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.

1. 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

3. 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

4. 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

5. 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

6. 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

7. What do patients complain of when
they have a vestibular impairment?
−
Dizziness
−
a combination of vertigo, lightheadedness, and
imbalance

8. What do patients complain of when
they have a vestibular impairment?
−
−
−
Vision
Hearing
Nausea

9. What do patients complain of when
they have a vestibular impairment?
−
−
−
Cognition
Balance, Coordination
Emotions

15. Central Connections
•
•
•
•
•
Vestibulo-ocular reflex
Vestibulo-spinal reflex
Vestibulo-collic reflex
Autonomic connections
Limbic connections

16. 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)

17. 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)

18. Peripheral Vertigo History and
Symptoms
Discomfort with watching
movement or patterns

Mild-Moderate Imbalance

(Herdman, 2007; Herdman & Clendaniel, 2007)

19. Peripheral Vertigo History and
Symptoms


Horizontal unidirectional gazeevoked nystagmus
http://www.youtube.com/wat
ch?v=YntJiBCz3pA
(Herdman, 2007; Herdman & Clendaniel, 2007)

20. Bilateral Vestibular Hypofunction
Not dizzy

Off balance

No balance in the dark

Oscillopsia (“things bounce
visually”)


21. 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

22. 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)

23. BPPV

Posterior canal: 95% of cases
(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)

24. 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)

25. BPPV is Designated by:
Canal
◦ Right or left
◦ Anterior (Superior)
◦ Posterior
◦ Horizontal
Otolith
Position
◦ Canalithiasis
◦ Cupulolithiasis

26. BPPV
Diagnosed
with Dix Hallpike maneuver

27. BPPV Nystagmus:
http://www.youtube.com/watch?
v=gyvSmTlGu2k

28. BPPV – Canalith Repositioning
Epley
Maneuver for Posterior Canal BPPV
canalithiasis

29. 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)

30. 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)

31. 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)

32. Vestibular Migraine
•
•
•
May be episodic
Or may “wax and wane”
Typically responds better to balance
and gentle habituation exercises
(Herdman, 2007; Herdman & Clendaniel, 2007)

33. 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)

34. 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)

35. Diagnostic Tests


Medical Tests: MRI, CT, cardiac
Audiology Tests:
−
−
−
−
−
−
Audiogram
VNG/ENG
Rotary Chair
Positional Testing including Dix Hallpike
VEMP
Computerized Dynamic Posturography (CDP)

36. 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)

38. 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)

39. Gaze-Evoked Nystagmus
http://www.youtube.com/watch?
v=mghGeKkNBzQ

40. Dynamic Visual Acuity and x1
http://www.youtube.com/watch?
v=8eWKMO7RNak

41. 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?

42. 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

43. Dix
Hallpike and Canalith Repositioning
Maneuver
PRACTICE!

44. American Academy of Neurology
BPPV Assessment and Treatment
(full video)
http://www.youtube.com/watch?v=hq-
IQWSrAtM

45. 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)

46. Habituation, continued
Exercises:
◦
◦
◦
◦
Head horizontal, vertical
Forward bend in straight plane, diagonal
Wall rolling, ball-to-wall
Add a functional task!

47. 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

48. 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)

49. 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

50. Evidence-Based Treatment
Techniques - summary




Canalith Repositioning (Epley) Maneuver
Vestibular Adaptation Exercise (x1)
Habituation Exercises
Static and Dynamic Balance Exercises

51. 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

52. 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

53. Case Study Examples



What is one thing you would like to
test?
If positive, what treatment would you
select?
What referrals might you make?

54. 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)

55. A Word about Non-Vestibular
Causes of Vertigo
Cardiac
Vertebrobasilar
insufficiency
Orthostatic hypotension
Low blood pressure
Low blood sugar
(Herdman, 2007; Herdman & Clendaniel, 2007)

56. 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)

57. A Word About Precautions
Neck
ROM, pain
Back pain
Fall Risk
Circulatory issues
◦ Vertebrobasilar Artery Compression
Autonomic
reactions
Nausea, vomiting
Seizures
Coexisting diagnoses

58. 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

59. 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).

60. 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)

61. Summary
Evidence-based
Occupation-based
Post-test
Course
Evaluation

62. http://www.youtube.com/watch?
v=rbwmfEXu75s
THANK-YOU FOR ATTENDING!

63. References


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
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