Introduction To Vestibular

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Introduction To Vestibular

  1. 1. Introduction to Vestibular Rehabilitation <ul><ul><li>presented by </li></ul></ul><ul><ul><li>Tony Gregory </li></ul></ul><ul><ul><li>At </li></ul></ul><ul><ul><li>Regional Orthopedic Rehab. Committee, Edmonton </li></ul></ul><ul><ul><li>March 11,2009 </li></ul></ul>
  2. 2. Vestibular Rehab <ul><li>According to the National Institute of Health, 90 million Americans will complain of dizziness to their Physicians at least once in their lifetime! </li></ul>
  3. 3. Facts <ul><li>The cost of medical care for balance disorders is estimated to exceed $1 billion per year. Balance disorders increase with age. By age 75, balance is one of the most common reasons for seeking medical attention. </li></ul>
  4. 4. Diagnoses commonly treated <ul><li>BPPV (Benign Paroxysmal Positional Vertigo) </li></ul><ul><li>Double vision - Meniere's Disease </li></ul><ul><li>Balance Disorders - Medication Toxicity </li></ul><ul><li>Dizziness - Neurological Disorders </li></ul><ul><li>Stroke - Head Injury </li></ul>
  5. 5. Therapies offered include <ul><li>Physical Therapy </li></ul><ul><li>Occupational Therapy </li></ul><ul><li>Speech & Language Therapy </li></ul><ul><li>Balance/Vestibular Therapy </li></ul>
  6. 6. Benefits of a Vestibular Rehabilitation Program <ul><li>Improved walking </li></ul><ul><li>Improved control of movements </li></ul><ul><li>Decreased feelings of dizziness </li></ul><ul><li>Increased feeling of body control </li></ul><ul><li>Decreased difficulty navigating stairs </li></ul><ul><li>Walk in crowded areas with increased ease </li></ul><ul><li>Sit and stand with increased control and balance </li></ul>
  7. 7. Benign paroxysmal positional vertigo (BPPV)‏ <ul><li>In Benign Paroxysmal Positional Vertigo (BPPV) dizziness is due to debris collected within a part of the inner ear.  </li></ul><ul><li>These debris are called &quot; otoconia &quot;. </li></ul><ul><li>They are small crystals of calcium carbonate derived from a structure in the ear called the &quot;utricle“. </li></ul><ul><li>While the saccule also contains otoconia, but they do not to migrate into the canal system. </li></ul><ul><li>The utricle may have been damaged by head injury, infection, or other disorder of the inner ear, or may have degenerated because of advanced age. </li></ul><ul><li>Normally otoconia appear to have a slow turnover. They are probably dissolved naturally as well as actively reabsorbed by the &quot;dark cells&quot; of the labyrinth. </li></ul>
  8. 8. Incidence <ul><li>BPPV is a common cause of dizziness. </li></ul><ul><li>About 20% of all dizziness is due to BPPV. The older you are, the more likely it is that your dizziness is due to BPPV. </li></ul><ul><li>About 50% of all dizziness in older people is due to BPPV. In a recent study, 9% of a group of urban dwelling elders were found to have undiagnosed BPPV (Oghalai, J. S., et al., 2000). </li></ul>
  9. 9. Signs and Symptoms <ul><li>Dizziness </li></ul><ul><li>A sense that you or your surroundings are spinning or moving (vertigo) </li></ul><ul><li>Light headedness </li></ul><ul><li>Unsteadiness </li></ul><ul><li>Loss of balance </li></ul><ul><li>Blurred vision associated with the sensation of vertigo </li></ul><ul><li>Nausea and Vomiting </li></ul>
  10. 10. Causes <ul><li>The Semicircular Canals in the Vestibular Labyrinth of your inner ear contains fluid and fine hair-like sensors that monitor the rotation of your head. </li></ul><ul><li>Otolith organs monitor movements of your head and your head’s position. </li></ul>
  11. 11. <ul><li>Semicircular canals and otolith organs in your inner ear contain fluid and fine, hair-like sensors that help you keep your eye focused on a target when your head is in motion and assist in helping you maintain your balance. </li></ul><ul><li>Benign paroxysmal positional vertigo occurs most often in people age 60 and older. </li></ul><ul><li>It can also occur after a minor to severe blow to your head. </li></ul><ul><li>Less common causes of BPPV include disorders that damage your inner ear or, rarely, damage that occurs during ear surgery or during prolonged positioning on your back (supine). </li></ul>
  12. 12. Summary of causes <ul><ul><li>Primary or idiopathic (50%–70%) </li></ul></ul><ul><ul><li>Secondary (30%–50%) *Head trauma (7%–17%) *Viral labyrinthitis (15%) *Ménière's disease (5%) *Migraines (< 5%) *Inner ear surgery (< 1%) </li></ul></ul>
  13. 13. Tests and diagnosis <ul><li>Signs and symptoms of dizziness that are prompted by eye or head movements and then decrease in less than one minute. </li></ul><ul><li>Dizziness with specific eye movements that occur when you lie on your back with your head turned to one side and tipped slightly over the edge of the examination bed . </li></ul><ul><li>Involuntary movements of your eyes from side to side (nystagmus). </li></ul><ul><li>Your ability to control your eye movements </li></ul>
  14. 14. ENG Test <ul><li>ENG TEST (Electronystagmography ) has 4 parts : </li></ul><ul><li>*Calibration Test – evaluates rapid eye movements. </li></ul><ul><li>*Tracking Test- E valuates movement of the eyes as they follow a visual target. </li></ul><ul><li>* P ositional test measures dizziness associated with positions of the head. </li></ul><ul><li>* Caloric Test measures responses to warm and cold water circulated through a small, soft tube in the ear canal. </li></ul>
  15. 15. Others Tests <ul><li>Rotational Chair test </li></ul><ul><li>VEMP testing </li></ul><ul><li>ECOG testing </li></ul><ul><li>Fistula testing </li></ul><ul><li>Moving platform Posturography </li></ul><ul><li>MRI </li></ul>
  16. 16. Dix-Hallpike Manoeuvres <ul><li>The patient is seated and his head is turned 45 0 towards the ear to be tested. </li></ul><ul><li>The patient is quickly lowered to supine position with the head extending to about 30 0 below the Horizontal. </li></ul><ul><li>The head is held in this position and examiner observes for nystagmus. </li></ul><ul><li>To complete the Manoeuvre, the patient is returned back to seated position and is observed for reverse nystagmus. </li></ul>
  17. 17. Surgical Treatment <ul><li>BPPV is a benign disease and, therefore, surgery should only be reserved for the most intractable or multiply recurrent cases. Furthermore, before considering surgery, the posterior fossa should be imaged to rule out central lesions that might mimic BPPV </li></ul><ul><li>Singular neurectomy of the Posterior Ampullary Nerve. </li></ul><ul><li>Posterior semicircular canal occlusion. </li></ul>
  18. 18. Conservatory Treatment <ul><li>BPPV usually resolves on it own. If the symptoms persist beyond 2 months then the following Manoeuvres have proved to be effective in treating BPPV. </li></ul><ul><li>Epley Manoeuvre </li></ul><ul><li>Semont or Liberatory Manoeuvre </li></ul>
  19. 19. Epley Manoeuvre <ul><li>The patient is briskly brought to supine from sitting with head tilted 45 0 towards the symptomatic side. This position is maintained for 30 to 60 secs. </li></ul><ul><li>Turn the head to the opposite side and maintained for 30 to 60 secs. </li></ul><ul><li>The patient turned on to his side with his head tilted 45 0 (and his nose facing down). And maintained for 30 secs. </li></ul><ul><li>The patient is brought back to sitting for 15secs. </li></ul><ul><li>The whole procedure is repeated another 2 reps. </li></ul>
  20. 20. Semont (Liberatory) Manoeuvres <ul><li>The patient is rapidly moving from sitting to lying on one side to lying on other while the head is tilted 45 0 towards the symptomatic side. </li></ul><ul><li>This manoeuvre relies on inertia, so that the transition from position 2 to 3 must be made very quickly. </li></ul><ul><li>This is 90% effective after 4 sessions. </li></ul>
  21. 21. Instructions post treatment <ul><li>To wait for 15 minutes before going home. </li></ul><ul><li>To avoid driving home. </li></ul><ul><li>To lie down 45 0 reclined for the first 48 hours. </li></ul><ul><li>To avoid positions with excessive movements of the head for one week. </li></ul><ul><li>To avoid dental and hairdresser appointments. </li></ul><ul><li>To avoid laying on affected side for one week. </li></ul><ul><li>After one week to carefully challenge the position which had produced vertigo and note any changes. </li></ul>
  22. 22. Home Program <ul><li>Brandt-Daroff exercises. </li></ul><ul><li>* Sitting to lying with chin facing up. </li></ul><ul><li>* Back to sitting position. </li></ul><ul><li>* Lying to the other side with chin facing up. </li></ul><ul><li>* Each position is maintained for about 30 secs or until dizziness subsides. </li></ul><ul><li>* Should be performed for 2 weeks. </li></ul><ul><li>* 5 Repetitions for 3 times a day. </li></ul>
  23. 23. References <ul><li>Amin M, Giradi M, Neill M, Hughes LF, Konrad H. Effects of exercise on prevention of recurrence of BPPV symptoms. ARO abstracts, 1999, #774 </li></ul><ul><li>Brandt T, Steddin S, Daroff RB. Therapy for Benign Paroxysmal Positioning Vertigo revisited. Neurology 1994 May;44(5):796-800. </li></ul><ul><li>Korres S and others. Occurrence of semicircular canal involvement in Benign Paroxysmal Positional Vertigo. Otol Neurotol 23:926-932, 2002 </li></ul><ul><li>Smouha EE. Time course of recovery after Epley maneuvers for benign paroxysmal positional vertigo. Laryngoscope 1997 107(2) 187-91 </li></ul><ul><li>BPPV by Mayo Clinic Staff -Mayo Foundation for Medical Education and Research (MFMER) 2008. </li></ul><ul><li>Lim DJ (1984). The development and structure of otoconia. In: I Friedman, J Ballantyne (eds). Ultrastructural Atlas of the Inner Ear. London: Butterworth, pp 245-269. </li></ul>
  24. 24. Thank you

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