Evidence-Based Practice in Vestibular Rehabilitation
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Evidence-Based Practice in Vestibular Rehabilitation



Presented at the Indiana Occupational Therapy Association Fall Conference, October 26, 2013, at IUPUI. This presentation gives occupational therapists a few tools to recognize, begin treatment, and ...

Presented at the Indiana Occupational Therapy Association Fall Conference, October 26, 2013, at IUPUI. This presentation gives occupational therapists a few tools to recognize, begin treatment, and refer patients with vestibular dysfunction, for earlier identification and return to productive living.



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Evidence-Based Practice in Vestibular Rehabilitation Evidence-Based Practice in Vestibular Rehabilitation Presentation Transcript

  • Evidence Based Practice in Vestibular Rehabilitation: An Occupation-based Perspective Brenda S. Howard MHS OTR Balance Point Indianapolis And University of Indianapolis, DHS Program October 26, 2013
  • How is Vestibular Rehabilitation Occupation-Based? • Vestibular function underlies all human activity • Vestibular impairment impacts all occupations • Occupational Therapy Perspective • Remediate vestibular function • Compensate for safety • Environmental modification
  • How is Vestibular Rehabilitation Evidence-Based? • Evaluation based in neurology & evidence • Treatment tools based in evidence • Foundation of evidence allows for creativity in practice • See reference list
  • Learning Objectives      Gain knowledge of vestibular rehab and evidence Identify vertigo, central vs. peripheral Three tools for evidence-based assessment and treatment When to refer Spark interest in further education
  • What do patients complain of when they have a vestibular impairment? − Vertigo − a sense of movement where there is no movement; an illusion of movement
  • What do patients complain of when they have a vestibular impairment? − Dizziness − a combination of vertigo, lightheadedness, and imbalance
  • What do patients complain of when they have a vestibular impairment? − − − Vision Hearing Nausea
  • What do patients complain of when they have a vestibular impairment? − − − Cognition Balance, Coordination Emotions
  • Central Connections • • • • • Vestibulo-ocular reflex Vestibulo-spinal reflex Vestibulo-collic reflex Autonomic connections Limbic connections
  • What can go wrong? Peripheral causes of vertigo  ◦ ◦ ◦ ◦ ◦ Unilateral Vestibular Hypofunction Peripheral Vestibular Asymmetry Labyrinthitis Vestibular Neuronitis Vestibular Infarct Vestibular Schwannoma/Acoustic Neuroma (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Peripheral Vertigo History and Symptoms Sudden onset (illness, trauma, or unknown)  Constant dizziness, provoked by motion (especially head and body turns)  (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Peripheral Vertigo History and Symptoms Discomfort with watching movement or patterns  Mild-Moderate Imbalance  (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Peripheral Vertigo History and Symptoms   Horizontal unidirectional gazeevoked nystagmus http://www.youtube.com/wat ch?v=YntJiBCz3pA (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Bilateral Vestibular Hypofunction Not dizzy  Off balance  No balance in the dark  Oscillopsia (“things bounce visually”) 
  • Bilateral Vestibular Hypofunction Dynamic Visual Acuity loss of greater than 6 lines  Immediate fall Romberg eyes closed on compliant surface   Causes: Chemotherapy, ototoxic antibiotics, autoimmune
  • BPPV (Benign Paroxysmal Positional Vertigo)  Etiology: Otoliths in semicircular canal  Cupula deflects more than usual  (Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)
  • BPPV  Posterior canal: 95% of cases (Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)
  • BPPV Symptoms       Dizziness with position changes Lying flat, rolling over, sit up, stand up, bend over, look up “Top Shelf or “Dentist Office” vertigo Strong spinning for less than one minute May have “leftover” symptoms for hours Seniors may describe symptoms differently; rocking, tilting, passing out (Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)
  • BPPV is Designated by: Canal ◦ Right or left ◦ Anterior (Superior) ◦ Posterior ◦ Horizontal Otolith Position ◦ Canalithiasis ◦ Cupulolithiasis
  • BPPV Diagnosed with Dix Hallpike maneuver
  • BPPV Nystagmus: http://www.youtube.com/watch? v=gyvSmTlGu2k
  • BPPV – Canalith Repositioning Epley Maneuver for Posterior Canal BPPV canalithiasis
  • What can go wrong? Central Causes of Vertigo • • • Migraine Associated Vertigo (MAV), Vestibular Migraine Post-Concussive Disorder CVA (cerebellar, pontine) (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Vestibular Migraine • May or may not have headache May have vertigo without migraine • Headache may be low grade but persistent A history of migraines (or persistent headaches) • • (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Vestibular Migraine • • Symptoms similar to a unilateral vestibular loss but with no objective findings on VNG Motion, light, and sound sensitive (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Vestibular Migraine • • • May be episodic Or may “wax and wane” Typically responds better to balance and gentle habituation exercises (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Post Concussive Disorder  Central AND Peripheral  Concussion  Labyrinth trauma  BPPV  Cognition  Headache – post-concussive migraines  Imbalance  Motion sensitive, visually sensitive (Herdman, 2007; Herdman & Clendaniel, 2007)
  • CVA – Cerebellar, Pontine ◦ ◦ ◦ ◦ ◦ Diplopia, dysmetria, dysarthria “Constant hum” of vertigo Pursuits/Saccades Subjective visual vertical Direction-changing nystagmus http://www.youtube.com/watch?v=jeYe- SMMW9k (Herdman, 2007; Herdman & Clendaniel, 2007)
  • Diagnostic Tests   Medical Tests: MRI, CT, cardiac Audiology Tests: − − − − − − Audiogram VNG/ENG Rotary Chair Positional Testing including Dix Hallpike VEMP Computerized Dynamic Posturography (CDP)
  • Vestibular Therapy Evaluation History − − − − Detailed description of symptoms Past Medical History, Medications Occupational Profile – the “so what” Questionnaires ◦ Dizziness Handicap Inventory (Jacobson, et al., 1990) ◦ ABC Scale (Whitney, et al, 1999)
  • Oculomotor Exam Pursuits Saccades Gaze Evoked Nystagmus Slow Head Rotation Eye-Head to Periphery Dynamic Visual Acuity (DVA) – using logMAR chart (Herdman et al., 2003)
  • Gaze-Evoked Nystagmus http://www.youtube.com/watch? v=mghGeKkNBzQ
  • Dynamic Visual Acuity and x1 http://www.youtube.com/watch? v=8eWKMO7RNak
  • Practice! Dynamic Visual Acuity Vestibular Adaptation Exercises – x1 Gaze Stabilization ◦ What are some ways you can grade this exercise? ◦ How can you add a functional component?
  • BPPV Evaluation and Treatment Dix Hallpike and Canalith Repositioning (Epley) Maneuver Dix Hallpike: http://www.youtube.com/watch? v=7pDOaFKrTbU Epley: http://www.youtube.com/watch? v=ZqokxZRbJfw
  • Dix Hallpike and Canalith Repositioning Maneuver PRACTICE!
  • American Academy of Neurology BPPV Assessment and Treatment (full video) http://www.youtube.com/watch?v=hq- IQWSrAtM
  • Habituation Test: Motion Sensitivity Quotient (Test) (Shepherd & Telian, 1995; Akin & Davenport, 2003) Habituation ◦ ◦ ◦ ◦ Exercises Otolith Semicircular Canals Functional Movement: Progressive Sequences Brandt Daroff: NOT a habituation exercise (Whitney & Sparto, 2011; Clendaniel, 2010; Cohen, et al., 2006; Cohen, et al., 1995; Cronin, 2013)
  • Habituation, continued Exercises: ◦ ◦ ◦ ◦ Head horizontal, vertical Forward bend in straight plane, diagonal Wall rolling, ball-to-wall Add a functional task!
  • Vestibular Habituation Vs. Adaptation – when to use? Use adaptation for impaired VOR (DVA) Use habituation for motion sensitivity You can use both, but be cautious to not overload the vestibular system
  • Balance mCTSIB (Modified Clinical Test of Sensory Integration and Balance) (Shumway-Cook & Horak, 1986; Cohen, et al., 1993) Dynamic balance ◦ Dynamic Gait Index (DGI) (Whitney, et al., 2000) ◦ Functional Gait Assessment (FGA) (Wrisley, et al., 2010)
  • Balance Demonstration and Practice! ◦ Come up with one adaptation of this test that could be used for treatment ◦ Come up with one functional activity to be used for balance treatment
  • Evidence-Based Treatment Techniques - summary     Canalith Repositioning (Epley) Maneuver Vestibular Adaptation Exercise (x1) Habituation Exercises Static and Dynamic Balance Exercises
  • Evidence-Based Treatment Techniques - summary   Compensatory techniques, sensory calming techniques (relaxation, deep breathing, visual targeting) Functional activities, of course! - always link treatment to the patient's occupation-based goals
  • Patient Education Resources Vestibular Disorders Association ◦ www.vestibular.org Dr. Timothy Hain MD – “The Dizzy Doctor” ◦ http://www.dizziness-andbalance.com/index.html ◦ http://dizzy-doctor.com/index.php Vestibular Seminars ◦ http://www.vestibularseminars.com/home.html
  • Case Study Examples    What is one thing you would like to test? If positive, what treatment would you select? What referrals might you make?
  • A Word about Fall Prevention Multiple ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ factors: Cognitive Environmental Strength, Endurance, Balance Peripheral Neuropathy Orthopedic Deficits Neurologic Deficits Vertigo Behavioral All must be addressed! (AGS/BGS, 2010)
  • A Word about Non-Vestibular Causes of Vertigo Cardiac Vertebrobasilar insufficiency Orthostatic hypotension Low blood pressure Low blood sugar (Herdman, 2007; Herdman & Clendaniel, 2007)
  • A Word about Non-Vestibular Causes of Vertigo Autoimmune disorders Other central disorders (MS, PD) Psychogenic – anxiety, depression Medications Cervicogenic (Herdman, 2007; Herdman & Clendaniel, 2007)
  • A Word About Precautions Neck ROM, pain Back pain Fall Risk Circulatory issues ◦ Vertebrobasilar Artery Compression Autonomic reactions Nausea, vomiting Seizures Coexisting diagnoses
  • When to Refer Refer to MD, ENT, Neurologist for diagnosis Refer to audiologist for VNG, audiogram for suspected ear pathology Refer to vestibular rehabilitation specialist if patient does not respond to treatment in 2-3 weeks OR if you are unsure what to do based on what you know
  • A Word about Logistics AOTA Position Paper (Cohen, et al., 2006) Indiana License (IPLA, 2011) Billing CPT codes: ◦ Initial: 97003 ◦ Timed treatment codes: 97112 (neuromuscular re-education), 97110 (therapeutic exercise), 97530 (therapeutic activity).
  • Recommended Courses Education Resources: Richard Clendaniel DPT, Gaye Cronin OTR Jeff Walters DPT - http://www.vestibularseminars.com/ Sue Whitney PT Janet Helminski PT, Dr. Timothy Hain MD APTA/Emory University Certificate Course (Susan Herdman PT) Dr. Richard Gans PhD http://dizzy.com/education_without_boundaries.htm (See Cohen, et al., 2011 for educational guidelines)
  • Summary Evidence-based Occupation-based Post-test Course Evaluation
  • http://www.youtube.com/watch? v=rbwmfEXu75s THANK-YOU FOR ATTENDING!
  • References      Akin, F., & Davenport, M. (2003). Validity and reliability of the Motion Sensitivity Test. Journal of Rehabilitation Research and Development, 40(5), 415-422. American Geriatrics Society & British Geriatrics Society (AGS/BGS). (2010). Clinical practice guideline: Prevention of falls in older persons. Journal of the American Geriatrics Society (special article). Retrieved May 17, 2013 from http://www.americangeriatrics.org/health_care_professionals/clinical_pr actice/ clinical_guidelines_recommendations/2010/ Clendaniel, R. (2010). The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary results [sic] [Abstract]. Journal of Neurologic Physical Therapy, 34(2), 111-116. Cohen, H. (2011). Assessment of functional outcomes in patients with vestibular disorders after rehabilitation. Neurorehabilitation, 29, 173178. Cohen, H., Blatchly, C., & L., Laurie. (1993). A study of the Clinical Test of Sensory Interaction and Balance. Physical Therapy Journal, 73, 346351.
  •        Cohen, H., Burkhardt, A., Cronin, G., & McGuire, M. (2006). Specialized knowledge and skills in adult vestibular rehabilitation for occupational therapy practice. American Journal of Occupational Therapy, 60(6), 669678. Cohen, H., Kane-Wineland, M., Miller, V., & Hatfield, C. (1995). Occupation and visual/vestibular interaction in vestibular rehabilitation. Otolaryngology-Head and Neck Surgery, 112(4), 526-532. Cohen, H., Gottshall, K., Graziano, M., Malmstrom, E., Sharpe, M., & Whitney, S. (2011). International guidelines for education in vestibular rehabilitation therapy. Journal of Vestibular Research, 21, 243-250. Cronin, G. & Steenerson, R. (2011). Disequilibrium of aging: Response to a 3-month program of vestibular therapy. Physical & Occupational Therapy in Geriatrics, 29(2), 148-155 Cronin, G. (June 14-15, 2013). Vestibular Rehabilitation: Treatment Intensive (course manual). Philadelphia, PA: Education Resources, Inc. Epley, J. (1992). The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery, 107(3), 399-404. Epley, J. (1995). Positional vertigo related to semicircular canalithiasis. Otolaryngology-Head and Neck Surgery,112(1), 154-161.
  •       Hain, T. Dizziness, imbalance, and hearing disorders. Retrieved on June 30, 2013 from http://www.dizziness-andbalance.com/disorders/index.html Haven, L. (2011, Summer/Fall). VEDA produces benchmark study to help reduce suffering. On the Level: Quarterly Newsletter of the Vestibular Disorders Association, 28(3-4), 1-8. Helminski, J., Zee, D., Janssen, I., & Hain, T. (2010). Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Physical Therapy Journal, 90(5), 663-678. Herdman, S.(Ed.). (2007). Vestibular Rehabilitation (3rd ed.). Philadelphia: FA Davis Co. Herdman, S. & Clendaniel, R. (March 13-17, 2007). Vestibular Rehabilitation: A competency-based course (course manual). Atlanta, Georgia: Department of Rehabilitation Medicine, Emory University School of Medicine and American Physical Therapy Association. Herdman, S., Schubert, M., Das, V., & Tusa, R. (2003). Recovery of dynamic visual acuity in unilateral vestibular hypofunction. Archives of Otolaryngology-Head and Neck Surgery, 129, 819-824.
  •       Hernandez, D. & Rose, D. (2008). Predicting which older adults will or will not fall using the Fullerton Advanced Balance scale. Archives of Physical Medicine and Rehabilitation, 89(12), 2309-2315. Indiana Professional Licensing Agency Occupational Therapy Committee (IPLA). (2011). Occupational Therapy Committee: Laws and Regulations: A compilation of the Indiana Code and Indiana Administrative Code. Retrieved from http://www.in.gov/pla/files/OTC.2011_EDITION.pdf Jacobson, G., Newman C., Hunter, L., et al. (1990). The development of the dizziness handicap inventory. Archives of Otolaryntology-Head and Neck Surgery, 116, 424-427. Shepherd, N. & Telian, S. (1995). Programmatic vestibular rehabilitation. Otolaryngology-Head and Neck Surgery, 112, 173. Shumway-Cook, A., & Horak, F. (1986). Assessing the influence of sensory interaction of balance: suggestion from the field. Physical Therapy Journal, 66, 1548-1550. Vestibular Disorders Association (VEDA). Living with a vestibular disorder. Retrieved on June 30, 2013 from http://vestibular.org/livingvestibular-disorder
  • Whitney, S., Hudak, M., & Marchetti, G. (1999). The Activities-specific Balance Confidence scale and the Dizziness Handicap Inventory: A comparison. Journal of Vestibular Research,9, 253-259.  Whitney, S., Hudak, M., & Marchetti, G. (2000). The dynamic gait index relates to self-reported fall history in indifivuals with vestibular dysfunction. Journal of Vestibular Research, 80, 896-903.  Whitney, S. & Sparto, P. (2011). Principles of vestibular physical therapy rehabilitation. Neurorehabilitation, 29, 157-166.  Wrisley, D. & Kumar, N. (2010). Functional gait assessment: Concurrent, discriminative, and predictive validity in communitydwelling older adults. Physical Therapy Journal, 90, 761-773. 