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.