vestibular rehabilitation presentation

1. VESTIBULAR
REHABILITATION IN
ELDERLY WITH BENIGN
PAROXYSMAL
POSITIONAL VERTIGO
(BPPV) OF CHRONIC
DECOMPENSATED
PERIPHERAL VESTIBULAR
DYSFUNCTION
D.REBILA



2. INTRODUCTION
 Dizziness and imbalance are amongst the most common complaints in older people, and are a
growing public health concern since they put older at a higher risk of accidental fall and consequent
injuries.
 In the vestibular system aging is associated with degeneration of the otoconia and haircells, loss of
vestibular afferents and declining numbers of cells in the vestibular nuclei.
 The terms dizziness and vertigo cover a variety of symptoms regarding disorders of spatial
orientation and motion perception such as the illusion of rotatory motion (or) the feeling of
unsteadiness, which can affect the ability to achieve a stable gaze, postural and gait.
 In addition, falls are the leading causes of accidental death in persons older than 65 years while
dizziness in one of the strongest.
 Although the causes of dizziness in older people are multifactorial, peripheral vestibular
dysfunction.
 The three most common peripheral vestibular dysfunction are BPPV, Vestibular Neuritis and
Meniere's.

3.  BPPV is found to be at higher rates as compared with that of the other two
conditions among the elderly.
PREVALENCE
 NATIONAL HEALTH INTERVIEW SURVEY CONDUCTED in 2008 in the USA , in
which 7.9% of people among 7 million were found with loose otoliths, which probably
indicates a diagnosis of BPPV.
 The 1 year prevalence of BPPV in patients older than 60 years rises abruptly with
age, being almost seven times higher in comparison with that of patients 18-39 year
old.
 It affects mostly women, at a ratio of 1.67 to male subject.
 A prospective case control study conducted in general practices in which
general physical examinations were performed reported 18% of patients with
dizziness who over 60 years old had peripheral vestibular disorders.
 A population based study in the united states reported that 24% of the people older
than 72 years have dizziness and another study reported that 30% of the people
older than 65 years have dizziness.

4. ETIOLOGY
 Idiopathic BPPV
 Most common cause in the elderly is degeneration of the vestibular system of
the inner ear 'wear and tear' involving the otoliths.
 Stress can also be factor in triggering this condition which may set off
changes in the otolithic membrane.
 Displacement of calcium carbonate crystals (or) otoconia within the fluid filled
semicircular canals of the inner ear.
 BPPV may also develop after long periods of inactivity.
 Prolonged lying may facilitate the deposition of otoconia on the cupula (or)
contribute to their loosening from the utricle.
 Endolymphatic hydrops.

5. VESTIBULAR
REHABILITATIO
N
 IT is defined as an
exercise based program
,designed by a specialty
trained vestibular
physical therapist to
improve balance and
reduce problems related
to dizziness.
Evidence has shown that
vestibular rehabilitation
can be effective in
improving symptoms related
to many vestibular [inner
ear/balance.
This Photo by Unknown author is licensed under CC BY-SA-NC.

6. NEED FOR STUDY
Benign Paroxysmal Positional Vertigo of chronic
vestibular dysfunction is a frustrating problem in
the elderly and can have a tremendous impact
on their life. So, there is a need for the study to
decrease the dizziness and vertigo in elderly
patients and to improve the quality of life.

7. AIMS OF
THE
STUDY
 To assess the effectiveness of
vestibular rehabilitation based
on Cawthorne and Cooksey
protocol exercises for dizziness
and imbalance in elderly people
who are affected with Benign
Paroxysmal Positional Vertigo
[BPPV] of chronic
decompensated peripheral
vestibular dysfunction.

8. OBJECTIVE
OF THE
STUDY
 To improve the balance
,to decrease the severity of
dizziness induced disability and
to improve the quality of life.

9. HYPOTHESIS
NULL HYPOTHESIS
There is no significant result in the vestibular
rehabilitation for Benign paroxysmal positional vertigo
(BPPV) of chronic decompensated peripheral vestibular
dysfunction in elderly based on Cawthorne and Cooksey
protocol exercise.
ALTERNATE HYPOTHESIS
There is significant result in the vestibular rehabilitation
for Benign paroxysmal positional vertigo (BPPV)of
chronic decompensated peripheral vestibular dysfunction
in elderly based on Cawthorne and Cooksey protocol
exercise.

10. METHODOLOGY
 STUDY DESIGN : It is an quasi
experimental study to determine the effect
of vestibular rehabilitation with Cawthorne
and Cooksey protocol exercises
in elderly patient with Benign paroxysmal
positional vertigo [BPPV].
 SAMPLING METHOD :Convenience
sampling
 SAMPLE SIZE : ten elderly patients
 DURATION OF STUDY : 2 months

11. CRITERIA
INCLUSION CRITERIA
 ELDERLY WITH AGE < 60 YEARS OLD
 PATIENTS WITH BENING PAROXYMAL POSITIONAL
VERTIGO(BPPV) OF CHRONIC DECOMPENSATED PERIPHERAL
VESTIBULAR DISORDER.
 BOTH GENDERS
 CHRONIC CASE SUFFERING FOR MORE THAN 4 MONTHS .
.

12. EXCLUSION
 Patients with cervical problems.
Visual problems.
 Orthopaedic
 Neurologic disorders
 Patients having fluctuating and intermittent vertigo.
 Duration of symptoms less than four months.
 Patients with bilateral decompensated vestibular disorder
were excluded from the study.

13. EXCLUSION
 Acute [or] chronic vestibular central disorders
 Central eye movement disorders [including cerebral infarction,
cerebral haemorrhage, and multiple sclerosis].
 Psychiatric disorders history [or] currently receiving
psychological therapies.
 Blood pressure [high and low]
 Patients with acute neck injuries.
 Minieres disease
 Vestibular neuritis
 Acoustic neuroma

14. ASSESSMENT
TOOLS
VESTIBULAR REHABILITATION

15. SPECIAL
TESTS
DIX HALLPIKE TEST [GOLD
STANDARD TEST FOR BPPV]
 The patient is moved from a
long sitting position with
the head rotated 45 degree
to one side, to supine
position with the head
extended 30 degree beyond
horizontal head still rotated
45 degree.

16. SUPINE ROLL TEST [PAGNINI-
MACCLURE MANEUVER]
The patient lies supine with the head up facing in a
central position.
Quickly rotate the patients head and body 90 degree to
one side so that the ear faces downward towards the
bed.
Observe the patients eyes for nystagmus when the
nystagmus reduces [or] if there are no symptoms,
return the head to the face up position
Turn 90 degrees to the side and observe again for the
presence of nystagmus.

17. DEFERENTIAL
DIAGNOSIS
 HEAD THRUST TEST
 The head thrust test , which is based on
the dolls eye phenomenon, is used to
evaluate the vestibular ocular reflex [VOR]
in the horizontal.
 To demonstrate the VOR, the patient
moves his [or] her head from side to side
while focusing on the midline target .
 This causes the eyes to move in a velocity
like that of the head movement but in the
opposite direction
 In a patient with a loss vestibular
function,VOR will not move the eyes as
quickly as the head rotation and the eyes
moves off the target.
 The patient will then make a correction
saccade reposition the eyes on the target.

18. ROMBERG TEST FOR BALANCE
 The romberg sign demonstrates loss of
postural control in the absence of visual input
suggestive of proprioceptive deficit in the
lower limbs as a result of severly
compromised proprioception.
 The patient is asked to stand with feet
together and arm by side with eyes first
opened and then closed.
 Patient may sway to the affected side.

19. GAIT
TEST
 An individuals gait is defined as his [or]her
method of walking.
 The patient is asked to walk along a straight
kine to a fixed point, first with eyes opened and
then eyes closed.
 Patient deviates to the affected side.

20. DIZZINESS
HANDICAP
INVENTORY
SCORING

21. BERG BALANCE
SCALE

22. VESTIBULA
R REHABILITATION

23. CAWTHORNE
AND
COOKSEY
EXERCISE
PROTOCOLS
 IN BED [OR] SITTING
 SITTING
 STANDING
 MOVING ABOUT [IN CLASS]

24. IN BED
[OR]SITTING
 EYE MOVEMENTS
1] UP AND DOWN [slowly at first then rapidly for 20
times]
2]FROM SIDE TO SIDE
3]FOCUSING ON FINGER MOVING FROM 3
FEET TO 1 FEET AWAY FROM FACE [repeat it for 20
times]
 HEAD MOVEMENTS AT FIRST SLOW THEN
QUICK LATER WITH EYES CLOSE
1] BENDING FORWARD AND BACKWARD
2] TURING FROM SIDE TO SIDE

25. EYE MOVEMENTS
 LOOKING UP AND DOWN AND LOOKING LEFT AND RIGHT
GAZE

26. EYE MOVEMENTS
 STRETCH ONE ARM
OUT STRAIGHT, HOLD
THUMB UP AND
FOCUS ON IT,
WHILE CONTINUING
TO FOCUS ON
THUMB, BRING IT IN
UNTIL ABOUT 30cm
FROM THE NOSE.

27. EXERCISE 2- in bed [or] sitting.
BEND HEAD BACK AS FAR AS POSSIBLE, THEN FORWARD TO
TOUCH CHIN TO CHEST.
TURN HEAD FROM SIDE TO SIDE AS FAR AS POSSIBLE.

28. SITTING[ IN CLASS]
EYE MOVEMENTS AND HEAD
MOVEMENTS AS BEFORE DONE
SHOULDER SHRUGGING AND CIRCLING
[20 times]
BENDING FORWARD AND PICKING UP
OBJECTS FROM THE GROUND

29. Shoulder shrugging and circling

31. STANDING [IN CLASS]
 Eye head and shoulder movements as before .
 Changing from sitting to standing position
with eyes open and shut
 Throwing a small ball from hand to hand
[above eye level]
 Throwing a ball from hand to hand under knee
 Changing from sitting to standing and turning
around in between

34. MOVING
ABOUT [IN
CLASS]
 Circle around center person who will
throw a large ball and to whom it will
be returned
 Walk across room with eyes open and
then closed.
 Walk up and down slope with eyes
open and then closed.
 Walk up and down steps with eyes
open and then closed .
 Any game involving stooping and
stretching and aiming .

37. DURATION OF TREATMENT
 8 WEEKS [2 MONTHS]
 EXERCISES WERE ADMINISTERED
TWICE A WEEK FOR 2 MONTHS
 FOLLOWED BY AN ASSIMILATION OF
REPETITIONS AT HOME .
 TESTS WERE MADE AT
 PRE EXERCISE
 POST EXERCISE --2 WEEKS
 POST EXERCISE – 8WEEKS

38. DIZZINESS HANDICAP INVENTORY
Scoring for individual patients: These are pre- and post-VRT differences, pre-test (initial visit), post-test 2nd week (15
days after VRT), post-test 8th week (56 days after VRT).
Scoring for individual patients: These are pre- and post-VRT differences, pre-test (initial visit), post-test 2nd week (15
days after VRT), post-test 8th week (56 days after VRT).

39. Scoring is based on the subjects emotional, functional and physical:
recording done as pre-test ( initialvisit), post-test 2nd week (15 days after
VRT) and post-test 8th week (56 days after rehabilitation).

40. BERG BALANCE SCALE
Balance assessment inpatients were made before and after VRT exercises pre-test (initial visit), post-test (2nd week), and post-test
(8th week).
Balance assessment inpatients were made before and after VRT exercises pre-test (initial visit), post-test (2nd week), and post-test
(8th week).

41. CONCLUSION
 It was concluded that the vestibular rehabilitation program with Cawthorne and
Cooksey protocol exercise which was conducted among the elderly people
above the age group of 60 years who were affected by the Benign paroxysmal
positional vertigo [BPPV] of chronic decompensated peripheral vestibular
dysfunction were benefitted with the Cawthorne and Cooksey protocol
exercises and showed improvement in their balance ,decrease in the severity
of dizziness induced disability, decrease in nystagmus and there was
improvement in the quality of life in the affected individuals.
 The study showed that age and gender does not affect the recovery of the
patients.