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.