Vestibular Rehabilitation

Vestibular Rehabilitation - Amy (Dizzy Day Clinics)

Introduction

  • Amy is a physiotherapist at Dizzy Day Clinics in Melbourne, with a background in neurophysiotherapy.
  • Thanks to Laura Power and Doctor Kate Murray for their contribution.
  • Lecture is divided into four sections:
    • Review of the vestibular system and symptoms of dysfunction.
    • Assessment of the vestibular system.
    • Common vestibular disorders (BPPV, vestibular neuronitis/neuritis, Meniere's disease, acoustic neuroma, vestibular migraine).
    • Vestibular rehabilitation.

Prevalence & Importance

  • Dizziness is common, affecting ~20% of working-age adults visiting GPs.
  • 80% of dizzy individuals seek medical help due to ADL disruption or work absence.
  • Vestibular dysfunction increases fall risk by eightfold.
  • Understanding vestibular anatomy is key to rehab.

Anatomy of the Vestibular System

Peripheral Vestibular Apparatus

  • Inner ear system: semicircular canals, saccule, and utricle.

Central Processor

  • Brain areas receiving input from the inner ear.

Motor Output

  • How the vestibular system impacts movement.
  • Five parts to each inner ear system.

Semicircular Canals

  • Oriented at roughly 45-degree angles (anterior, posterior, and horizontal).
  • Filled with endolymph: fluid movement stimulates the cupula.
  • Cupula: dome-shaped structure with hair cells at the canal's base.
  • Fluid movement deflects the cupula, stimulating hair cells.
    • This signals head motion to sensory nerve fibers.

Canal Pairs

  • Right anterior & left posterior: detect diagonal movement on one plane.
  • Left anterior & right posterior: detect diagonal movement on another plane.
  • Horizontal canals: detect side-to-side movement.

Otolith Organs (Utricle & Saccule)

  • Contain otoconia: calcium carbonate crystals on a gel.
  • Detect linear acceleration and gravity.
    • Head moves forward -> crystals fall backward -> stimulate hair cells.
    • Going up in a lift -> gravity pushes crystals down -> compress hair cells.

BPPV Relevance

  • Benign Paroxysmal Positional Vertigo.
  • Crystals displace from utricle into semicircular canals.
  • Causes spinning sensation due to inappropriate crystal location.

Vestibulo-Ocular Reflex (VOR)

  • VOR enables eyes to remain fixed on a target during head movement.
  • Semicircular canals detect head movement.
  • Vestibular nerve transmits info to vestibular nuclei in the brainstem.
  • Information relayed to medial and lateral rectus muscles to stabilize gaze.
  • Reflexive eye movement stabilizes the target; gaze stability.

VOR Gain

  • Ratio of eye movement to head movement velocity.
  • Ideally, eye velocity = opposite head velocity (VOR Gain = 1).
  • Head moves 100°/s right; eyes move 100°/s left.
  • If eye movement is slower than head movement, VOR Gain < 1, causing blurring or 'catching up' sensation.

Central Processor (Brain)

  • Vestibular nuclear complex (superior, medial, lateral, descending nuclei) in pons and medulla.
  • Clinical relevance in assessing dizziness to rule out stroke in the pontine or medullary area of the brain.
  • Relays information for the VOR and vestibulospinal reflex.
  • The brain helps coordinate eye stability during head turns and maintains upright posture.

Cerebellum

  • Receives inner ear input; adapts VOR gain and coordinates vestibulospinal reflex.
  • Clinical cerebellar testing via limb coordination assesses potential cerebellar pathology in vestibular clients.

Motor Output

  • Ocular muscles & motion nuclei via the medial longitudinal fasciculus mediate reflexive eye movements during head motion (VOR).
  • Vestibulospinal reflex activates spinal muscles for protective extension during head turns, preventing falls.
  • Vestibular colic reflex stabilizes the head via neck muscle activation during head turns.

Symptoms of Vestibular Dysfunction

  • Complex system: motion sensor, eye stabilizer, balance maintenance.

Primary Symptoms

  • Dizziness: impaired motion sensing.
  • Vertigo: spinning sensation (e.g., Meniere's, BPPV).
  • Imbalance and unsteadiness: peripheral or central issues.
  • Gaze instability: blurred vision during head movement.
  • Nausea and vomiting.

Secondary Symptoms

  • Fatigue: system's role in posture, eye stability, and head position.
  • Concentration issues: "foggy head".
  • Anxiety: concern about serious conditions.
  • Depression and frustration: prolonged recovery.
  • Loss of confidence: in walking and balance is affected.

Functional Restrictions

  • Impact on activities of daily living (ADLs): difficulties with putting on shoes).
  • Driving limitations: head checks are difficult.
  • Return to sports is challenging (especially post-concussion).
  • Gardening difficulties: head down.
  • Balance-dependent activities: roller skating is affected.
  • Increased fall risk: reduces independence.
  • Social isolation: fear of dizziness in crowds.
  • Movement avoidance: stiff necks from guarding.
  • Neck and shoulder issues: guarding posture.
  • Reduced fitness and endurance: overall decline.

Clinical Examination of the Dizzy Patient

Subjective Examination

  • Detailed history: differentiate spinning vs. dizziness vs. imbalance.

Objective Examination

  • Visual testing.
  • Dix-Hallpike test: crystal assessment.
  • Balance and gait assessment.
  • Possible vestibular function tests or MRI brain.

Subjective Examination Details

  • Type of sensations (true vertigo vs. vague dizziness).
  • Imbalance or disequilibrium.
  • Falls.
  • Lightheadedness.
    • Note: Vestibular dysfunction should not cause fainting.
  • Onset (acute vs. gradual) suggests different etiologies.
    • Sudden onset suggests crystal problem.
    • Gradual onset suggests acoustic neuroma.
  • Duration of attacks is important.
    • Short spins (seconds, e.g., BPPV).
    • Minutes to hours (e.g., Meniere's, vestibular migraine).
    • Hours to days (vestibular neuronitis, stroke red flag).
  • Associated symptoms:
    • Hearing loss (unilateral: acoustic neuroma, labyrinthitis; bilateral: age/work-related).
    • Tinnitus: ringing in ears (high or low pitched).
    • Aural fullness: Meniere's disease.
    • Headaches, photophobia, phonophobia: vestibular migraine.
  • Exacerbating factors:
    • Movements (rolling in bed exacerbates crystals in wrong spot).
    • Upright posture and head turns: vestibular neuronitis.
    • Dietary factors (chocolate, coffee, red wine): vestibular migraine.

Oculomotor Examination

  • Eyes provide info about the inner ear and brain.
Nystagmus
  • Involuntary eye movement from peripheral or central nervous system dysfunction.
  • Defined by the direction of the fast phase.
    • Upbeat, downbeat, horizontal, or torsional (BPPV).
  • Spontaneous nystagmus: observe eye movement with patient looking straight ahead.
  • Gaze-evoked nystagmus: observe eye movement when patient looks left and right.
    • Downbeating nystagmus in all planes is a central sign.
Smooth Pursuit
  • Eyes smoothly follow a moving target.
  • Peripheral pathology: smooth movement is expected.
  • Saccadic smooth pursuit: jerky eye movements suggesting cerebellar pathology.
Saccadic Eye Movements
  • Quick and accurate movement between two points.
  • Normal saccades: quick and accurate.
  • Slow saccades: slowness and inaccuracy suggest central pathology.

Head Impulse Test

  • Tests peripheral vestibular function.
  • Patient fixates on clinician’s nose during quick head rotations.
  • Normal: eyes remain fixed on target.
  • Abnormal: eyes fail to stay fixed on the target; corrective saccade is observed.
  • Positive head impulse test suggests VOR impairment.

Dynamic Visual Acuity Test

  • Active VOR testing.
  • Patient reads a chart (Snellen) or looks at a target while head rotates.
  • Note any blurring or dizziness.
  • Compare visual acuity during head movement to acuity at rest.
  • More than three lines difference implies vestibular deficit.

Dix-Hallpike Examination

  • Assesses for crystals in the wrong part of the inner ear system; BPPV.
  • Contraindications: vulnerable necks (recent surgery/trauma), rheumatoid arthritis, neck instability, myelopathy etc.
  • Technique: Turn the head 45 degrees and lie the patient down with 20-30 degrees of head extension.
  • Positive test: Patient experiences severe vertigo and torsional nystagmus.

Balance Examination

  • Tests vestibulo spinal reflex.
  • Romberg test (feet together, one foot in front of the other).
  • Standing on soft surfaces with eyes closed.
  • Assesses vestibular contribution by noting postural sway with eyes closed and head turns.

Gait Assessment

  • Walking with head turns assess vestibulospinal reflex.
  • Assess comfortable pace, tandem walking, eyes closed.

Common Vestibular Problems

Benign Paroxysmal Positional Vertigo (BPPV)

  • Crystals (otoconia) from the utricle enter the semicircular canals.
  • Canalithiasis: Crystals floating in the canals.
  • Cupulolithiasis: Crystals stuck to the cupula.
  • Most common cause of dizziness.
  • Peak onset: 50-70 years old (but also seen in younger people after head trauma).
  • Posterior canal BPPV: most common type (85%).
  • Symptoms: brief episodic positional vertigo.
  • Diagnosis: positive Dix-Hallpike test.
  • Treatment: Epley maneuver, Semont maneuver, Brandt-Daroff exercises.
Epley Maneuver
  • Sit patient long sitting, turn head to the side of the problem, and bring into Dix hallpike position
  • If the test is positive (vertical and upwards rotary nystagmus during vertigo), proceed.
  • Keeping the tilt, rotate the head 90 degrees towards the other shoulder.
  • Chin tuck, nose points down. Wait a minute.
  • Lift the patient to a sitting position, keeping their head turned.
  • Used to re-position crystals back in the utricle.

Vestibular Neuritis or Labyrinthitis

  • Inflammation of the vestibular nerve (superior and/or inferior).
  • Suspected viral cause (shingles, respiratory virus).
  • Labyrinthitis involves hearing organ: hearing loss occurs as well.
  • Accounts for ~7% of presentations to dizzy clinics.
  • Occurs in younger people (30-60 years old).
  • Males are slightly more affected.
  • Low recurrence rate.
  • Symptoms: acute onset severe vertigo lasting hours to days.
  • Nausea/Vomiting.
  • Hearing loss (labyrinthitis).
  • Impaired balance and dizziness.
  • Clinical examination:
    • Spontaneous horizontal nystagmus (beating to the side that is working well).
    • Positive head impulse test on affected side.
    • Balance impairments.
HINTS Examination
  • Head Impulse, Nystagmus, Test of Skew.
  • Performed in acute setting on patients with continuous vertigo/nystagmus.
  • Differentiates vestibular neuronitis from stroke.
  • Reassuring HINTS: unidirectional nystagmus, positive head impulse, no vertical skew.
  • Worrisome HINTS: direction-changing nystagmus, abnormal skew, normal head impulse.
  • HINTS Helpful only in acute settings
Treatment
  • Bed rest.
  • Prednisolone or corticosteroids (within 72 hours ).
  • Stematil for nausea.
  • Vestibular rehab (gaze stability, walking).

Meniere's Disease

  • Endolymphatic hydrops: fluid buildup in the inner ear due to endolymphatic sac dysfunction (volume/pressure regulation) leading to swelling/pressure.
  • May have genetic component.
  • Can be bilateral.
  • Symptoms: Vertigo longer than BPPV 20 minutes to 24 hours.
  • Nausea/vomiting.
  • Hearing loss (fluctuates with vertigo).
  • Low roaring tinnitus.
  • Aural fullness.
  • Bouts of vertigo that go for longer.
  • Oculomotor examination is normal between episodes. head impulse and dix hallpike test are negative.
Treatment
  • Medical treatment.
    • Medications: diuretics, circ (ineffective).
    • Stematil for nausea (short-term only).
    • Low-salt diet.
  • Surgical intervention: Gentamicin ablation, steroids.
  • Physiotherapy: for chronic imbalance between bouts (not for acute vertigo).

Acoustic Neuroma (Vestibular Schwannoma)

  • Benign tumor of the vestibular nerve.
  • Peak incidence 40-60 years old.
  • Slow-growing -> may not cause dizziness, but may see them post-surgically.
  • Must be medically diagnosed by neurosurgeon or ENT specialist.
  • Diagnosis: MRI with contrast is gold standard.
  • Unilateral hearing loss requires assessment by ENT specialist.
  • Other symptoms: tinnitus, imbalance, headaches, mandibular aching, facial numbness, rare vertigo.
  • Clinical examination: eye signs are normal, head impulse test usually negative, Dix-Hallpike test negative.
  • Treatment: observation, microsurgical removal, stereotactic radiosurgery; pre/post-surgical vestibular rehab.

Vestibular Migraine

  • Migraine causing vertiginous symptoms.
  • Second most common cause of dizziness.
  • 7-11% of specialized dizzy clinics, 1% of general population.
  • Women affected more.
  • Mean age onset 50.3 years old
  • Symptoms: episodic vertigo (short spins or longer spells as in Meniere's disease/vestibular neuritis).
  • Headache, photophobia, nausea/vomiting, tinnitus, aural fullness sound sensitivity present.
  • Eye sign results are usually normal.
  • Can be tricky to diagnose.
  • BPPV can be a trigger.
  • Treatment spends long time talking about prevention. dietary changes can also help with triggers.
  • Medical referral to neuroautologists.
  • Migraine preventer medications may be helpful such as Sandomigraine, Propranolol or Topamax act on the brain (6 weeks at least).
  • Vestibular rehab is important for vestibular system strengthening.

Vestibular Rehabilitation

  • Detailed assessment: history, oculomotor exam, head impulse/Dix-Hallpike, active VOR, balance/gait, neuro exam.
  • Treatment is then customized to the patient's needs.

Goals of Vestibular Rehabilitation

  • Enhance gaze stability (VOR).
  • Enhance postural & gait stability.
  • Improve dizziness with ADLs.
  • Cardiovascular fitness.

Specific Exercises

  • Gaze Stability Exercises:
    • Retrain VOR (improve gain).
    • Focus on a small target with head movements.
    • Horizontal, vertical.
    • Small but frequent, three times a day.
  • Habituation (Desensitizing) Exercises:
    • Repeated graded exposures to provocative movements.
    • Spinning, head shaking, bending over.
    • 3 times a day.
  • Balance and Gait Training:
    • Exercises with head turning (vestibulospinal reflex).
    • Standing on foam with eyes closed (reduce visual input).
    • Standing on one leg doing gaze stability.
    • Ball throwing.
    • Emphasis on returning to normal activity e.g. Trampolining, swimming, sports.

General Principles

  • Patients generally need to get moving again.
  • Maintain an active lifestyle (walking, running, exercise, bike, Tai Chi, yoga).
  • Strong evidence for treating BPPV.

Who to Refer

  • Stable vestibular lesion (vs. fluctuating).
  • Meniere's patients also help with balance for stable vestibular lesion vs fluctuating.
  • Movement-provoked symptoms.
  • Impaired balance and gait.
  • Limited lifestyle.