In-service project for clinical affiliation with Hingham PT, Inc. (Januay 2014-April 2014) Review of vestibular system, common diagnosis and how to examine, evaluate and treat. I also reviewed and supplied the clinic with the Four Step Square Test and Dynamic Gait Index in order to allow them to implement these outcome assessments into their clinic for individuals with balance/vestibular deficits

1. Vestibular Rehabilitation
Amy E. Rosen, SDPT

2. “I am dizzy”
 Vestibular Disorders Association1
◦ Recognizes 19 different types of vestibular disorders
 “Dizziness” is one of the most common
complaints to physicians by persons over 65
years of age2
 Dizziness Definitions1,2
◦ Vertigo: illusion of movement, rotation and/or
spinning- either of the self or surrounding objects
◦ Disequilibrium: feeling of being unsteady, loss of
balance; often accompanied by spatial disorientation
◦ Presyncope: a feeling of
faintness, lightheadedness, or sense of falling;
sudden decrease in BP

3. Balance3
 “…a complex process involving the reception and
integration of sensory inputs and the planning and
execution of movement to achieve a goal requiring upright
posture”
◦ Ability to control the COG over BOS in a sensory environment
Choice of body
movement
Determination of
body position
Compare, select &
combine senses
Neck
Muscle
s
Trunk
Muscle
s
Thigh
Muscle
s
Ankle
Muscle
s
Somato-
sensatio
n
Vestibula
r System
Vision
Environmental
Interaction
Select & adjust muscle
contractile pattern
Generation of
body movement

4. Dizziness and Fall Risk
APTA Fact Sheet4
 Those with a vestibular dysfunction & self reported dizziness
were 12x more likely to fall (Yuri, 2010)
◦ Pt. with vestibular dysfunction alone was also shown to be at a
higher risk for falling
 Increased risk of fall & recurrent falls in those reporting
dizziness. (Tromp, 2001)
 Dizziness when standing correlates with falls & recurrent falls.
(Grassfmans, 1996)
 Pt. with bilateral vestibular dysfunction were shown to have
significant increase in falls compare to general population
(Herdman, 2000)
 Dizziness & vertigo were found to be the leading cause of falls
(Gananca, 2006)
◦ Indiivduals who fell due to dizziness/vertigo were more likely to
experience 2 or more falls
 Those with chronic dizziness were found to be at increased risk
of fall (Tinetti, 2000)
 Those reporting dizziness 2x more likely to fall (O’Loughlin, 1993)

5. ANATOMY REVIEW
Image:
greymattersjournal.com

6. Vestibular Labyrinth3
 3 Semi- circular canals
◦ Anterior, Posterior &
Lateral
◦ Angular Accelerations
◦ High Frequency
 2 Otolith Organs
◦ Utricle & Saccule
◦ Sensitive to gravity
◦ Linear Accelerations
◦ Low Frequency

7. Processing3
 CN 8: Vestibulocochlear Nerve
◦ Tonic firing
 Deflections toward kinocilium cause depolarization
 Deflections away from kinocilium cause hyperpolarization
 Central Processing
◦ CN8 projects information ipsilaterally to 4 Vestibular
nuclei in dorsal Pons & Medulla
◦ Vestibular nuclei send output to
 Cerebellum to coordinate movements & monitor
performance
 CN3,4,6: contralateral CN6 then projects to Medial
Longitudinal fasciculus (MLF) to contralateral Oculomotor
Nucleus
 Spinal Cord descending pathways to adjust limbs and trunk
to regain balance
 Reticular Formation to adjust circulation & breathing for new
body position
 Through the thalamus to Somatosensory Cortex for

8. Without you realizing…3
 Motor Output Reflexes
◦ Vestibulo-ocular Reflex (VOR)
 Allows for stable vision upon head movements
 Eye movements in opposite direction of head in
1:1 ratio
 CN3: Oculomotor, CN4: Trochlear, CN6:
Abducens
◦ Vestibulo-spinal Reflex (VSR)
 Stabilize the head and body
 Lateral & Medial Vestibulospinal Tracts
 Reticulospinal Tract
 Nystagmus
◦ Involuntary, rhythmic oscillation of the eyes
characterized by the direction of the fast
phase
◦ Can derive from physiologic, pathologic,
peripheral &/or central lesions
◦ Can cause reduced visual acuity and vertigo

9. Putting it all together
Image:
Reference 1

10. DISORDERS

11. General: Vestibular Disorders2,3
Peripheral Central
 Nystagmus generally
horizontal
 Vertigo as severe as
nystagmus
◦ Response typically fatigues
or habituates
 More intense feeling of
vertigo
 Hearing loss & tinnitus
frequent
 Long-tract sensory, motor
involvement are unusual
 Nystagmus can be
horizontal, rotatory or
vertical; multi-directional
 Vertigo relatively mild or
absent
◦ persistent
 Hearing loss & tinnitus
rare
 Associated sensory,
motor, cerebellar, & other
CN involvement more
common

12. BPPV1-3,5
 Between 17-42% of dizzy patients diagnosed with
vertigo
 Benign Paroxysmal Positional Vertigo
◦ Form of Positional Vertigo
 Spinning sensation produced by changes in head position
relative to gravity
 BPPV- characterized by repeated episodes of positional
vertigo
◦ Canalithiasis: otoconial debris become free floating in the
endolymph of SCC
◦ Cupulolithiasis: otoconial debris dislodged from otolithic
organs deposits upon cupula of SCC
 ~85% Posterior Canal & 10-15% Horizontal Canal
 Most common in 5-7th decades of life
◦ Degeneration of cilia during natural aging
 Characterized by: acute, discrete episodes of brief
positional vertigo without associated hearing loss

13. Differential Diagnosis of BPPV5
Peripheral Central
 Meniérès Disease
 Vestibular neuritis
 Labyrinthitis
 Superior Canal
dehiscence syndrome
 Post-traumatic vertigo
 Migraine-associated
dizziness
 Vertebrobasilar
insufficency
 Demyelinating diseases
 CNS lesions
Other: Anxiety or panic disorder, cericogenic vertigo, medication
side effects, and postural hypotension

14. Meniérès Disease1-3,5
 ~10% of Pt. presenting with vertigo
 Chronic disorder due to abnormalities in
quantity, composition &/or pressure of endolymph
◦ Mixing of endolymph & perilymph
 Characterized by attacks:
◦ Attacks can last 20min- 24hrs
◦ Attack frequency: few per week to years between
◦ Early Stage: spontaneous & disabling vertigo, fluctuating
hearing loss, ear fullness &/or tinnitus
◦ Between Attacks: fatigue, anxiety, LOB, headache, vision
difficulties, vomiting/nausea, neck pain, sound sensitivity
◦ Late Stage: hearing loss, tinnitus, constant struggle with
vision and balance
 Any age, most common 40-60yo
 Tx: medication, reduce- sodium diet, vestibular
rehab, surgery

15. Neuritis/Labyrinthitis1-3,5
 ~41% of Pt. presenting with vertigo
 Inflammation of inner ear caused by viral or
bacterial infection
◦ Vestibular hypofunction
◦ Unilateral or Bilateral
◦ Acute or chronic, lasting several wks.
 Neuritis: inflammation of the nerve affecting
vestibular ganglion
 Labyrinthitis: inflammation of the labyrinth affecting
both branches of CN8
 Sx: very sudden attacks of severe dizziness,
vertigo, nausea and imbalance lasting for hours or
even days.
◦ Labyrinthitis- tinnitus &/or hearing loss
 Secondary conditions:
◦ Neuritis: BPPV & Labyrinthlitis: Endolymphatic hydrops

16. Neuritis/Labyrinthitis1-3,5
Image:
http://www.lookfordiagnosis.com/mesh_info.php?term=Neuritis&lang=1

17. Migraine-Associated Vertigo (MAV)
1-3,5
 Migraine is one of the most debilitating chronic disorder in
US
◦ ~40% of Pts with migraines have a vestibular component
affecting balance &/or dizziness
 Characterized by migraine with:
◦ Episodic vestibular symptoms
 Dizziness, motion intolerance, spontaneous vertigo attacks,
diminished eye focus with photosensitivity, LOB and ataxia
◦ Sound sensitivity & tinnitus, cervioalgia with muscle spasms,
anxiety, confusion, spatial disorientation
◦ No other cause of vertigo
 Cause: combinations of vascular events, neuritis of
portion of vestibular nerve as result of migraine.
◦ Utricle is typically more affected
 Difficult to diagnosis
◦ Vestibular-evoked myogenic potentials (VEMP) testing
◦ Common to also have true BPPV

18. Cervicogenic Dizziness1-3,5
 A clinical syndrome of disequilibrium & disorientation
in patients with neck problem, ie. cervical trauma,
whiplash, cervical arthritis/denegerative, and others1
 Characterized by:
◦ Dizziness worse during head movements or after
maintaining one head position for prolonged time
◦ Dizziness after the neck pain
◦ May be accompanied by headache
◦ Dizziness can last minutes-hours
◦ Also complain of general imbalance, increasing with
head movements
 No diagnostic test to confirm
◦ Difficult to truly diagnose- rule out other conditions
 Dizziness typically improves with conservative
treatment of underlying neck issue.

19. CLINICAL EXAM

20. What to look for3,5,6
 Take thorough history of symptoms
◦ Frequency, Duration, Severity & Description of Sensation
◦ Current vestibular suppressant medications?
 Oculomotor Exam
◦ Test VOR
 BPPV testing
 Test for hearing loss
 Caloric Testing
 Assess static and dynamic balance
 Assess routine postural transitions
◦ Sit-supine, rolling, forward leaning, history
 Also assess for strength, ROM and functional
limitations

21. Oculomotor Exam3
 Gaze nystagmus
◦ Gaze at target 20-30° off midline for 20sec (R & L)
 Look for nystagmus or change in characteristics of gaze
 Smooth Pursuit
◦ Tracking H
 Look for saccadic substitution
 Saccades
◦ Jump gaze between 2 pts ~12in apart (Vertical & Horizontal)
 Look for speed, accuracy and conjugate EOM
 Alteration in oculomotor movements indicate central origin
of vestibular dysfunction7
◦ Electronystagmograph vs. MRI
 83.3% sensitivity & 21.2% specificity
 Severe alterations: 71.4% sensitivity & 50% specifity
 MAV: saccadic eye motion testing generally normal1

22. Testing VOR2,3
 Head Trust (Impulse) test
◦ Visual fixation on a target
◦ Rapid, passive rotation to one side
 Perform slowly first & ensure adequate Cspine ROM
◦ Look for loss of fixation with saccadic reacquisition
 Test function of ipsilateral ear to thrust
 Head Shaking test
◦ Seated, with head tilted 30°, head shake @20Hz for
20 seconds
◦ Look for nystagmus after head shake
 Peripheral Origin: fast phase of nystagmus toward
stronger/intact labyrinth
 Central Origin: prolonged nystagmus, dysconjugate
nystagmus, or vertical nystagmus after horizontal stimulus

23. Testing for Posterior BPPV3, 5
 Hallpike- Dix
◦ Head turned 45° to one side
◦ Quickly from seated position
to supine, head 20° below
horizontal
◦ Observe for latency,
direction & duration of
nystagmus
 Latency: 5-20sec
 Direction: mixed torsional &
vertical components with fast
phase (upper pole) toward
dependent ear
 Duration: should resolve
within 60seconds
◦ Sit up & repeat contralateral
ear, if necessary.

24. Testing for Horizontal BPPV3,5
 Pagnini-McClure Maneuver
◦ aka: Supine Roll Test
 Pt. supine with head in neutral
 Quickly rotate head 90° to one side
 Observe for nystagmus
 Head returned to neutral then quickly rotated 90° to other
side
 Observe for nystagmus
◦ In most cases, Geotropic nystagmus is produced
 Fast component toward the ground
 Less common Apogeotropic nystagmus is toward upper
ear
◦ Affected ear is thought to be the one to which the
side of rotation produced the more intense
nystagmus/vertigo

25. Exclusions for BPPV testing5
 Pt with physical limitations including:
◦ Cervical stenosis
◦ Serve kyphoscoliosis
◦ Limited cervical ROM
◦ Down syndrome
◦ Severe rheumatoid arthritis
◦ Cervical radiculopathies
◦ Paget’s disease
◦ Morbid obesity
◦ Ankylosing spondylitis
◦ Low back dysfunction
◦ Spinal cord injuries

26. Tests for hearing loss2,3
 Rinne Test
◦ Place vibrating tuning fork (512Hz) against Pt’s
mastoid bone, ask Pt to tell you when sound is no
longer heard
◦ Once sound is no longer heard, place still vibrating
tuning fork 1-2 cm from the auditory canal, ask Pt to
tell if they are able to hear tuning fork
 Normal Hearing: Air conduction should be greater than bone
conduction
 Weber Test
◦ Place tuning fork (256Hz) in the middle of the Pt’s
forehead, equidistant from each ear.
◦ Pt asked to report which ear the sound is heard
louder
 Normal Hearing: Equal in both

27. Caloric Testing2, 3, 8
 To evaluate integrity of unilateral vestibular apparatus.
◦ Determine unilateral vestibular hypofunction, ie neuritis/labrynthitis
 Performed irrigation to external auditory canal in supine
with head elevated 30°
◦ Cold & warm water for 30secs
◦ 5mins between each condition
 Normal: COWS
◦ Cold opposite, Warm same
 Cooling- increase, Warming- decrease in the specific gravity of the endolymph
 Measure time of onset of nystagmus from beginning
irrigation, duration & direction of each side under each
condition
◦ Approx. 20% different is considered significantly abnormal
◦ Ask Pt about sensation, intensity and any differences they experience
 80% accurate at diagnosing nerve damage as a cause of
vertigo
◦ Electronystagmograph
 Central origin dizziness/vertigo

28. Outcome Measures3
 Dynamic Gait Index9
◦ Time to Administer <10min
◦ Assess ability to modify
balance while walking in the
presence of external
demands
◦ Vestibular
disorders, geriatrics, PD, po
st-stroke, brain injury & MS
 ≤19/24 increased fall risk
◦ Pt. with vestibular disorders
scoring ≤19/24 are 2.58
times more likely to have a
fall in last 6 months
 Excellent test-retest
reliability (ICC= 0.86)
 Four Square Step Test10
◦ Time to Administer <5min
◦ Active stepping for
Functional Tasks
◦ Vestibular disorders,
geriatrics, PD, post-stroke
& transtibial amp.
 Increased Risk of Falls
◦ Vestibular: >12s
◦ Geriatric: >15s
◦ Acute Stroke: >15s
 Excellent test-retest
reliability (ICC= 0.93)

29. Helpful Tools for
Assessment3,5
 Frenzel Goggles
◦ Video or optical
◦ Enlarge (and record)
oculomotor function
◦ Help monitor performance
& oculomotor function
during testing (Nystagmus)
Gordon College: Center for Balance, Mobility, and Wellness
(Wenham, MA)
http://www.interacoustics.es/com_en/Pages/Product/BalanceSystems/_in
dex.htm?prodid=57249
 “Balance Master”
 Computerized Dynamic
Posturography
 6 conditions
 Pt. relative reliance
on
visual, vestibular, an
d somatosensory
inputs

30. INTERVENTION

31. Treating the “Dizzy”
Patient2,3,5,6
 Vestibular Rehabilitation
◦ Goals:
 to help retrain the ability of the body and brain to process balance
information1
 to allow free head movement without dizziness, especially during gait6
 Enhace gaze stability, postural stability, improve dizziness/vertigo &
activities of daily living
◦ Canalith repositioning exercises (CRP), postural control
exercises, fall prevention training, relaxation training, strength
conditioning exercises, functional skills retraining, education
and…
 Habituation
◦ Retrain brain to manage offending stimuli
◦ Conditioning
 Adaptation
◦ Active head movements to compensate for retinal slip
 Substitution
◦ Visual and somatosensory systems to compensation

32. Treating Posterior BPPV3,5
 Epley maneuver
 Pt in upright position with head turned 45° toward affected ear
 Rapidly laid back to supine head-hanging position, held 20-30sec
 Head turned 90° toward unaffected side, held 20sec
 Head turned further 90° (switch Pt to s/l facing floor), held 20-30sec
 Bring Pt to upright sitting position
◦ Most researched and most effective in short and long term treatment
◦ Canal switch occurs in 6-7% of those treated with CRP
 Semont’s maneuver
 Pt in upright position with head turned 45° away from affected ear
 Rapidly moved to s/l position, looking up at ceiling, held 30sec
 Rapidly move to opposite s/l position, looking at table, held 30s
 Bring Pt to upright sitting position
◦ Less researched than Epley maneuver and possibly less effective long
term
 Brandt- Daroff Exercises
◦ Overall less effective but good for HEP as Habituation Exercises
◦ Self-administered CRP appeared to be more effective, 64%
improvement, than self-treatment with Brandt-Daroff exercises, 23%
improvement . (Radtke, 1999)

33. Effectiveness of Posterior Canal
BPPV treated with Epley
Maneuver5

34. Treating Horizontal BPPV3,5
 Lempert Roll Maneuver
◦ ~75% effective in treating Lateral BPPV
 Begin supine, turn head slowly toward unaffected side
 Maintain each step for 15sec.
 Complete maneuver, Pt brought to upright with head bowed
30°
http://www.tinnitusjournal.com/detalhe_artigo.asp?id=

35. Therapeutic Intervention2,3,5,6
 Pt’s with BPPV
◦ Evaluate & Treat, if positive, prior to beginning other treatment
◦ Should be re-evaluated after 1month from initial CPR
◦ Discuss safety and possible reoccurrence
 Challenge the systems
◦ Reduce influence of dominant sensory systems, strengthen the weak
 Visual
 Somatosensory
 Vestibular
 Gaze stabilization
◦ Most common exercises for peripheral vestibular hypofunction
 Work at tolerable level of dizziness
◦ Increase in symptoms should last no longer than 20mins following
treatment
 Frequency & Duration of treatment are dependent on Pt. &
symptoms
◦ 2-3 times per week to 1 time every 2-3 weeks
◦ 1-2 weeks to several months

36. Activities3,6
 Get Creative & Consider Real-Life Function
◦ Gaze stabilization: active head and eye movements
 Adjust for distance, speed & frequency, plane of movement, BOS, posture, surface, etc.
◦ Static stance
 EC/EO, change surfaces, change BOS, vary combinations
◦ Walking
 head turns, change speed, change direction, change surface, change BOS, navigate
obstacles, etc.
◦ Manipulate BOS for functional activities
◦ Reaching out of BOS
◦ Vary surfaces
 Foam, Trampoline, Dyna Discs, balance boards, BOS
 Transfers from one surface to another- stepping stones
◦ Physioballs for sitting balance
 Add EC, add bouncing, add feet on foam
◦ Hurdles
◦ Cones
◦ Obstacle Course
Do Not forget general strengthening, stretching & conditioning for functional
activities.

37. Effectiveness of Vestibular
Rehab11
Systematic Review of 71 articles dated until 2006
 Strong evidence for vestibular rehab
◦ Vestibular hypofunction: Neuritis/Labyrinthitis
◦ Multisensory dizziness
◦ Meniérès Disease
 Moderately strong evidence
◦ After vestibular surgery
 Insufficient evidence
◦ BPPV
◦ PPV
◦ Neurological causes of dizziness
◦ Dizziness from whiplash-associated disorder
◦ Migraine- associated dizziness
STRONG EVIDENCE: VESTIBULAR REHAB FOR VESTIBULAR
DISORDERS

38. Practice Makes Perfect
 Oculomotor testing
 VOR testing
 BPPV testing
 Outcome Measures
◦ Dynamic Gait Index
◦ Four Square Step Test
 Instructional Exercises

39. Vestibular Rehabilitation
Gordon College: Center for Balance, Mobility & Wellness (Wenham,

40. References
1. Vestibular Disorders Association. Understanding Vestibular Disorders. Available at:
http://vestibular.org/understanding-vestibular-disorder/types-vestibular-disorders
2. Reeves AG, Swenson RS. Disorders of the Nervous System. Dartmouth Medical School. Chapter
6, 14. Copyright 2008. Available at: http://www.dartmouth.edu/~dons/.
3. Umphred DA, Lazaro RT, Roller ML, Burton GU. Umphred’s Neurological Rehabilitation, Sixth Ed.
Chapter 22. Elsevier, Inc. Copyright 2013.
4. Bloom M. Research Studies that Associate Dizziness and Falls: Fact Sheet. APTA, Section of
Neurology. Available at: http://www.neuropt.org/docs/vsig-physician-fact-sheets/research-studies-
that-associate-dizziness-and-falls.pdf?sfvrsn=2
5. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo.
Otolaryngology-Head and Neck Surgery 2008; 139, S47-S81
6. Hoffer M, Balaban C, Whitney S, Sparto P. Principles of vestibular physical therapy rehabilitation.
Neurorehabilitation [serial online]. July 2011;29(2):157-166. Available from: CINAHL Complete,
7. Tirelli G, Rigo S, Bullo F, Meneguzzi C, Gregori D, Gatto A. Saccades and smooth pursuit eye
movements in central vertigo. Acta Otorhinolaryngologica Italica: Organo Ufficiale Della Società
Italiana Di Otorinolaringologia E Chirurgia Cervico-Facciale [serial online]. April 2011;31(2):96-102.
Available from: MEDLINE
8. MedlinePlus. Caloric Stimulation. Last modified: 2/26/14. Available at:
www.nlm.nih.gov/medlineplus/ency/article/003429.htm
9. Rehabilitation Measures Database. Rehab Measures: Dynamic Gait Index. Last modified 1/30/14.
Available at: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=898
10. Rehabilitation Measures Database. Rehab Measures: Four Step Square Test. Last modified:
1/31/14. Available at:
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=900
11. Hansson EE. Vestibular rehabilitation-For whom and how? A systematic review. Advances in
Physiotherapy. 2007; 9: 106-116