therapist from other medical professionals with less knowledge about the vestibular system
● BPPV is a “catch-all” diagnosis
History Taking
Elements that help with diagnosis
1. Tempo2. Symptoms3. Circumstances
History Taking - Tempo
● Acute or chronic (>3 days)?● FIRST onset of dizziness
○ Sudden or slowly developing?○ Provoked or spontaneous?○ Prior illness?
● Average duration of spells
History Taking - Symptoms
● What does dizzy mean?○ Disequilibrium ○ Lightheadedness ○ Rocking/swaying ○ Motion sickness ○ Nausea/vomiting ○ Oscillopsia ○ Floating/swimming/rocking/spinning ○ Vertigo
History Taking - Circumstance
Under what circumstance does the patient’s dizziness occur?
● With certain movements?● Spontaneously?● Exacerbated by head/visual movement?
History Taking - Other Considerations
● Often a psychological component to vestibular disorders● What medications is the patient taking?
Screening TestsTo rule out non-vestibular causes of vertigo
HINTS1
Head Impulse, Nystagmus, Test of Skew
Indicative of stroke:
INFARCT
Impulse Normal, Fast-phase Alternating, Refixation on Cover Test
HINTS plus Hearing
Head Impulse Test
Video: https://www.youtube.com/watch?v=fiqAkhYNPRk
Direction-Changing Nystagmus
Video: https://www.youtube.com/watch?v=0rHNappbYtE
Skew Deviation
Video: https://www.youtube.com/watch?v=-J170K7VAdA
Vertebral Artery Screening
● VBI often presents with vertigo, nausea, and vomiting○ Other symptoms are important in history
● Clinical tests - poor sensitivity○ Vertebral artery compression test (VAT)
■ Performed in supine with full cervical rotation/extension● What might be wrong with this?
○ Modified VAT (mVAT)■ Patient is in sitting
● Then rotates head to one side and flexes forward at hips thus extending the cervical spine
Vestibular Assessment
Oculomotor/Vestibular Examination
Oculomotor/Vestibulo-Ocular Examination
● Convergence● Smooth Pursuit
○ Combine with test for gaze-evoked nystagmus for efficiency
● Saccades● Spontaneous Nystagmus● Gaze-Evoked Nystagmus● Skew Deviation● VOR Cancellation
VOR Testing
● Head Impulse Test● Head-Shaking Nystagmus● Dynamic Visual Acuity● VOR I/II
Outcome MeasuresWhat measures have been validated in the vestibular disorder population?
Functional Gait Assessment (FGA)
● Modification of DGI to improve reliability and decrease ceiling effect● 10 items scored 0-3 for total possible score of 30● May be performed with or without assistive devices● Equipment
○ Stop watch○ 20ft x 12in walking path○ 9in obstacle (2 shoe boxes)○ Steps
● Cut-off scores2
○ </= 22/30 predicts falls (older adult data)■ Sensitivity 85%, Specificity 86%
Timed Up-and-Go (TUG)
● 3m (10ft) course, with patient seated in chair to start, and turn in middle● Timing begins on “go” and ends when patient sits
○ One practice trial should be given
● In vestibular population, both right and left turns should be tested● Cut-off scores3
○ >11.1s■ Sensitivity 80%, Specificity 56%
BPPV Diagnosis and Treatment
BPPV
● The only vestibular diagnosis that you can fix with one treatment○ Therefore it is a great skill for any physical therapist to have
● Remember○ Characterized by episodic vertigo precipitated by position changes that last for 30s - 2min and
is fatiguing even if the offending head position is maintained○ Characteristic nystagmus patterns
● Diagnosis can be difficult without the use of Frenzel/infrared goggles○ Why?
BPPV Mechanism
● Canalithiasis○ Debris dislodged from the otoconia becomes freely floating in the endolymph of an SCC
○ Head movement causes movement of the otoconia which in turn causes movement of the endolymph, thus deflecting the cupula
■ Delay in onset of vertigo/nystagmus up to 40 seconds■ Vertigo generally rises in intensity to a peak, and then improves rapidly and disappears
● Cupulolithiasis○ Debris dislodged from the otoconia becomes adhered to the cupula
■ Causes sudden onset vertigo/nystagmus that is non-fatiguing○ Relatively uncommon
● Treatments for canalithiasis and cupulolithiasis are different
Types of BPPV - Posterior Canal
MOST COMMON - 76% of cases
● Diagnostic Test○ Dix - Hallpike
● Observed Nystagmus and Canal Involvement (Left Dix-Hallpike Test) ○ Left posterior canal - upbeating and left torsional○ Left anterior canal - downbeating and left torsional○ Right anterior canal - downbeating and right torsional
● Treatment○ Canalith Repositioning Treatment/Epley Maneuver (CRT)○ Liberatory/Semont Maneuver○ Brandt-Daroff exercises
Posterior Canal BPPV Nystagmus - Video
Video: https://www.youtube.com/watch?v=jrp8iPfvP4Y
Types of BPPV - Anterior Canal
13% of cases
● Diagnostic Test○ Dix - Hallpike
● Observed Nystagmus and Canal Involvement (Left Dix-Hallpike Test) ○ Left posterior canal - upbeating and left torsional○ Left anterior canal - downbeating and left torsional○ Right anterior canal - downbeating and right torsional
● Treatment○ Deep Head-Hanging Maneuver4
○ Canalith Repositioning Treatment/Epley Maneuver (CRT)○ Liberatory/Semont Maneuver○ Brandt-Daroff exercises
Anterior Canal BPPV Nystagmus - Video
Video: https://www.youtube.com/watch?v=qW-tBDU9RRc
Types of BPPV - Horizontal Canal
5% of cases
● Diagnostic Test○ Roll Test
● Observed Nystagmus and Canal Involvement○ Geotropic (towards floor)
■ Canalithiasis○ Apogeotropic (away from floor)
■ Cupulolithiasis○ Which side is involved?
■ More intense nystagmus/increased symptoms and duration on pathological side● Treatment
○ Bar-B-Que Roll (fast or slow), Appiani/Casani Maneuvers○ Forced prolonged positioning
Horizontal Canal BPPV Nystagmus - Video
Video: https://www.youtube.com/watch?v=MtmkD5rDU0o
BPPV Treatment
Lab Portion
Referring to Outpatient Vestibular Therapy
● When should you refer a patient to outpatient vestibular physical therapy?○ BPPV○ Other vestibular disorders
● What is outpatient vestibular physical therapy like?○ Habituation, adaptation, gaze stabilization, balance training
● How long does it take patients to recover?
Questions?
References1) Newman-Toker DE, Curthoys IS, Halmagyi GM. Diagnosing stroke in acute vertigo: the HINTS family
of eye movement tests and the future of the “eye ECG.” Semin Neurol 2015;35(5):506-521. 2) Wrisley DM, Kumar NA. Functional gait assessment: concurrent, discriminative, and predictive
validity in community-dwelling older adults. Phys Ther 2010;90(5):761-773.3) Whitney SL, Marchetti GF. The sensitivity and specificity of the timed up & go and the dynamic gait
index for self-reported falls in persons with vestibular disorders. J Vestib Res 2004;14: 397-409.4) Yacovino DA, Hain TC, Gualtieri F. New therapeutic maneuver for anterior canal benign paroxysmal
positional vertigo. J Neurol 2009:256(11);1851-1855.
All other slides adapted from:
Herdman SJ. Vestibular Rehabilitation, 3ed. Philadelphia: FA Davis; 2007.