Vestibular Rehabilitation


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Learn more about the types, symptoms and causes of balance disorders. Diagnostic and treatment options such as vestibular rehabilitation and cognitive behavioral therapy will be discussed.

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  • Point out cochlea, semicircular canals, vestibular nerveAbout the size of your pupilVestibular disorders effecting this region are considered “peripheral”, where as some forms of dizziness or imbalance may be due to a “central” problem involving the vestibular nerve entering the brainstem and brain.
  • Important to understand how normal balance occurs.Vestibular: both sides need to be telling the brain the same thing, otherwise a mismatch signal is perceived by the brain, giving the perception of dizzinessVision: a reflex between the vestibular system and the eye muscles coordinate head motion and visual focus. This is why when we run, the world around us is not jumping all around.Sensation: what we feel in our feet, skin, muscles and joints all give our brains information about where we are in space.
  • Romberg EO vs EC demo
  • Depending on the nature of the problem, people with VD can present with difficulty with balance/ steadiness, dizziness with certain position changes, or a sense of motion when either the person is moving, or the world around them is moving.
  • Visual: blurriness or difficulty focusing with head mov’t—commonly experienced in a busy setting like a supermarket. Reading , watching TV, computer scrollingAuditory: involving loss of hearing, fullness or clogged sensation in the ear, ringing.
  • This includes testing a patient’s ROM, strength, sensation, balance, eye/head coordination.Reminder: how normal balance occurs.Vestibular: both sides need to be telling the brain the same thing, otherwise a mismatch signal is perceived by the brain, giving the perception of dizzinessVision: a reflex between the vestibular system and the eye muscles coordinate head motion and visual focus. This is why when we run, the world around us is not jumping all around.Sensation: what we feel in our feet, skin, muscles and joints all give our brains information about where we are in space.
  • Knowing which systems are intact and functioning well, as well as identifying systems that are impaired help direct the treatment.For instance, someone who has vague complaints of dizziness when going from sit to stand and has low blood pressure may have nothing wrong with their vestibular system. They may be better served by monitoring their BP and adjusting their medication as per their physicians’ instructions.Another example of fully understanding the patient’s health is identifying any sensory loss, common in diabetics or other reasons for peripheral neuropathy.
  • Understanding the anatomy of the vestibular system helps makes sense of why this occurs and why the treatment works.Crystals (otoconia) that are a normal part of the vestibular system’s anatomy, detach and can migrate into one of the 3 semicircular canalsMost common: posterior canal
  • This diagram demonstrates how certain head positions that stimulate the canal with crystals in it can provoke vertigo symptoms
  • Symptoms typically last from 5-30 seconds, although it seems like an eternity while its happening!In rare cases it can last for longer than 60 seconds and is treated differently than the short lasting variety of BPPV.
  • If there are crystals in the canals, this will provoke that spinning sensation.
  • The treatment starts with the same position as the testing procedure. To further relocate the crystals back to their proper home, the patient is taken through a series of head positions, using gravity and knowledge of anatomy to guides the crystals back to the vestibule. Each position is typically held for 30 seconds and may provoke spinning sensation. The maneuver is repeated 2-3 more times and usually results in less symptoms or they can be completely gone.
  • After a patient undergoes the Epley maneuver, they are given a few simple instructions to follow, including the Brandt-Daroff exercises to relocate any residual crystals remaining in the canals.This self treatment technique mimics the head position and is similar to the Epley maneuver. Each position is held for 30 seconds or until the dizziness stops. Once you can do these position changes for 2 days in a row without symptoms, you can stop.This is a treatment technique I use for those patients with neck and back issues or general mobility problems.
  • What seems to help is gaining an understanding of the problem and learning how to manage it. It is probably the most frightening when it first occurs b/c you have no idea why this is happening. Once you recognize the symptoms and learn how it can be treated, most people can go on and live their normal life.
  • This vestibular disorders arises not from crystals in the wrong location, but from an unequal signal from right and left vestibular systems to the brain. Recall that normal balance occurs from the right and left vestibular systems “saying the same thing” to the brain.
  • Sometimes the normal aging process can also lead to a vestibular hypofunction.
  • Patients with a vestibular hypofunction almost always report symptoms of foggy headedness, “not feeling right” in their head, headache, and difficulty focusing, “off balance”.
  • This is where its so important to listen to the patient! People with a vestibular hypofunction will tell me they can’t tolerate visually busy environments like supermarkets, Target, train stations, airports.They may have difficulty focusing on visual tasks at work, particularly computer work, columns of text to scroll through.They may have difficulty driving, either from quickly turning their head for lane changes, or are bothered by the peripheral visual busyness of the highway.Firm vs foam, EO vs EC demo on Dr. K. This test assesses how well the brain uses vestibular input for orientation when other sensory cues (vision and touch) are not available
  • Gaze stabilization ex: Start with simple visual targets and progressively more complicated tasks as symptoms allow.Exercises must be done regularly, but in small doses so symptoms do not become too elevated. It is normal, however, for patients to have a mild increase in their symptoms when first starting these exercises.Eventually , exercises should mimic real life situations that are bothersome to the patient, including work related tasks.
  • Remain active! Change positions frequently. Strengthen the important muscles of balance. Maintain good flexibilitySit to stand, turning and reaching activities, standing on variety of surfaces, EO vs EC.WalkingChair yogaTai chi
  • Introduce Gina Byrnes, LCSW with our Behavioral Health Department to speak about the anxiety related to Vestibular and Balance Disorders
  • Vestibular Rehabilitation

    1. 1. Vestibular Rehabilitation Presented by: Dina Leyden,PT January 30, 2014
    2. 2. Physical Therapy Evaluation In order to know which treatment to prescribe to the patient, the PT must perform a thorough evaluation to determine where the symptoms are coming from.
    3. 3. Vestibular Evaluation • General musculoskeletal exam • Sensation • Coordination • Blood pressure • Oculomotor • Balance
    4. 4. Dizziness is a symptom that can manifest from a vestibular disorder, but can also occur from • Cardiovascular • Neurological • Metabolic • Visual • Psychological disorders
    5. 5. Benign Paroxysmal Positional Vertigo • BPPV • Most common vestibular disorder • 2.4% of all people will experience it at some point in their lifetime • 50% of dizziness in people over age 50
    6. 6. When the head moves crystals shift sends a false message to brain spinning sensation
    7. 7. BPPV Symptoms • Spinning/Dizziness • Imbalance • Difficultly concentrating • Nausea Common head movements that cause symptoms include: • looking up • rolling over • getting out of bed.
    8. 8. Test for BPPV • Hallpike Dix or Roll Test • Observing for nystagmus and patient report of spinning • Guides therapist to know which canal is affected and, therefore, which treatment for repositioning to implement
    9. 9. Hallpike-Dix Test for BPPV
    10. 10. Treatment for BPPV • • • • CRT- canal repositioning treatment Most common – Epley manuever Post- treatment instructions Brandt-Daroff home exercises
    11. 11. Epley Manuever
    12. 12. Brandt- Daroff exercises
    13. 13. Can BPPV come back? Even with successful treatment, • 1/3 patients have symptoms recur after 1 year. • 50% recur after 5 years
    14. 14. Vestibular Hypofunction Occurs when one or both vestibular systems are not functioning at full capacity.
    15. 15. Vestibular Hypofunction • • • • • vestibular neuritis labyrinthitis Meniere’s disease Post surgical Post-concussive syndrome
    16. 16. When the vestibular system malfunctions unresolved sensory conflict dizziness,vertigo,dysequilibrium
    17. 17. Test for Vestibular Hypofunction • Oculomotor exam-coordination of eye and head movement. • Balance testing with eyes open and closed, firm/foam surface • Walking tests involving head movement
    18. 18. Treatment for Vestibular Hypofunction • Gaze stabilization exercises- to coordinate eye and head motion • Habituation exercises- to become more tolerant of movement • Standing balance activities • Walking, fitness and endurance when tolerated
    19. 19. Neck Pain and Stiffness • Common side effect since movement causes dizziness, therefore patients tend to avoid head movement. • PT for heat, soft tissue mobilization, joint mobilization, stretching, strengthening, postural re-education.
    20. 20. What Can I Do to Improve My Balance? •Standing balance exercises •Walking •Yoga •Tai chi
    21. 21. Summary • Thorough evaluation to determine where deficits are coming from • Choosing appropriate treatment method • Compliance with home exercise program • Support