1. Vestibular Rehabilitation: Evaluation and Treatment Strategies for Common Vestibular Disorders
Burt DeWeese, PT, MCMT
Rebound Physical Therapy
Vestibular Rehab Specialist

2. Background Graduate of Kansas State University, 1999
Master’s in Physical Therapy from Mayo School of Health Sciences, Rochester, MN, 2002
Completed APTA Competency Based Certification Course: Vestibular Rehabilitation-Emory University, 2004
Working toward manual therapy certification through NAIOMT – will complete level III this year
Clinical Director at Rebound Physical Therapy, Topeka, KS

3. Objectives
Describe the anatomy and physiology of the vestibular system.
Describe the pathophysiology of common vestibular disorders.
Complete and interview and examination of a person with vestibular dysfunction.
Identify appropriate standardized assessment tools for use in vestibular rehabilitation.
Demonstrate skill in performing the occulomotor exam.
Demonstrate skill in differentiating between types of BPPV.
Identify appropriate treatment intervention with patients with vestibular disorders.

4. Anatomy and Physiology

5. Anatomy of the Ear

6. Anatomy of the Ear The External Ear The Middle Ear
External auditory canal
Ends at the tympanic membrane
The Middle Ear
Space between the tympanic membrane and the inner ear
Contains the malleus, incus and stapes
Transmits sound into waves inside the cochlea
Filled with air

7. Anatomy of the Ear The Inner Ear Saccule and Utricle
Contains sensory organs for hearing and balance
Bony labyrinth within the temporal bone
Central portion is names the vestibule
Saccule and Utricle
Cochlea is anterior and vestibular portion post
Tissue layers: bony labyrinth, perilymph, membranous labyrinth, endolymph

8. The Labyrinth Bony Labyrinth Perilymph Membranous labyrinth Endolymph
Between bony and membranous labyrinth
Membranous labyrinth
Endolymph
Inside membranous labyrinth
Parnes, 2003

9. The Labyrinth 3 Semicircular Canals Anterior, Posterior Horizontal
Cochlea
Hearing component
Vestibule
Saccule and Utricle

10. The Hair Cell
Found in cochlea, semicircular canals, saccule and utricle
Send in information to the vestibularcochlear system
“Hair” of the hair cell consists of:
Sterocilia (40-70 in one hair cell)
Kinocilium (1 per hair cell)

11. Semicircular Canals Hair Cells Motion Sensors Kilocilia
Always sending info to the brain
Kilocilia
Deflection Towards- Excites
Deflection Away- Inhibits

13. Semicircular Canals Provides input about angular head velocity
Three canals on each side
Anterior (superior), Posterior (inferior) & Horizontal (lateral)
90 degree angle from each other
Horizontal canal
30 degree elevation

14. Semicircular Canals Mate on the opposite side
L ant/R post, R ant/L post
Each semicircular canal has a ampulla housing the sensor organs
Hair cells covered by the cupula
Both ends terminate in the utricle

15. The Otoliths Utricle (Linear) Horizontal Movements Head Tilt
Saccule (Linear)
Up & Down Movements
Otoconia “Ear Rocks” (Calcium Carbonate Crystals)
Hair Cells
Herdman, 2000

16. Vestibular Occular Reflex
Allows clear vision through gaze stabilization
Coordinates eye and head movements
Sensory stimulation sends info to the brainstem region that controls eye movement
Example: Head left, eyes turn right while focusing on an object
R lat rectus/L med rectus excited and opposite inhibited

17. Causes of Vertigo
Herdman, 2000

18. Causes of Vertigo BPPV Vestibular Neuritis Labyrinthitis
Meniere's Disease
Bilateral Vestibular Loss
Cervicogenic Dizziness

19. Common Disorders Vestibular Neuritis
Semi-Circular
Canals
Inflammation of the
Vestibular Nerve
Cochlea
Vestibular Neuritis
Symptoms
Sudden onset of vertigo
Nausea/vomiting
Imbalance
Sensitivity to motion
Last hours to days
Can result in chronic dysequilibrium
Caused by viral infection
Treatment
Inner Ear

20. Common Disorders Vestibular Labyrinthitis
Viral or bacterial infection of the membranous labyrinth
Acute onset of hearing loss, vertigo, nausea/vomiting
Can last 1-4 days
Will demonstrate imbalance and sensitivity to head movements

21. Common Disorders Meniere’s Disease Increased endolymph pressures
Episodic
Low frequency hearing loss
Tinnitus
Can last hours to days

22. Common Disorders Fear of Falling Disuse Dysequilibrium
Orthostatic Hypotension
Cervicogenic Dizziness
Anxiety

23. Common Disorders
Central
TBI
CVA
Multiple Sclerosis

24. Vestibular Evaluation
Subjective component
Thorough History
Dizziness Handicap Inventory
ABC confidence scale

25. Common Questions Tell me about your symptoms.
When did your symptoms begin?
How long did/does your symptoms last?
Are your current symptoms better, worse or the same?
Can you rate the severity of your symptoms 0-10/10?
Do your symptoms increase with positional changes or certain movements?
Do you have difficulty with keeping objects in focus?
Do you have ear fullness, pressure, ringing or hearing loss?
Do you have a history of these symptoms?
Have you had any falls or unsteadiness?
Currently what meds are you taking?

26. Dizziness Handicap Inventory

27. Vestibular Evaluation
Bedside Exam
Occulomotor
Smooth Pursuit
Saccades
VOR
VOR cancellation
Head Thrust/Head Shake
Upper and lower extremity screen
Cervical screen-may choose to do first

28. Vestibular Evaluation
Other testing options
Videonystagmogtaphy (VNG)
Caloric Testing
Test horizontal semicircular canals only
External auditory canal is irrigated with warm and cold water with head in degrees flex
Significant finding 25% or more reduction indicates a unilateral weakness

29. Observation Tools
Frenzel Goggles
Video Frenzel Lenses
Room Light

30. Vestibular Evaluation
Functional Testing
Dynamic Gait Index-videos
Berg Balance Scale
Timed Up and Go
Static Balance Testing
Eyes Open/Eyes Closed
Head turns
Firm and Foam

31. Dynamic Gait Index

32. Dynamic Gait Index
Video

33. Berg Balance Scale

34. Timed Up and Go (secs) (7,12,14)
Back against chair, arms on armrests –get up and walk at comfortable place to line 3 meters away, return to chair and sit down; repeat, take average
Age Male Female
(years)
Time < 10 seconds is normal
11-20 seconds is normal for frail elderly
>14 seconds indicates risk for falls
>20 seconds indicates impaired functional mobility
>30 seconds indicates dependency in most ADL and mobility skills
Video

35. Static Balance Testing
Modified CTSIB
Ground-Eyes open and closed
Foam-Eyes open and closed
½ Tandem and Tandem
SLS
Computerized Dynamic Posturography

37. Computerized Posturogrphy

38. Benign Paroxysmal Positional Vertigo

39. BPPV Statistics
BPPV is the most common cause of vertigo in patients with vestibular disorders (Bath et al, 2000)
About 20% of all dizziness is due to BPPV (Hain, 2010)
About 50% of all dizziness in older people is due to BPPV (Hain, 2010)

40. BPPV Defined
Benign- It does not signify anything life- threatening. Not malignant.
Paroxysmal- Refers to the fact that the episodes are brief and self-limited – "paroxysm" means "attack."
Positional-Change in position provokes symptoms.
Vertigo-Room spinning sensation.

41. Causes of BPPV “Idiopathic”-50%-70% Head injury- 7%-17% Viruses
Vestibular neuritis- 15%
Degeneration?

42. BPPV Nystagmus Non-voluntary oscillation of the eye
Defined fast and slow phases in opposite direction
Fast phase defines direction of nystagmus
Semicircular canals connected to specific eye muscles, which dictates direction of nystagmus
Video

43. BPPV – Nystagmus Posterior canal Anterior canal Horizontal canal
Up-beating, torsional nystagmus toward involved ear
Anterior canal
Down-beating, torsional nystagmus toward involved ear
Horizontal canal
Lateral, slight torsional nystagmus, greater toward involved ear

44. Occurrence Rates Percentages
Posterior canal- 92% occurrence
Horizontal canal- 6% occurrence
Anterior canal- 2% occurrence
Once patient has had BPPV, re-occurrence rate is about 25-30%

45. BPPV Classic Symptoms Room spinning, nausea, imbalance
Brief episodes of vertigo with changes in head position relative to gravity
Lying down in bed
Sitting up from lying down
Rolling over in bed
Bending over
Looking up- Top Shelf Syndrome

46. Challenges Musculoskeletal restrictions Use of table/plinth Pain
cervical, lumbar, shoulder and hips
Fear of falling off table in sidelying when spinning
Hip replacements
Use of table/plinth

47. Use of Plinth

48. BPPV – Clinical Exam Dix-Hallpike Test Practice
45 degree cervical rotation
Align canals with gravity
Sit to supine with 20 deg of cervical extension
Look for nystagmus and symptoms of vertigo
Practice
Herdman, 2000

49. BPPV – Clinical Exam Typical Nystagmus Fatigues with repeated testing
Latency- before nystagmus starts
1-30 seconds
Direction
Mixed up-beating, torsional nystagmus (post.)
Duration
Less than 1 minute
Fatigues with repeated testing

50. BPPV – Clinical Exam All you need to know… Direction Duration
The direction of the elicited nystagmus will tell you which canal is involved
Duration
Will tell you the type of BPPV

51. BPPV – Clinical Exam Two types of BPPV Canalithiasis (A)
Cupulolithiasis (B)

52. BPPV – Canalithiasis Otoconia are freely moving in the canals
Fall to the lowest point in canal
Induces flow of endolymph
Deflection of cupula
Fatiguing Nystagmus
Last less than 1 min

53. BPPV – Canalithiasis
Video Animation

54. BPPV – Cupulolithiasis
Otoconia are adherent to the cupula of the semicircular canal
Increased density of cupula
Sensitive to gravity
Persistent-last greater than 1 min
Hain, 2010

55. Repositioning Procedures
Parnes, 2003

56. Patient Response Sensation of spinning Clammy Sweating Nauseous
May feel like they will fall of the table
Clammy
Sweating
Nauseous
Vomitus

57. Canal Alignment Reminder
Will treat R post. canal and L ant. canal the same way
Opposite eye movement
Post-Up beat/Rot
Ant-Down/Rot

58. BPPV Treatment – Posterior/Anterior Canals
Canalith Repositioning Technique
Starting Position is Dix-Hallpike
Nystagmus should be same direction in all positions
Practice

59. Liberatory or Semont Maneuver
Used for Cuplulolithiasis
Posterior and Anterior Canal
Rotate head 45 degrees away from affected side
Quick movements to jar otoconia loose
Parnes, 2003

60. Case Study 74 yo female with past medical history of BPPV
Slipped and fell at home
Hit her head on the floor
Admitted to hospital for 2 days
Patient self report of BPPV
Dizziness with getting in bed and rolling to the left
Patient positive for Left Posterior Canal BPPV
Treatment-Left CRT

61. Case Study 68 yo male with sudden onset of dizziness
Increased with rolling over in bed and looking up
Mild imbalance in Romberg eyes closed position
Positive R Dix-Hallpike with persistent upbeating and R torsional nystagmus

62. Case Study All other evaluation info was negative Treatment
Semont Maneuver performed
Then performed CRT for post canal BPPV, once otoconia are dislodged from cupula
Symptoms were resolved after one visit

63. Horizontal Canal BPPV How do you test? Roll Test
Head in 30 degrees flexion
Rotate head either direction
Nystagmus will be lateral
Treat the side with greater symptoms
Herdman, 2003

64. Horizontal Canal BPPV Canalithiasis Cupulolithiasis
Eyes will beat geotropic
Cupulolithiasis
Eyes will beat ageotropic
Parnes, 2003

65. Horizontal Canal BPPV Horizontal Canal CRT Barbeque Roll
Head rotated to involved side first
Roll away from involved side
Keep head in 30 degrees flexion
Herdman, 2000

66. BPPV – Flow Chart

67. Horizontal Canal BPPV HC- Semont maneuver Used for Cuplulolithiasis
Head in neutral position
Quick movements to jar otoconia loose
Then perform CRT

68. BPPV Treatment Post-Treatment Instructions- typically 24 hours Debate
Avoid lying down until you go to bed.
Avoid up and down head movements.
Prop head up at night with pillows.
Avoid sleeping on affected side.
Debate

69. Other Treatment Options
Brandt-Daroff
Home CRT
Balance retraining
Surgery-canal plugging

70. Brandt-Daroff Exercises
3-5 cycles
3 times per day
Hold position for 30 seconds after vertigo stops
Parnes, 2003

71. Home CRT Same as CRT Place pillow under shoulders
Tip head over pillow and rest on mattress

72. Balance Re-training
Progress toward balance activities if the patient continues to have imbalance.
Will discuss balance activities in the Vestibular Rehabilitation section.

73. Vestibular Rehabilitation

74. Output of CNS Vestibulo-Ocular Reflex (VOR)
Allows clear vision while the head is in motion.
Vestibulo-Spinal Reflex (VSR)
Generates compensatory body movement in order to maintain head and postural stability.
Prevents Falls

75. Vestibular Function Testing
Video Infrared Recording
Eye Movements and Head Shake
BPPV
Caloric Testing
Head and Eye Movements
Saccades, Smooth, Pursuit, Head Thrust, Slow VOR

76. Vestibular Testing Computerized Dynamic Posturography
Dynamic Visual Acuity
Dynamic Gait Index
Static Balance Testing
Romberg, Sharpened Romberg, SLS
Timed Up and Go

77. Treatment Theory

78. Treatment Theory for Dysfunctions
Compensation
Response to permanent vestibular lesion.
Goals- approximate normal gaze stability and postural control.
CNS changes to optimize function.
Visual input important.
Mechanism for Compensation- Habituation

79. Treatment Theory Habituation
Long-term reduction of a response to a noxious stimulus.
Repeated movements of provocative stimulus.
Patients who move more, improve more.
Need to provoke symptoms to reduce symptoms.
Examples (MSQ)

80. Treatment Theory Adaptation Long term changes in neuronal responses.
Goals
Decrease retinal slip- gaze stabilization.
Improve postural stability.
Decrease symptoms.
Decrease sensitivity.
Increase balance and function.

81. Treatment Exercises Based on Models of VOR Main Exercises
Retinal Slip and Head Movements
Main Exercises
x1 and x2 Viewing Exercises

82. Viewing Exercises

83. Treatment Exercises Guidelines Target Seen Clearly
Head Movement +/- 30 degrees
Smooth
Continuous
Pushes Upper Limit

84. Treatment Exercises Progression Duration: 1-2 minutes
Frequency: 3-5x/day
Target Size: Small
Position of Head: Level, Slightly Down
Position of Patient: Sit, Stand
Target Distance: Near, Far
Compliant vs. Non-Compliant Surface

85. Treatment Exercises Active Head Movements b/t 2 Targets
Remembered Target
Walking Fwd/Bwd with Head Turns
Bean Bag Toss (1 & 2)
180 & 360 Degree Turns
Ball Against Wall
Walk in Circle with Ball Toss

86. Treatment Exercises Sit to Stand with head turns
Wobble board with head turns
Hurdles with ball toss
Obstacle course
Stairs

87. Balance Re-training Romberg ½ Romberg Full Romberg
On ground and on foam
Add head turns

88. Home Exercise Program All the previous discussed exercises
Can modify as needed
Can create any exercise incorporating head and eye movements
Include balance activities.

89. Billing PT evaluation- 97001 Neuromuscular Re-ed-97112
Canalith Repositioning-95992
One unit per day
Therapeutic Activity-97530

90. Treatment Frequency 1-3 times per week Can take up to 8-12 weeks
Most often 4 weeks length of treatment
BPPV only: 1-3 visits
If BPPV and neuritis
Treat BPPV first, once resolved, treat neuritis and balance disorders

91. Any Questions?

92. Bibliography
Herdman, Susan. Vestibular Rehabilitation. Philadelphia: F.A. Davis Company, 2000.
Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003; 169:
balance.com/disorders/bppv/bppv.html. Timothy Hain, MD. Benign Paroxysmal Positional Vertigo. July 19, 2010.
Vestibular Rehabilitation: A Competency Based Course. Emory University. Atlanta, Georgia.

93. Thank You!