Vestibular PT (guest lecture)

What is the vestibular system?

• 3 part system that controls balance, gaze stability, and spatial orientation

• Consists of:

  • 3 semicircular canals

  • Brain

  • Vestibulocochlear nerve (8th CN)

• Vestibular orans inside your inner ear sense head mvmts and send info to your brain

Sensory Reweighting Theory

• The reason PT can help vestibular systems

• Dec one system to make the other work hard (in relation to balance and spatial orientation)

• Involves affecting eyes, ears, and touch

What are the cardinal signs and symptoms of vestibular issues?

● Vertigo (spinning)

● Nystagmus (involuntary eye movement)

● Balance loss / veering while walking

• a. To weaker ear

• b. Fakuda test

● Motion sensitivity

● Nausea / vomiting

● Oscillopsia (blurring with head movement)

What does BPPV stand for?

Benign Paroxysmal Positional Vertigo

BPPV

Common vestibular disorder where tiny calcium crystals (otoconia) break loose from the utricle and move into one of the semicircular canals

• Causes abnormal fluid mvmt in the canal, sending false signals to the brain about head position

• Results in sudden, brief episodes of vertigo triggered by head position changes - causes nystagmus, nausea, and autonomic response

What causes BPPV?

Otolith displacement from utricle into a canal

• Often follows

  • Head trauma

  • Inner ear infection

  • Prolonged bed rest

  • Age-related degeneration

  • Can be idiopathic (unknown cause)

Otoconia

Calcium carbonate deposits, often called crystals

What is the dic-hallpike?

Used to diagnose posterior/anterior canal BPPV

What is the roll test used for?

Used to diagnose horizontal canal BPPV

How does posterior BPPV present and what can be done for it?

• Nystagmus: Rotational

• Maneuver: Epley

How does horizontal BPPV present and what can be done for it?

• Nystagmus: Horizontal

• Maneuver: Quick roll

How does anterior BPPV present and what can be done for it?

• Nystagmus: Vertical

• Maneuver: Deep head hang

What are contraindications for using dix-hallpike and the roll test?

New neuro deficits, severe headache, slurred speech, double vision, drop attacks, sudden hearing loss, continuous (non-fatiguing) vertigo.

What are precautions related to the cervical spine for using the Dix-Hallpike and roll test?

Recent neck trauma, cervical instability, severe vertebral artery insufficiency symptoms, severe osteoarthritis/RA, Chiari malformation—use modified Epley (less extension) or defer to PT/MD.

What are post-epley precautions?

• Postural restrictions

• Expect residual imbalance

• Start gaze stabilization and gradual activity within 48 hrs

• For at least 48 hrs:

  • no looking up

  • No quick head mvmts

  • Don’t sleep on affected side

Vestibular hypofunction

• Weak inner ear

• Most common after BPPV (can also be caused by BPPV)

Labyrinthitis

Inflammation of the inner ear

Vestibular neuritis

Inflammation of the auditory nerves - vestibular portion

Vestibular schwannoma

Acoustic neuroma (swelling of acoustic ear nerve tissue)

Meniere’s disease

• Too much fluid in the inner ear

• Person needs to dec sodium in take

What are Gaze Stabilization Exercises (GSE)?

● Purpose: Strengthen vestibulo-ocular reflex (VOR)

● How: Keep eyes fixed on target while moving head

● Examples:

• VOR x1 – Head moves, target stays still

• VOR x2 – Head moves opposite to moving target

● Dosage: 1–2 min per set, multiple times/day

● Progressions:

• Increase speed of head turns

• Narrow base of support, soft ground

• Add background distractions; optokinetics

What is VOR cancellation (VORc)?

● Purpose: Train brain to suppress VOR when head & visual field move together

● How:

1. Patient focuses on thumbs at arm’s length

2. Move head and target together in same direction

3. Keep image clear, no lag or double vision

● Used for: Reducing symptoms in visually busy environments (e.g., grocery stores)

Sensory Reweighting

● Purpose: Improve ability to switch between sensory systems for balance

● Approach: Manipulate sensory input so other systems compensate

● Examples:

○ Foam pad → reduces somatosensory input

○ Eyes closed → removes visual input

○ Eyes closed + foam pad → mostly all vestibular

○ Head turns during gait → challenges vestibular input

● Goal: Increase adaptability in different environments

What is the PTAs role in vestibular PT (specifically BPPV)?

• Assist with safe execution, patient education, Maneuvers, symptom monitoring, and communication with PT

• Also, screen for red flags, guard during maneuvers, and adapt for cervical/medical precautions