Vestibular Rehabilitation What s the Spin?

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1 Vestibular Rehabilitation What s the Spin? Carolyn Tassini, PT, DPT, NCS Vestibular Certified Rehabilitation Supervisor Bancroft NeuroRehab

2 Objectives Attendees demonstrate a basic understanding of the role of the vestibular system. Attendees will recognize basic signs of vestibular dysfunction. Attendees will be able to describe the role of rehabilitation for individuals with vestibular dysfunction.

3 Role of Vestibular System Gaze stability Postural control Motion detection Orientation in space

4 Symptoms of Dysfunction Dysequilibrium Dizziness with certain positions Motion sensitivity Nausea Unstable visual environment Gait ataxia

5 So Peripheral vs Central. PERIPHERAL VESTIBULAR SYSTEM Semicircular canals Otolith organs Utricle Sacccule Vestibular nerve CENTRAL VESTIBULAR SYSTEM Vestibular nuclei Vestibuloccular pathway Vestibulospinal pathway Vestibuloautonomic pathway Vestibulocerebral pathways Primary and secondary cortical areas Vestibuloccerebellum

6 Incidence Nearly 7 million physician visits per year in the US (Gans 2002, McDonnell 2015) Estimated 42% of the adult population report dizziness or vertigo to their physician (Watson 1992) Vestibular dysfunction is the cause in 85% of patients reporting these symptoms (Watson 1992) Incidence increases with age

7 Dizziness. A vague term often further described as a sensation of movement Important to clarify the complaint Vertigo: sensation of movement, spinning, twisting or turning Lightheadedness: sensation of floating or woozy Dysequilibrium: unbalanced, unsteady

8 Peripheral vestibular disorders Hypofunction Distorted signals Fluctuating function Central vestibular disorders Stroke TBI Tumors Demyelinating disease Other Cardiogenic Medication related Pathophysiology

9 BPPV Vestibular Pathologies Benign paroxysmal positional vertigo Free floating debris (otoconia) in the semicircular canal Semicircular canal system now sensitive to gravity Symptoms: positional dizziness

10 Vestibular Pathologies Vestibular neuritis Irritation of the vestibular nerve Often preceded by an infection Symptoms: Acute onset of vertigo (can be severe, usually worse with head movement) Horizontal nystagmus Nausea Oscillopsia Decreased balance

11 Vestibular Pathologies Labyrinthitis Infection of the labyrinth or inner ear Symptoms similar to vestibular neuritis but hearing often involved Tinnitus often present

12 Vestibular Pathologies Meniere s disease Endolymphatic hydrops Fluctuating and disabling disease May have some genetic factors associated Cause is unknown Rare Symptoms: Sensation of fullness in the ear Hearing loss, tinnitus Vertigo Nausea Postural imbalance Nystagmus

13 Vestibular Pathologies Bilateral Vestibular Loss May be a result of certain medications, meningitis, any disease with bilateral hypofunction, some types of chemotherapy No vertigo if both ears are affected equally Symptoms: Oscillopsia Poor balance especially in the dark or on compliant surfaces May complain of lightheadedness Gait ataxia

14 Vestibular Pathologies Central Vestibular Disorders Varied presentation and not clear cut Often oculomotor exam reveals impaired smooth pursuit and saccades May complain of double vision Pure vertical nystagmus is a red flag for central disorders

15 Non-Vestibular Pathologies Other issues which result in patients feeling dizzy without a vestibular pathology: Migraines Cervicogenic dizziness Peripheral neuropathy Orthostatic hypotension Vertebrobasilar insufficiency Anxiety Pharmacology

16 My head is spinning now what?

17 Vestibular Rehabilitation Decrease dysequilibrium Decrease oscillpsia Improve functional balance Improve ability to see clearly with head movement Improve overall conditioning Enable a return to life roles Reduce social isolation

18 Vestibular Rehabilitation Approaches Gaze stabilization Used to work to restore the VOR gain (Balaban 2012, Cullen 2009, McDonnell 2015) Aim to induce long term changes in the error response of the vestibular system Habituation Decrease symptoms by systematically provoking them Postural stability and balance retraining Repositioning maneuvers

19 General Rehabilitation Goals Unilateral vestibular hypofunction: Gaze stability Dynamic visual acuity (DVA) Postural stability Normal Romberg Normal gait Return to IADLs

20 Support for Vestibular Rehabilitation Unilateral peripheral vestibular dysfunction 2015 Cochrane Review by McDonnell Moderate to strong evidence that VR is safe and effective approach for unilateral peripheral vestibular disorders. VR more effective than control or sham interventions for improving subjective reports of dizziness and improving participation in life roles Support for VR to improve walking, balance, vision and ADLs No evidence that one form of VR is superior to another

21 Support for Vestibular Rehabilitation McDonnell 2015 Review con t Moderate evidence that gains can be maintained post treatment Post surgical- moderate evidence that VR is effective in improving function Moderate evidence for support of VR in patients with vestibular neuritis or acute unilateral vestibular dysfunction

22 General Rehabilitation Goals Bilateral Vestibular Hypofunction Gaze stability Improved DVA Rapid gaze shifts Postural stability/balance Improved Romberg Independent ambulation Return to IADLs Safety

23 Support for Vestibular Rehabilitation Bilateral vestibular dysfunction Individuals with BVH improved outcomes on DVA compared to controls (Herdman 2007) Age did not appear to be a factor in improvement Recovery of DVA occurred fairly rapidly (5 weeks of treatment) Krebs found that pts performing customized vestibular and balance exercises had better stability with walking and stair climbing than pts performing isometric and conditioning exercises (Krebs 1993) Using adaptation eye-head exercises, balance and gait Improvements in perception of dizziness and balance as well as outcome measure of gait and balance (Brown 2001) Still fall risk Not all exercise approaches appropriate, found habituation to not be successful (Telian 1991)

24 BPPV Treatment Canalith repositioning maneuvers Treatment technique varies depending: Canal involved Location of the debris

25 Support for Vestibular Rehabilitation BPPV Canalith repositioning maneuver (CRM) well tolerated and effective for the posterior SCC (Hilton 2010) CRM more effective than sham for treating posterior SCC canalithiasis (Helminski 2010) Liberatory maneuver vs sham Up to 86% improvement compared to 14% improvement in 2 recent studies (Mandala 2012, Chen 2012) Weaker evidence for the horizontal SCC however still find that roll treatment and Gufoni have higher remission rate than sham (Kim 2010) BPPV- Combining VR with repositioning maneuvers in people with BPPV improved functional recovery longer term (McDonnell 2015)

26 Who Can Benefit? Study by Herdman 2012 looked at factors impacting outcome for individuals with UVH Age not a factor Chronicity wasn t a factor Comorbidities didn t impact improvement Exception: Anxiety and/or depression Patterns: Poor subjective complaint at DC was associated with high anxiety Slower gait speed at DC associated with slower initial gait speed and older subjects Poorer fall risk scores were associated with subjects who were prior fallers

27 Non-Vestibular Dizziness Efficacy of Gaze Stability Exercises in Older Adults with Dizziness Hall et al RCT with placebo studied older adults with non-vestibular dizziness 6-week rehab course Control: placebo eye-exercises, balance and gait Gaze group: vestibular adaptation and substitution exercises to improve gaze stability, balance and gait Both groups improved in measures of dizziness, balance confidence, gait speed, fall risk and SOT 90% of gaze group improved reduction of fall risk compared to 50% of control group

28 Take Home Points Dizziness and vestibular disorders are very common and incidence increases with age Vestibular rehabilitation is effective for managing a variety of different vestibular deficits Vestibular rehabilitation a high chance of improvement and low risk of injury treatment Vestibular rehabilitation can make a positive impact on a patient s balance, perception of dizziness and thus an improved quality of life.

29 Resources Vestibular SIG for the Neurology section of the APTA Working on clinical practice guideline currently for peripheral vestibular hypofunction stay tuned! VEDA

30 Thank you!!

31 References Balban C, Offer M, Gottshall. op-down approach to vestibular compensation translational lessons from vestibular rehabilitation. -. Brown KE, Whitney SL, et al. Physical Therapy outcomes for individuals with bilateral vestibular loss. The Laryngoscope. Vol 111, issue 10, Oct 2001 Chen Y, Zhuang J, Zhang L, et al. Short-term efficacy of Semont maneuver for benign paroxysmal positional vertigo: a double-blind randomized trial. Otol Neurotol 2012; 33: Cullen, Minor, Beranec M, Sadeghi S. eural substrates underlying vestibular compensation contribution of peripheral versus central processing. ournal of Vestibular Research -. Gans RE. Vestibular rehabilitation Critical decision analysis. -. Hall CD, Heusel-Gillig L, Tusa RJ, Herdman SJ. Efficacy of gaze stability exercises in older adults with dizziness. J Neurol Phys Ther 2010; 34: Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther 2010; 90: Herdman SJ, Hall CD, Delaune W. Variables associated with outcome in patients with unilateral vestibular hypofunction. Neurorehabil Neural Repair 2012; 26: Herdman SJ, et al. Recovery of dynamic visual acuity in bilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg. 2007; 133(4):

32 References Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo (Review). The Cochrane Collaboration. John Wiley & Sons, Ltd; Kim JS, Oh SY, Lee SH, et al. Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo. Neurology 2010; 79: Krebs DE, et al. Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: Preliminary report. Otolaryngol Head Neck Surg. 1993; 109:735. Mandala M, Santoro GP, Asprella Libonati C, et al. Double-blind randomized trial on short-term efficacy of the Semont maneuver for the treatment of posterior canal benign paroxysmal positional vertigo. J Neurol 2012; 259: McDonnell M, illier S. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction review., ssue. Art. o. CD. DO..CD.pub. Telian SA, et al. Bilateral vestibular paresis: diagnosis and treatment. Otolaryngol Head Neck Surg. 1991: 104:67. Watson MA, Sinclair.. Portland, OR Vestibular Disorders Association.

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