Dizziness and balance problems affect over 70% of people with multiple sclerosis. These issues are linked to reduced mobility and increased falls, and negatively impact quality of life. The vestibular system helps with gaze stability and postural control. In MS, vestibular deficits can cause impairments in these areas as well as dynamic balance and participation. Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo in MS and is treated with particle repositioning maneuvers. Vestibular rehabilitation aims to improve vestibular compensation through exercises targeting gaze stability, postural control, and motion tolerance.

1. David Herdman
DavidHerdmanPT
Vestibular and balance disorders in MS

2. Learning Objectives
To be able to understand and discuss:
• Basic role of the vestibular system
• Assessment and treatment of PC-BPPV
• Basic concepts of vestibular rehabilitation
• Evidence-base of VR for people with MS

3. Substantial burden of dizziness in MS
• Dizziness affects more than 70% of persons with multiple sclerosis
• Vertigo affects 7-30%
• Dizziness differentially impacts persons of lower socioeconomic status

4. Substantial burden of dizziness in MS
• Balance dysfunction is directly associated with limited mobility and increased falls in MS (Hoang
et al., 2014)
• Contributing to functional limitations, disability, and poor quality of life (Berrigan et al., 2016;
Marrie et al., 2013)
Harrison et al., 2015

5. Vestibular deficits in pwMS
• Compared to HC, PwMS
demonstrated significant
impairments in:
• Gaze stability
• Dynamic Balance
• Participation Measures
• Vestibular function was partly
correlated with balance (FGA)
The Anatomical Record, Volume: 301, Issue: 11, Pages: 1852-1860, First published: 05 May 2018, DOI: (10.1002/ar.23852)

6. Vestibular deficits in pwMS
• Positional vertigo (BPPV) is the most common cause of vertigo in patients with MS
• Many patients are treated with vestibular suppressants which do not have a role in the treatment
of BPPV and may actually contribute to gait instability and disequilibrium over time.
• Treatment response similar to people without CNS disorders

7. Vestibular System Function
What does it do?
• Linear and angular accelerometer
• Senses rotational movements of the head
• Senses linear movements of the head
What does it do with that information?
• Vestibulo-ocular = Gaze stability
• Vestibulo-spinal = Postural stability
• Vestibulo-cortical = orientation in space,
sense of self, spatial cognition and memory
• Vestibulo-autonomic = nausea, pallor,
anxiety

8. Multisensory control of balance

9. Vestibular System Dysfunction
Symptoms
• Oscillopsia
• Disequilibrium
• Abnormal sense of movement (vertigo)/ orientation (dizziness)
Signs
• Decreased visual acuity during head movements
• Ataxia
• Imbalance

10. 2 sides work together
Lorne S. Parnes et al. CMAJ
2003;169:681-693

11. Subjective Symptoms
History
• Dizziness:
• Acute, Episodic, Chronic, or Mixture
• Type (e.g. lightheaded, spinning, off balance etc)
• Frequency
• Duration
• Triggers
• Specific environments
• Position changes
• Activities
• Speed of movement
• Anxiety
• Other
• Activity level and tolerance/sport/employment
• Migraine/headache hx; Cervical/lower back hx;
Vision hx
• Sleep /psychological symptoms/cognition
Validated Questionnaires / Outcomes
• Dizziness Handicap Inventory (Jacobson &
Newman., 1990)
• Activities specific Balance Confidence Scale (Myers et
al., 1996)
• Dizziness and Balance Visual Analogue Scales
(Herdman et al., 2007)

12. BPPV: The Basics

13. Benign Paroxysmal Positional Vertigo
Short attacks of vertigo
< 1 minute
Provoked by certain head movements
Turning over in bed
Lying down
Tilting the head backwards
Spontaneous remissions after days to weeks
Recurrences in ~50%
‘Unsteadiness’, ‘difficulty walking’

14. Pathophysiology

15. Pathophysiology
• Utricle detects tilt and linear acceleration
• Calcium carbonate crystals held in place in the
utricle
• SCC detect angular accelerations
• Otoconia break free from macula of utricle
• Fall into SCC, change response to gravity

16. Assessment
The Dix-Hallpike manoeuvre
• 1 minute
• Only way to make definitive diagnosis
• Sensitivity dependent on experience of examiner (48-88%) and paroxysmal nature of condition
• Positive test is sufficient to diagnosis BPPV
• Negative test cannot rule out BPPV

17. Contraindications
• Neck vessel dissection is suspected
• Known cervical spine instability
There is no proven risk of harm from this assessment.

18. Diagnosis: Dix-Hallpike
• Turn head 45 degrees to the side you want to test
• Lie down, maintaining the rotation
• The head should be in 20-30 degrees extension
• Observe for AT LEAST 30 seconds. Look for
nystagmus and reproduction of symptoms
Furman & Cass, N Engl J Med 1999;341:1590-1596

19. When to make adjustments
Precautions…
Significant vascular disease
Cervical/spinal disorders (e.g. stenosis, severe kyphoscoliosis, Down’s syndrome, severe RA, Paget’s
disease, AS, spinal cord injuries)
Morbid obesity
Consider
Additional assistance
Tilting bed/examination table
Side-lying manoeuvres

20. Particle repositioning manoeuvres: Epley (right)
Lorne S. Parnes et al. CMAJ
2003;169:681-693
©2003 by Canadian Medical Association

21. Liberatory manoeuvre (Semont)
Lorne S. Parnes et al. CMAJ
2003;169:681-693
©2003 by Canadian Medical Association

22. Central Positional Nystagmus
Macdonald NK, Kaski D, Saman Y, Al-Shaikh Sulaiman A, Anwer A and Bamiou
D-E (2017) Central Positional Nystagmus: A Systematic Literature
Review. Front. Neurol. 8:141. doi: 10.3389/fneur.2017.00141

23. Central Positional Nystagmus
• No latency
• Persists for as long as the precipitating head
position is maintained
• Not attributable to the stimulated canal plane
• Prominent nausea or vomiting on positioning
(or asymptomatic!)
• Does not resolve with repeated repositioning
manoeuvres

24. Useful app (I have no conflict of interest)

25. FAQs
Should we obtain radiographic imaging in a patient who meets criteria for BPPV? No
Should we obtain vestibular testing? No, as long as they don’t exhibit additional vestibular
symptoms/signs inconsistent with BPPV
Can we just wait and see? Delays in the diagnosis and treatment of BPPV have cost and quality-of-life
implications for patients and their caregivers!
Postprocedural restrictions? Do not recommend postural restrictions after treatment
Should we offer medication? Clinicians should not routinely treat BPPV with vestibular suppressant
medications (e.g. prochlorperazine, betahistine, cinnarizine)

26. FAQs
When should you offer follow up? Should reassess within 1 month after initial observation or treatment.
Can reassess after 5 mins.
When to refer on? Patients with persistent signs/symptoms after >3 attempts should be referred to
clinic that can evaluate for underlying peripheral vestibular or CNS disorder. Or patients with
atypical nystagmus/signs
What should we tell patients with BPPV? Should educate patients regarding the impact of BPPV on
safety, potential for recurrence, and the importance of follow up

27. Vestibular Rehabilitation

28. Vestibular rehabilitation
• Gold standard for patients with vestibular dysfunction
• Purpose: To facilitate the ability of the central nervous system to compensate for vestibular
deficits
Lacour et al, 2016

29. Mechanisms of recovery
Habituation
• Long-term reduction of a response to a
noxious stimulus (specific movement),
brought about by repeated exposure to the
provocative stimulus
Adaptation
• Capability of the vestibular system to make
long term (plastic) changes in the neuronal
response to head movement
Substitution
• The substitution of alternative strategies to
replace the lost or compromised function

30. Identification of Problems
Is there a vestibular deficit or dysfunction?
• Vestibular hypofunction
• Head thrust test
• Dynamic visual acuity (DVA)
Abnormal vestibular function
• Episodic symptoms
• Positional vertigo

31. Identification of Problems
• Not all causes of dizziness are due to vestibular dysfunction
• Not all causes of dizziness are treatable with exercises
• Exercises are beneficial in patient’s with stable vestibular function, and
• When symptoms are provoked by movements, positions, or environmental situations
• Treatment is symptom driven – rather than determined by diagnosis
• Therapist identifies problems
A. Gaze stabilisation
B. Postural instability
C. Motion provoked dizziness
D. Environmental triggers

32. A. Gaze Stabilisation
Functional complaints
• Dizziness with head motion
• Poor visual acuity with head motions (DVA)
• Movement of visual world with head motion

33. A. Gaze Stabilisation
• Based on the principles of VOR adaptation
• Best stimulus to induce adaptation is one that
produces an error signal
• Adaptation takes time
• VOR is context specific
• Exercises will provoke symptoms
Retinal slip =
error signal
Increase in the
gain of the
vestibular system
Improvements in
gaze stability and
function

34. A. Gaze Stabilisation
• VOR X 1, VOR X 2; horizonal and vertical
Treatment variables
1. Duration
2. Speed
3. Background distraction
4. Position
5. Distance
6. Target size
7. Frequency

35. A. Gaze Stabilisation
Treatment considerations
• Image must be stable
• Symptoms should not exceed 20-30 minutes following HEP
• All patients will not progress through all stages (i.e. X2 viewing due to cognitive / coordination
deficits)
• Academy of Neurologic Physical Therapy recommendations
• 12 minutes daily for acute vestibular dysfunction and,
• 20 minutes daily for chronic vestibular dysfunction (Hall et al., 2016)

36. B. Postural instability
Functional complaints
• Disequilibrium with head motions
• High risks of falling with head movements
• Loss of balance while walking
• Difficulty negotiating uneven terrain
• Difficulty walking in the dark
Outcome measures
• Modified Clinical Test of Sensory Integration
in Balance (mCTSIB)
• Functional Gait Assessment
• Dynamic Gait Index
• BESTest / miniBESTest
Horak, 2009

37. B. Postural instability
Treatment variables
1. Altering visual input
Eyes open / closed, sunglasses, busy
environments, head turns, ball tossing
2. Altering proprioceptive input
Foam, grass, gravel, balance board, balance
beam
3. Altering both
Stand/walk on foam or uneven surfaces with
eyes open/closed , while practicing head
movements or functional movements Proprioception
✓ ✓
Visual
✓ ✓
Vestibular
✓ ✓ ✓ ✓

38. B. Postural instability
Gait variables
1. Speed
2. Direction
3. Distance
4. Base of support
5. Head motion
• Speed
• Range
• Frequency
• Plane
6. Simple vs complex environments
7. Dual task
Treatment considerations
• Safety
• Cognition: plays a major role in performance
level
• Variables can be modified independently or
simultaneously to increase level of difficulty
• Target functional deficits and treatment
goals: be specific

39. B. Postural instability
Phys Med Rehabil Int. 2015; 2(4): 1044.

40. C. Motion provoked dizziness
Functional complaints
• Dizziness with movement/position changes
• Anxiety with motion
• Avoid particular movements
Based on principle of habituation
‘Reduction in the pathologic response to a
specific movement, brought about by repeated
exposure to the provocative stimulus’
• Formal Motion Sensitivity Testing and/or,
• Patient’s history / subjective examination

41. C. Motion provoked dizziness
Typically large amplitude, fast movements to
induce symptoms
• Head rotations
• Sit to side-lying to sit
• Rolling over in bed
• Sitting trunk flexion and extension
• Rapid, whole body rotation
Treatment considerations
• Intensity: moderately stimulating (not
severe)
• Up to 4 movements
• 3-5 repetitions in a given set
• Frequency: 1 -2 times daily
• Symptoms MUST return to baseline before
continuing, wait an extra 30 seconds
• After 2-3 weeks symptom duration and/or
intensity should diminish

42. D. Environmental triggers
Visual induced dizziness
Dizziness triggered by a complex, distorted, large field or
moving visual stimulus including the relative motion of the
visual surround associated with body movement (Bisdorff
et al., 2009)
• Inappropriate reliance on visual cues (Maire et al.,
2017)
Questionnaires
• Situational Characteristic Questionnaire (Pavlou et al.,
2006; Guerraz et al., 2001; Jacob et al., 1989)
• Visual Vertigo Analogue Scale (Dannenbaum &
Chilingaryan, 2011)

43. D. Environmental triggers
• Visual desensitisation based on theories of adaptation and habituation
• Optokinetic stimulation
Treatment considerations
• Progressive levels (beginner, intermediate, and advanced)
• Exercises must be structured:
• Fixation target
• Background lighting
• Duration
• Screen size
• Varying distances from screen
• Progression from sitting to standing/walking + head movements
• Patients with migraine CAN tolerate gradual, progressive exposure BUT
must begin with short duration (i.e. 15 seconds) and number of OKS
exercises
YouTube: Optokinetic Training by Gabrielle
Pierce

44. Evidence base of VR for PwMS

45. What's the evidence for PwMS?
• 6 weeks training programme
• Sig improvements in:
• Balance
• Dizziness Handicap
• Fatigue
• Quality of Life
• Participants improved regardless of whether
brainstem/cerebellar lesions were present

46. What’s the evidence for PwMS?

47. What’s the evidence for PwMS?

48. Studies to look out for…

49. Get creative…
…thank you!