Unit 5 - Vestibular Examination

Vestibular System Function

• Subjective sensation of motion: linear and angular accelerometer

• Maintains body posture and balance

  • allowing us to stand, walk, and move with stability

• Spatial orientation of the head in space

  • Senses linear and rotational movements of the head

  • Stabilizes eyes with head movements: Gaze stability

• Spatial orientation of the body in space

Vestibular System Components

• Peripheral Sensory Apparatus: located in the labyrinth

• Central processor

• Motor output

Vestibular System Components

Peripheral Sensory Apparatus: located in the labyrinth

• Vestibule (sensory organ) and semi-circular canals

  • detect head movement and position

• Cranial nerve VIII (Vestibulo-cochlear nerve)

  • send sensory information

Vestibular System Components

Central processor

• Brainstem vestibular nuclei

• Cerebellar pathways

interpret the incoming sensory input and coordinate appropriate motor responses

Vestibular System Components

Motor output

• Vestibulo-ocular reflexes (VOR)

• Vestibulo-collic reflexes (VCR)

• Vestibulo-spinal reflexes (VSR)

highly integrated system essential for equilibrium, spatial orientation, and movement coordination

Vestibular System Components

Motor output —> Vestibulo-Ocular Reflex (VOR)

stabilizes vision during head movements

Vestibular System Components

Motor output —> Vestibulo-Collic Reflex (VCR)

stabilizes the head by activating the neck muscles

Vestibular System Components

Motor output —> Vestibulo-Spinal Reflex (VSR)

maintains the balance and upright posture by maintaining muscle tone in response to head movement

Vestibular System Components

Labyrinth

• Bony labyrinth and membranous labyrinth

• Perilymph circulates between the bony and membranous labyrinths (similar in composition to CSF)

• Endolymph circulates within the membranous labyrinth (similar in composition to intracellular fluid)

• Semi-circular canals: bony and membranous components

  • Three in each ear: Anterior (Superior), Posterior, and Horizontal

  • Canal are orthogonal (rt. angles) to each other

Vestibular System Components

• Sensory organs: Contained within the membranous labyrinth

• Three semicircular canals: Three in each ear

• Two otolith organs: Utricle and Saccule

Vestibular System Components

Horizontal SCC

approximately 30º from horizontal

Vestibular System Components

Anterior and Posterior SCCs

in vertical planes

Vestibular System Components

two horizontal SCCs

lie in the same plane 

Vestibular System Components

Left Anterior SCC and Right SCL

lie in the same plane 

Vestibular System Components

SCC: Contain ampulla

dilated space at the end of each canal before it connects to the Utricle

Vestibular System Components

Cupula

a gel like bud within the ampulla that is embedded with sensory hair cells

Vestibular System Components

Utricle and Saccule

• So called because they contain crystals of calcium carbonate

• These organs make up the medial portion of the vestibule

Vestibular System Components

Utricle

horizontal translation of the head and head tilt

Vestibular System Components

Saccule

vertical translation of the head

Vestibular System Components

Labyrinth

• part of the peripheral vestibular

• consists of two main parts-- the bony labyrinth and the membranous labyrinth, and the perilymph, which is similar in composition to the cerebrospinal fluid, which circulates between the bony and membranous labyrinth

• Inside the membranous labyrinth is the endolymph, a fluid that is more like intracellular fluid in composition

  • this unique ionic makeup is essential for generating electrical signals that travel to the brain

Vestibular System Components

Semicircular canals

• both the part of bony and membranous labyrinth, and each ear consists of three canals-- the anterior superior, the posterior, and the horizontal canals

• positioned approximately at right angles to each other, or orthogonal, allowing the detection of head movements in all three spatial planes

  • ensures that the vestibular system can accurately sense and respond to complex rotational movements of the head

Hair Cells

• Endolymph within the SCC and otolith organs contain specialized hair cells: Type I and Type II

• These hair cells have 50-100 stereocilia and a single taller kinocilium

  • highly sensitive to movement of the surrounding endolymph

• During head movements, deflection of the hair bundle toward the kinocilium causes increase in firing rate and deflection away from kinocilium causes decrease in firing rate

• This informs the brain about the direction of head movement

• SCCs respond to angular acceleration and the otoliths to linear acceleration

Co-planar Pairing

• When angular head motion occurs, the endolymph of the two sets of SCC is displaced in opposite directions resulting in increase in firing rate of one vestibular nerve and decrease in firing rate of the opposite vestibular nerve

• The SCCs are linked in functional pairs

  • Left and Right horizontal SCC

  • Right Anterior SCC and Left Posterior SCC

  • Left Anterior SCC and Right Posterior SCC

• Assist in compensation for sensory overload

• The push-pull mechanism ensures redundancy of sensory input

The SCCs are linked in functional pairs

• the horizontal canals

  • responsible for rotational movements, like shaking your head no

• the vertical canal pairs

  • the right anterior and the left posterior, and the left anterior and right posterior semicircular canals

  • work together to detect head movements in the pitch and roll planes, like nodding yes or tilting your head side to side

Push-pull mechanism

1. helps to compensate for sensory overload

   1. By having an excitatory and inhibitory signal, the brain receives a clear, unambiguous signal even during rapid head movements

2. ensures redundancy of sensory input

   1. If one side signal is slightly compromised, the opposing signal is still providing valuable information, contributing to the remarkable resilience and accuracy of our balanced systems

Vestibulocochlear nerve (CN VIII)

• carries the sensory information from the inner ear to the brain stem, helping you hear and maintain a sense of balance

• two parts: The superior portion innervates the anterior and horizontal SCC and the utricle; and the inferior portion innervates the posterior SCC and the saccule

Nerve and Blood Supply

• Labyrinthine artery is the main blood supply to the vestibular organs

• It arises from the anterior inferior cerebellar artery (AICA) which arises from the Basilar artery

• The labyrinthine artery splits into

  • anterior vestibular artery

    • supplies the anterior SCC, horizontal SCC, and the utricle

  • posterior vestibular artery

    • supplies the posterior SCC and the saccule

Central Processor 

Input

• Brainstem Vestibular nuclei

  • 4 pairs —> act as a central hub, integrating signals not just from the vestibular organs but also from the visual and proprioceptive systems

    • crucial for a complete picture of a body's position in space

• Cerebellum

  • fine-tunes movements, adapts responses, and learns from our experiences, ensuring that the balance reflexes are precise and appropriate for the task at hand

Central Processor

Output

• VOR

• VSR

• VCR

Vestibular Nuclei

Lateral/Deiter’s Nucleus

Helps maintain posture through the vesitbulospinal reflexes

• sends signals down to the spinal cord to control the muscles of the trunk and limbs

• This is how our body automatically adjusts to keep you from falling when you encounter uneven ground or experience unexpected movements

Vestibular Nuclei

Medial and Superior Nucleus

Coordinates eye, head and neck movements through the vestibulo-ocular reflex

• the midline of the vermis of the cerebellum

• maintain equilibrium during both static postures and dynamic movements

• cerebellar flocculus is a central key player in adaptive control of VOR

Vestibular Nuclei

Inferior Nucleus

Integrates information from the cerebellum and other sensory systems (no primary outflow of its own)

Cerebellum

Midline (Vermis)

regulate balance and eye movements

Cerebellum

Cerebellar flocculus

adjust and maintains the vestibulo-ocular reflex (VOR)

Cerebellum

• Lateral regions control muscles of the extremities

• fine tunes movements and plays a central role in modulating various reflexes

Vestibulo-Ocular Reflex (VOR)

Function

Generate equal and opposite eye movements in response to head movements in order to stabilize gaze during head movements

Vestibulo-Ocular Reflex (VOR)

• Extraocular muscles driven by the ocular motor nuclei

• Single pair of SCCs connected predominantly to single pair of extraocular muscles

• Types of movement: abduction/adduction, elevation/depression, torsion

Vestibulo-Ocular Reflex (VOR)

Abduction and adduction

for horizontal head turns

Vestibulo-Ocular Reflex (VOR)

Elevation and depression

for vertical head nods

Vestibulo-Ocular Reflex (VOR)

Torsion

for head tilt

Vestibulo-Ocular Reflex (VOR)

Connections

Labyrinth to Medial longitudinal fasciculus (MLF) and paramedian Pontine reticular formation connect to the  Abducens nucleus (CN VI), Trochlear nucleus (CN IV) and Oculomotor nucleus (CN III)

Vestibulo-Spinal Reflex (VSR)

• Connections to the anterior horn cells of the spinal cord

• Vestibular input used to stabilize head and body in space for movement and stabilization

• Maintains vertical alignment of the trunk

• When head side flexes on one side, there is an extensor response on that side and flexor response on the opposite side

Vestibulo-Collic Reflex (VCR)

• Activates neck muscles to stabilize head in space

• Compensated for displacements of the head with gait

Medical Screening

Dizziness

• During history ask questions that help differentiate between vestibular and non-vestibular related dizziness

• Ask them to describe their dizziness

• Does the room spin around? VERTIGO

• Do you feel unsteady? DISEQUILIBRIUM

• Do you feel LIGHTHEADED?

• Do you feel faint? PRE-SYNCOPE

• Alteration in thought? CONFUSION

Medical Screening

Categories of Dizziness

• Vertigo (45-54%)

• Disequilibrium (Up to 16%)

• Pre-syncope (Up to 14%)

• Light-headedness (10%)

Medical Screening

Categories of Dizziness —> Vertigo

False sense of motion, possibly spinning sensation

Medical Screening

Categories of Dizziness —> Disequilibrium

Off-balance or wobbly when walking or standing 

Medical Screening

Categories of Dizziness —> Pre-syncope

Feeling of losing consciousness or blacking out

Medical Screening

Categories of Dizziness —> Light-headedness

Vague symptoms, possible feeling disconnected with the environment

Medical Screening

Dizziness: Peripheral

• Sudden (Onset): Yes

• Positional: Yes 

• Intensity: Severe

• Nausea/Diaphoresis: Frequent

• Nystagmus: Torsional/horizontal

• Ear (hearing loss): Can be present

• Duration: Paroxysmal

• CNS signs: Absent

Medical Screening

Dizziness: Central

• Sudden (Onset): Slow, gradual

• Positional: No

• Intensity: Ill defined

• Nausea/Diaphoresis: Infrequent

• Nystagmus: Vertical

• Ear (hearing loss: Absent

• Duration: Constant

• CNS signs: Usually present

Medical Screening

Red Flags – Vestibular Screening

• Symptom presentation: dizziness, vertigo, imbalance and visual disturbances (oscillopsia)

• Differentiate between peripheral vs central vestibular pathologies

• Rule out non-vestibular causes of dizziness/imbalance

• Help plan out rehabilitation or medical intervention

• Screening:

  • History and intake

  • Physical examination

  • Assessment – vascular, cervical and CNS

Medical Screening

Red Flags – Vestibular Screening

5 Ds

• Diplopia: double vision

• Dysarthria: slurred or difficult speech

• Dysphagia: difficulty swallowing

• Dysmetria: Incoordination or difficulty with accuracy of movements

• Dizziness: severe, sudden onset or atypical presentation

• Others: numbness, weakness, severe headaches, loss of consciousness, new hearing loss/tinnitus

Medical Screening

Cervical Integrity Testing

• To rule out cervical spine instability, injury, or arterial dissection that could mimic vestibular symptoms

• Essential when there is a history of head/neck trauma

• Key testing:

  • Cervical ROM assessment

  • Palpation for tenderness and muscle spasm

  • Ligament stability tests

  • Neurologic screening: dermatomes, myotomes and reflexes

  • Signs of cervical instability: nystagmus, pupillary changes or ataxia with neck movements

Medical Screening

Vascular Integrity: Seated Vertebral Artery Testing

• To screen for potential compromise of the vertebral basilar artery system which supplies the brainstem and cerebellum

• Performed when patients have dizziness associated with neck movements

• Assessment:

  • Patient is seated and examiner stabilizes trunk. Patient actively rotates the head to one side and then extends neck maximally, holding for 10 seconds in each position

  • Positive sign is reproduction of dizziness, nystagmus, diplopia, blurred vision, dysarthria or loss of consciousness

  • Caution: this test has low sensitivity to rule out the disorder

Medical Screening

CNS Integrity: Ocular Motor Exam- Nystagmus

Peripheral Origin

• Nystagmus Direction

  • Primarily horizontal with a slight torsional component

• Gaze-evoked Nystagmus

  • Does not change direction with gaze, nystagmus intensity increases when looking in direction of fast component

• Removal of Visual Fixation

  • Increases

Medical Screening

CNS Integrity: Ocular Motor Exam- Nystagmus

Centrla Origin

• Nystagmus Direction

  • Typically pure horizontal, vertical, or torsional

• Gaze-evoked Nystagmus

  • Persistent and changes direction depending on direction of gaze

• Removal of Visual Fixation

  • Does not change or decreases

Medical Screening

CNS Integrity: Ocular Motor Exam

Oculomotor Tests: Smooth Pursuit

• Patient follows the examiner’s finger as the examiner moves the finger horizontally and vertically in a rhythmic manner

  • Test is performed with the target moving slowly (20 deg/sec) and at low frequency (<1 Hz)

  • Normal result is if the eyes track smoothly

  • Abnormal result when there are consistent saccadic intrusions with pursuit (saccadic or cogwheel) in either or both directions – suggestive of CNS disorder

Medical Screening

CNS Integrity: Ocular Motor Exam

Oculomotor Tests: VOR cancellation

• The examiner grasps the patient’s head and oscillates the patient’s head at 1Hz. The examiner moves with the patient so that the target (examiner’s nose) moves with the patient

  • This is a test of the central oculomotor pathways

  • Individuals (regardless of vestibular loss) should be able to maintain fixation on a point moving with them as they turn side to side

Medical Screening

CNS Integrity: Ocular Motor Exam

Oculomotor Tests: Saccade testing

• extremely fast and very accurate eye movements used to shift gaze from on point to the other

  • The patient is cued to switch their gaze between 2 targets, typically the examiner’s nose and finger. Repeat in horizontal and vertical directions

  • Saccades should be conjugate (both eyes moving together)

  • Accuracy: accurate, hypometric (short of target), hypermetric (overshooting), multiple saccades

  • Velocity: very fast

  • Lesions: cerebellum, brainstem, neuromuscular junction

Medical Screening

CNS Integrity: Ocular Motor Exam

Oculomotor Tests: Vergence

• The patient is cued to focus on the examiner’s fingertip, placed 24 inches in front of the bridge of the patient’s nose

  • Examiner’s finger is gradually brought in towards the bridge of the patient’s nose.

  • Patient is instructed to inform the examiner when the image doubles

Medical Screening

CNS Integrity: Ocular Motor Exam

VOR Testing: Slow head rotations

• Patient’s head is oscillated back and forth horizontally at approximately 2Hz

  • Normal vestibular function: no problem

  • Bilateral vestibular loss: Corrective saccades with head rotation in both directions

  • Acute unilateral vestibular loss: corrective saccades occurring with head rotation to the side of decreased function

Medical Screening

CNS Integrity: Ocular Motor Exam

VOR Testing: Head thrust test (HTT)

• Patient’s head is suddenly and rapidly rotated through a small range (15 – 30 degrees) then stopped

  • Patient is asked to maintain fixation on a visual target

  • Repeat on both sides: unpredictable in terms of timing and direction

• Normal: no problem with visual fixation

• BVL: corrective saccades with both sides head thrust

• UVL: corrective saccades with head rotation to the side of decreased function

Medical Screening

CNS Integrity: Ocular Motor Exam

VOR Testing: Dynamic Visual Acuity

• Patient reads the lowest line possible with the head stationary, and then they read the lowest line possible with head rotations side to side at 2Hz

  • Normal: 2 line or less difference between static and dynamic visual acuity

  • Abnormal: 3 line or greater difference suggests vestibular deficit

  • DVA will improve with central compensation

Medical Screening

CNS Integrity: Ocular Motor Exam

Head Shaking Nystagmus

• Performed with eyes closed. The patient’s head is oscillated horizontally for 20 cycles. Eyes are opened just prior to stopping the head shaking

  • Look for post head-shaking nystagmus

  • Unilateral Peripheral Vestibular Loss: Horizontal nystagmus with nystagmus beating to the more active side

  • Central Vestibular Disorder: Vertical nystagmus

Purpose of the Subjective Examination

• Establish rapport and gather detailed information

• Screen for red flags and non-vestibular causes of dizziness

• Identify patterns to support clinical reasoning

• Guide selection of objective tests and initial interventions

• Generate clinical hypotheses

• Determine goals and monitor progress

Current Patient Medical History: Tempo, Symptoms, Circumstances

• Onset: sudden, gradual?

• Duration: seconds, minutes, hours, days, constant?

• Frequency: single episode, intermittent, constant?

Current Patient Medical History: Description of Symptoms

• Vertigo: spinning sensation

• Dizziness: lightheadedness, unsteadiness, disequilibrium?

• Oscillopsia: bouncing vision?

Current Patient Medical History: Circumstances

• Provoking Factors: Specific head positions, rapid movements, environmental (busy stores)?

• Alleviating Factors: Rest, specific positions, medication?

• Associated Symptoms: Nausea, vomiting, headache, hearing loss, tinnitus, ear fullness, neurological symptoms (5 D's)?

Stable Symptoms

• Symptoms are consistent in nature and intensity

• Often associated with a fixed lesion or compensation process

• Predictable triggers, predictable duration

• Example: Chronic unsteadiness after initial acute phase of vestibular neuritis

Unstable Symptoms

• Symptoms are fluctuating in nature, intensity, or frequency

• Often suggests an active disease process or episodic disorder

• Unpredictable onset, variable duration

• Example: Meniere's disease, Vestibular Migraine

Management Categories Overview

BPPV

triggered by head position (rolling in bed, looking up); treat with repositioning maneuvers

Management Categories Overview

Adaptation

Stable unilateral vestibular hypofunction, for reduced VOR; treat with gaze stability exercises (VOR X1, VOR X2)

Management Categories Overview

Substitution

When adaptation is insufficient or with bilateral vestibular loss, rely on other sensory systems; treat with balance training, visual and head/eye strategies

Management Categories Overview

Habituation

symptom provocation by specific movements; reduce motion sensitivity

Management Categories Overview

Balance

disequilibrium and unsteadiness; address postural instability

Assessment of Dizziness

Visual Analog Scale (VAS) for Dizziness

• 0 (no dizziness) to 10 (worst imaginable dizziness)

• Used for current dizziness intensity or during a typical episode

• Provides a simple, quantifiable measure of subjective intensity

Assessment of Dizziness

Dizziness Handicap Inventory (DHI)

• 25-item self-report questionnaire

• Quantifies the perceived handicap imposed by dizziness in three domains: Functional, Emotional, and Physical

• Scoring: 0-100, where higher scores indicate greater perceived handicap

• Tracks progress and identifies areas of greatest patient concern

Pharmacological History

• Ask about:

  • Vestibular suppressants

  • Antiemetics

  • Ototoxic medications

  • Consider timing and dosage of medications

  • antihypertensives or sedatives can contribute to dizziness through effects like orthostatic hypotension or general sedatio

• Watch for masking of symptoms

Developing a Clinical Hypothesis

Acute

sudden onset, constant symptoms (e.g., vestibular neuritis, stroke)

Developing a Clinical Hypothesis

Chronic Constant

gradual onset, persistent symptoms (e.g., uncompensated, unilateral vestibular hypofunction or bilateral vestibular loss)

Developing a Clinical Hypothesis

Chronic Episodic 

recurrent episodes, intermittent attacks (e.g., BPPV, vestibular migraine, Meniere’s disease)

Benign Paroxysmal Positional Vertigo (BPPV)

• Caused by displaced otoconia (calcium carbonate crystals) from the utricle into one of the semicircular canals

• Most commonly affects the posterior canal

• Triggered by changes in head position relative to gravity

• Characterized by brief episodes of vertigo, usually lasting < 60 seconds

• No hearing loss or tinnitus

Benign Paroxysmal Positional Vertigo (BPPV)

Core mechanism

• tiny calcium carbonate crystals called otoconia, which normally reside in the utricle. For various reasons, these crystals can become dislodged and fall into one of the semicircular canals.

• When you then move your head in a specific position, these rogue crystals shift, causing the fluid within the canal to move abnormally, leading to that brief, intense spinning sensation

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike Test: Purpose and Procedure

• Patient’s head is turned 45˚ horizontally while the patient is in sitting position

• The patient then quickly lies down with head hanging over the edge of the treatment table approximately 30˚ below horizontal

• Observe in this position for at least 30-60 sec

• The patient is brought back to sitting

• Repeat the test on the other side

• This places the posterior canal on the downside ear in the plane of the pull of gravity. The debris adhering to the cupula, or free floating in the canal, will shift down, resulting in vertigo and nystagmus

  

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike Test: Interpretation

• Positive Test: Reproduction of vertigo and presence of characteristic nystagmus

  • Posterior Canal BPPV: Upbeating and torsional (rotary) nystagmus, beating towards the affected ear

  • Anterior Canal BPPV (Rare): Downbeating and torsional nystagmus, beating away from the affected ear

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike: Canalithiasis

most common, ~90-95% of cases

• Latency

  • Vertigo/nystagmus typically begins after a 2-10 second delay after positioning

• Duration

  • Symptoms last less than 60 seconds (usually 10-30 seconds)

• Fatigability

  • Vertigo/nystagmus decreases with repeated positioning

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike: Cupulolithiasis

5-10% of cases

• Latency

  • Vertigo/nystagmus begins immediately upon positioning

• Duration

  • Symptoms last longer than 60 seconds (can be very prolonged)

• Fatigability

  • Vertigo/nystagmus does not decrease with repeated positioning
    

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike Test

Nystagmus Features by Canal Affected: Posterior canal

Upbeating + torsional top pole beating toward downward ear

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike Test

Nystagmus Features by Canal Affected: Horizontal canal

Horizontal geotropic direction changing (right beating in head right position, left beating in head left position) or Horizontal apogeotropic direction changing (left beating in head right position, right beating in head left position)

Benign Paroxysmal Positional Vertigo (BPPV)

Dix-Hallpike Test

Nystagmus Features by Canal Affected: Anterior canal

Downbeating possibly with a slight torsional component

Benign Paroxysmal Positional Vertigo (BPPV)

Side Lying Test

• This test can be a substitute for the Dix-Hallpike test if the patient cannot extend the head or cannot lie on their back

• The patient sits on the side of the treatment table

• The head is turned 45˚ to one side and the patient quickly lies down on the opposite side

• This puts the posterior canal of the downside ear in the plane of the pull of gravity

• The debris adhering to the cupula or free-floating in the canal will shift down

• This results in vertigo and nystagmus

• Sit the patient up and test the opposite side

  

Benign Paroxysmal Positional Vertigo (BPPV)

Roll Test: Purpose and Procedure

• Patient lies supine with head elevated 20-30 degrees (Head elevation helps align the horizontal canal in the horizontal plane for optimal testing)

• Rapidly rotate head 90 degrees to one side, observing eyes for nystagmus and asking about vertigo. Hold for 30-60 seconds.

• Return head to center

• Rapidly rotate head 90 degrees to the opposite side, observing eyes for nystagmus and asking about vertigo. Hold for 30-60 seconds

  

Benign Paroxysmal Positional Vertigo (BPPV)

Roll Test: Interpretation

• Positive Test: Reproduction of vertigo and presence of characteristic nystagmus

  • Horizontal Canal BPPV: Purely horizontal nystagmus (no vertical or torsional component)

  • Geotropic Nystagmus: Beats towards the ground (Indicates canalithiasis on that side)

  • Apogeotropic Nystagmus: Beats away from the ground (Indicates cupulolithiasis on that side)

Benign Paroxysmal Positional Vertigo (BPPV)

Roll Test: Canalithiasis

most common

• Latency

  • Vertigo/nystagmus typically begins after a 2-10 second delay after positioning

• Duration

  • Symptoms last less than 60 seconds

• Side

  • Nystagmus is stronger and lasts longer when turning to the affected side

• Nystagmus

  • Geotropic (toward the ground)

Benign Paroxysmal Positional Vertigo (BPPV)

Roll Test: Cupulolithiasis

least common

• Latency

  • No Latency, Vertigo/nystagmus begins immediately upon positioning

• Duration

  • Symptoms last longer than 60 seconds

• Side

  • Nystagmus is stronger and lasts longer when turning to the unaffected side

• Nystagmus

  • Apogeotropic (away from the ground)

ICF Framework Applied to BPPV

• Health condition: Benign Paroxysmal Positional Vertigo (BPPV)

• Body Functions & Structures:

  • Dizziness/vertigo

  • Nystagmus

  • Altered gaze stability, balance, and postural control

• Activity Limitations:

  • Difficulty with bending over, lying down, rolling in bed

  • Problems with walking in low light or crowded environments

• Participation Restrictions:

  • Fear of falling

  • Avoidance of daily activities, work, or social events

• Environmental/Personal Factors:

  • Age, co-existing anxiety, home setup, caregiver availability

  • Lighting, uneven surfaces, crowded spaces

Unilateral Vestibular Hypofunction (UVH): Clinical Presentation

• Dysfunction in one labyrinth or vestibular nerve

• Common causes: vestibular neuritis, labyrinthitis, acoustic neuroma, stroke

• Symptoms: vertigo (severe), gaze instability, imbalance, nausea, nystagmus

Binilateral Vestibular Hypofunction (BVH): Clinical Presentation

• Loss of vestibular function on both sides

• Common causes: ototoxicity, autoimmune disease, idiopathic

• Symptoms: oscillopsia, severe balance impairment, minimal vertigo

Impact and compensation

Unilateral Vestibular Hypofunction

Over time, the central nervous system compensates for the asymmetry, leading to a reduction in static symptoms (vertigo, nausea) but persistent dynamic symptoms (imbalance, gaze instability during head movement)