MShah Vestibular Revitalize - cdn.ymaws.com · Central & Peripheral Pathway Communication ......

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Vestibular Rehabilitation: There’s more than BPPV

Mickey Shah, PT, D.Sc. OCS, FAAOMPT, Cert.MDT, CSCS

Certified Vestibular Rehabilitation Specialist (APTA-Emory)

2017 CONFERENCE & EXPO

Background & Disclosures

• 14 years in clinical practice: Neuro-Vestibular-Ortho

• Certified Strength & Conditioning Specialist (CSCS-NSCA)

• Certified Mechanical Diagnosis & Therapy Cert. MDT

• Clinical Orthopedic Specialist (OCS)

• Completed Orthopedic Manual Physical Therapy Fellowship (FAAOMPT)

• Certified Vestibular Rehabilitation Specialist (APTA-EMORY)

• Certified Vestibular Rehabilitation Specialist (AIB) & (RIC)

• Doctor of Science with an emphasis in Neuroscience, Locomotion and Motor Control s/p CVA

• Private Practice – GoodLife Physical Therapy – 8 years

• Teaching Assistant/ Adjunct /University Lecturer – Governors State University (12 years) Teaching Assistant – Northwestern University –Orthopedic Manual Physical Therapy

• President of Evidence CEU

Material presented at IPTA 2017 REVITALIZE Conference

Course Objectives:

Upon completion of this course the participant will be able to: 1. Describe normal and patho-anatomy and physiology of the

vestibular system.2. Describe mechanisms of postural control (connections between

vestibular, oculomotor and somatosensory systems.)3. Recognize patients that are not appropriate for treatment and

require referral.4. Differentiate between central & peripheral vestibular disorders.5. Differentiate BPPV, Vestibular Hypofunction, Central Vertigo,

Cervical Dysfunction, Psychogenic, Mal de Debarquement Syndrome, Meniere’s Disease, concussion, Superior Canal Dehiscence.

6. Interpret responses to clinical examination to aid in diagnosis and treatment.

7. Describe evidence supporting the use of vestibular interventions.


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Why Learn Vestibular Rehabilitation?

Impact of Vestibular Disorders


• One recent large epidemiological study estimated that as many as 35% of adults aged 40 years or older in the United States—approximately 69 million Americans—have experienced some form of vestibular dysfunction.

• The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million

Prevalence of Vestibular Dysfunction

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Unmet Medical Need

Chabbert, C. New insights into neuropharmacology: From bench to bedside. Journal of Vestibular Research. 2013: 23; 107-111.

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What is Dizziness?

“Unsteadiness, Light-headedness, Disequilibrium, Vertigo, Wooziness, Feeling Tipsy, Foggy, Pressure in Head, ears, or eyes, etc.”

Classification of Vestibular Symptoms

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• Vertigo: A sensation of self-motion when no self motion is

occurring. (spinning or non-spinning)

• Dizziness: Sense of disturbed or impaired spatial

orientation without a false or distorted sense of motion

• Oscillopsia: Gaze instability

• Unsteadiness: Instability, disturbed postural control

• Visual Vertigo: Dizziness evoked with complex or

moving visual stimulae

• Pre-syncope: feeling of faintness or “passing out


Normal Vestibular Anatomy

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Vestibular System: What does it do?

• Linear and angular

accelerometer

• Senses rotational movements of

the head

• Senses linear movments of the

head

• Since gravity is linear

acceleration, it also senses head

position in space


“Which way is up?” “Where am I going?”

What does it do with that information?

• Gaze stability

• Postural stability

• Orientation in space i.e. position

sense


“Linear Motion”

Adapted from Herdman, 2007, 3rd ed.

Feedforward System

Feedback to cerebellum for compensation

(VOR)

(VSR)

Rely on Information from the Environment

Vestibular System: Processing

12Chabbert, C. New insights into neuropharmacology: From bench to bedside. Journal of Vestibular Research. 2013: 23; 107‐111.

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What Makes up the Vestibular System?


Vestibular System: Structure


Semicircular Canal Orientation


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Endolymph & Perilymph

• Endolymph

• Perilymph

• Endolymphatic Sac


Semicircular Canals: Sensory Processing

• Ampulla

• Cupula

• Hair Cells


Vestibular Detection


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• Function

• Detect linear acceleration

• Gravity

• Each organ contains sensory hair cellsimbedded within a membrane with otoconia


Otolith Organs: Utricle & Saccule

Vestibular System Receptors


Semicircular Ducts = Ampullary Crests or Cristae Ampullares.

Utricle & Saccule = Maculae

Macula

• Macula of Utricle = detects horizontal plane motion

• Macula of Saccule = detects vertical plane motion

• The kinocillia and sterocilla are oriented toward the utricle and away in the saccule

21Khan & Chang. Anatomy of Vestibular System. A review. Neurorehabilitation. 2013. 32: 437-443

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Canning electron micrograph of calcium carbonate crystals (otoconia) in the utricular

macula of the cat. Each crystal is about 50 mm long. (From Lindeman, 1973.)

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Structure of the Macula

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Intact Otoconia — Calcium Carbonate Crystals

Neuro-Vascular Supply

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Innervation

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Vascular Supply

Vertebral Arteries merge at top of cervical spine into the basilar artery.

PICA = central vestibular

AICA = peripheral & central

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Vertebral Basilar Arterial System

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Anterior inferior cerebellar artery: branches off basilar artery

Vascular Supply

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Central Vestibular Processing

• 1. Vestibular Nuclear Complex• 2. Cerebellum

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1. Lateral vestibular nucleus

2. Superior vestibular nucleus

3. Medial vestibular Nucleus

4. Inferior vestibular nucleus

5. At least seven minor nuclei (Herdman, 2014)

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The Vestibular Nuclear Complex

1. Monitors vestibular performance and readjusts the central processing.

2. Both Cerebellum and nuclei process information in association with somatosensory, proprioceptive and visual input.

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Cerebellum

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• VOR –Vestibular Ocular Reflex

• VSR – Vestibular Spinal Reflex

• VCR – Vestibular Colic Reflex

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Vestibular Reflexes

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• The VOR generates compensatory eye movements that help to stabilize eye position during head movements.

Vestibular Ocular Reflex

Oscillopsia

• Visual illusion of oscillating

movement of stationary objects

• Can arise with peripheral or

central lesions.

• Indicative of diminished VOR

gain

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• Sends descending motor control signal to musculoskeletal system for postural control

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VSR — Vestibulo-Spinal Reflex

VCR – Vestibulocollic Reflex

• Acts on the muscles in the neck to stabilize the head. The head responds to movement sensed

by the otolithic or SCC organs

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COR Cervico-Ocular

CSR Cervico-Spinal Reflex

CCR Cervico-collic Reflex

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Cervical Reflexes

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Central & Peripheral Pathway Communication


Vestibular Nuclei

Peripheral Vestibular Organs

Cervical Proprioceptors CerebellumMVST, LVST (VSR)

Thalamus

Ocular Motor Nuclei (VOR)

ANS

Cerebral Cortex

Vestibular Disorders

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3. VESTIBULAR DISORDERS

Most Common Vestibular Disorders

How do we know when something is wrong?

Symptoms

Oscillopsia

Disequilibrium

Abnormal sense of movement/orientation

Signs

Decreased visual Acuity

Ataxia

Imbalance

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Vestibular System Dysfunction

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YELLOW FLAGS

• Anxiety/Stress• Depression• Orthostatic BP

RED FLAGS

• C-spine instability• CAD or VBI• Myelopathy• Stroke or Other Neurological

Conditions• Cardiac Conditions

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Vestibular System

Central“Brain”

Peripheral“Not the Brain”

Central Stroke / TIAs

TBI/Head Trauma

Neurodegenerative Disorders

Migraine

Tumors

Peripheral BPPV

Meniere's Disease

Vestibular Neuritis/ Labyrinthitis

Perilymph Fistula

Acoustic Neuroma

Superior Canal Dehiscence

Motion Sickness/Sensitivity

Ototoxicity

Age-Related?

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Central vs. Peripheral Vestibular

• Neurological Screening Examination

• Balance Testing

• Oculomotor / CN Testing (3, 4, 6)

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Adapted from Herdman, 2007, 3rd ed.

Feedforward System

Feedback to cerebellum for compensation

(VOR)

(VSR)

Rely on Information from the Environment

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Vestibular System: Processing

X

X

X

Central Findings


• PICA

• AICA

• SCA

• Basilar Artery or Vertebrobasilar

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Common Strokes with Dizziness

Lee H. Neuro‐Otological Aspects of Cerebellar Stroke Syndrome. J Clin Neurology, 2009.

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• Persons experiencing a stroke from ischemia or hemorrhage can have the following

symptoms:

• Weakness:

• Hemi-sensory deficits

• Monocular or binocular visual loss

• Diplopia (double vision)

• Dysarthria (difficulty in speech articulation)

• Facial droop

• Ataxia (lack of muscle control)

• Vertigo (rarely in isolation)• Aphasia (lack of language abilities)

• Sudden decrease in level of consciousness

• Sudden severe headache in approximately 50% of those with ICH(Jauch, 2015; Liebeskind, 2016)

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Besides Dizziness

HINTS Study (Kattah, 2009)Head Impulse Test Nystamus – direction changing, vertical

Test of Skew

100% Sensitive and 96% Specific. Better than diffusion-weighted imaging (DWI) MRI up to 48 hrs.

Junior neurology residents similar ability (Chen, 2010)

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Hints Testing

• Meningioma

• Cerebellar Astrocytoma

• Cerebellar

Hemangioblastoma

• 4th Ventricular

Ependymoma

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Brain Tumors Causing Dizziness

Brown et al. Arch Phys Med Rehabil. 2006; 87:76-81

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Peripheral Vestibular Disorders

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Meniere’s Disease

• What is Meniere’s Disease?

• Clinical Diagnosis?

• Histological Findings?

• Management?


Endolymphatic hydrops should be considered as a histologic marker for Ménière’s syndrome rather than

being directly responsible for its symptoms

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Merchant et al. 2005 Endolymphatic Hydrops

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• Prevalence: 1-2/100,000

• Disequilibrium is typical

• NOT = vertigo or hearing loss

• Later may experience unilateral

tinnitus, hearing loss, or

possibly facial numbness

• Identified using MRI with

gadolinium

• Therapy candidates:

• - Post surgery

• - Non- surgical 52

Vestibular Schwannoma / Acoustic Neuroma

Mal de Debarquement

• Sensation of movement following prolonged exposure to some form of conveyance such as a boat, train, plane or automobile

• Medication does not typically relieve symptoms• Female gender bias and typical pre‐menopausal agree with

agree with a migraine association with some patients (26%)

Treatment: spontaneous resolution; vestibular rehabilitation

As the brain must readapt from a passively moving environment to a now stable land based stimulus.

Mechanisms: Not entirely understood


BPPV

• What is BPPV/Etiology?

• Clinical Diagnosis?

• BPPV Variants?

• Clinical Management?


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CupulolithiasisDescribes particles adherent to the

cupula of a SCC. (Schuknecht, 1969).

CanalithiasisDescribes free-floating particles

within a SCC. (Hall et al,1979; Parnes & McClure, 1992)

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BPPV Variants

• What is it?

• Symptoms?

• Medications?

• Prognosis?

• Management?

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Vestibular Neuritis

• What is it?

• Symptoms?

• Medications?

• Prognosis?

• Management ?

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Labyrinthitis

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• What is it?

• Symptoms?

• Medications?

• Prognosis?

• Management?

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Ramsey Hunt Syndrome

The "Tullio Phenomenon” consists of dizziness

induced by sound.

For example, use of one's own voice or a musical instrument. Tullio's occurs mainly in 3 ear conditions: Superior canal dehiscence, perilymph fistula, Meniere's syndrome, Referral to Neuro-otology

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Tullio Phenomenon

• MOI – Trauma or direct blow

• Soft tissue damage to the membranous labyrinth post-

trauma

• Immediate vertigo post-trauma

• Possible tinnitus and hearing loss in affected ear

• Weakened – Vestibulopathy

• Films may not show signs of concussion

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Labyrinthine Concussion

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• What is BVH?

• Oscillopsia

• Bedside Dx:

- Romberg

- DVAT – 0-2 lines normal, 4-7 lines drop

with movement is abnormal.

Gentamicin Toxicity:

• Motion Intolerance / Unsteady

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Bilateral Vestibular Hypofunction

• What it is it?

• Etiology?

• What does a classic patient look like?

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Cervicogenic Vertigo

ExaminationCase Based Approach

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Key Clinical Considerations

• Key Clinical Questions? 1. What differentiates peripheral from central vetigo?

2. What differentiates BPPV from other peripheral causes of vertigo, such as UVL and BVL, etioglogies– Vestibular or labyrinthitis, Menieres, etc.

What is the optimal treatment for BPPV.


Case 1

• Pt is a 62 year-old man who rolled over in bed early in the am developed a sudden severe onset of nausea, as well as the unpleasant sensation that the room was spinning around him.

• The spinning resolved within 30 seconds but occurred again in the opposite direction when he rolled back to his original position. This had never happened before.

• Occupation: Road safety patrol• Denies tinnitus, hearing loss, recent viral illness or

Head trauma. • PMH: HTN


Clinical Exam: DHI – 16% ABC Scale: 95%

Oculomotor Testing: Unremarkable.

Vestibular testing – Hall-pike or Nylan Barany Test was performed demonstrating torsional nystagmus in the right head-hanging position, along with reproduction of the patient’s symptoms .


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• What did you see?

• What is the most likely Diagnosis?

• Based on the Findings what is the likely treatment?

• Post Maneuver Restrictions?


Clinical Practice Guidelines

• Best Practice Guidelines

• Post maneuver precautions

• What if > 6 sessions???

• Most effective Treatment PC Canal? Cupulo? -


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Additional Videos


Case 2

• Patient c/o waking up dizzy in the am when rolling over to turn off her alarm clock. Reports Sudden onset of dizziness that subsided within 2 minutes after sitting up.

• C/c unsteadiness, dizziness when rolling, driving and occasionally walking.

• PMH: Prior history of BPPV posterior canal, MVA –trauma 10 years ago requiring bone resurfacing.


What do you see?


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Case 2




• Post Maneuver Restrictions?


Two Types of BPPV involving the horizontal canal

• Geotrophic Nystamgus Otoconia situation in the posterior segment of the

lateral canal (canalolithiasis) More intense when the head is turned toward the

affected ear

• Apogeotrophic nystagmus Otoconia attached to the cupula Free floating within the anterior arm of the horiztonal

SCC More intense when the head is turned toward to the

healthy ear


Additional Video


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IN HSCC BPPV the nystagmus is always more intense when it is beating toward the affected ear. (regardless or geotropic or apogeotropic)~ Michael

Schubert, PT, PhD.

Johns Hopkins Medicine.


Case - 3

• Patient is a 48 y/o female

• 2 weeks ago she reports sudden violent vertigo, nausea, vomiting.

• She reports unable to get up out of bed due to severe dizziness.

• PMH: Allergies, Multiple Ear Infections.

• Work: Secretary, unable to work at this time, nor is she able to drive.

• Medications: Meclizine


Case 3

• What do you think is going on based on the history?

• What tests would be important to perform?


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Case 3

• Spontaneous Nystagmus –Unilateral

• Head Thrust +

• Loss of Balance –EC, Foam (mCTSIB#4)

• DVAT

• DGI – impaired 17/24


Case 3





Case 3

• Vestibulopathy – general term referring to the peripheral vestibular end-organ Or vestibular division of CN 8. (Does not specify the end-organ)

• Vestibular Neuritis, Labrythinitis, Post-trauma vestibular concussion, Meniere's – unilaterally. Hypofunction - up train


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• Apply a rapid rotation of the head (<20

• degrees) in the plane of each canal

• Sensitivity is maximized by performing the

test with:

• Unpredictable head thrusts

• Frequency (>2 hz) and velocity >180

deg/sec

• Movement strictly within the plane of the

Canal of interest

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Head Impulse — Angular VOR

• Sensitivity and Specificity are 100% for patients

with complete unilateral vestibular loss

• Sensitivity varies with the severity of the

unilateral vestibular loss.

• Pooled data with a variety of patient populations

• Sensitivity 76%

• Specificity 94% 83

Head Impulse: Sensitivity / Specificity

Data summarized in:“Balance Function Assessment and Management” Jacobsen / Shepard

2008

• Sensitivity / Specificity varies

with the severity of unilateral

vestibular loss.

• Pooled data with a variety of

patient populations

• Sensitivity 56%

• Specificity 71% 84

Head Shake: Sensitivity/Specificity

Data summarized in:“Balance Function Assessment & Management” Jacobsen / Shepard 2008

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• 2 hz head shaking

horizontal or vertical

for 10-15 seconds

• Fixation removed

• Peripheral dysfunction

> than 3 beats of post

head shaking

nystagmus = +

unilateral vestibular

dysfunction

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Head Shaking Test

• Compare static vs. dynamic, >1-2 line

degradation considered significant

• Oscillate head at 2-4 cycles/sec within a 20

degree arc of rotation (horizontal and

vertical)

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Dynamic Visual Acuity Test

Subject NormalDVA (%)

AbnormalDVA (%)

Normal subjects N=51 96.1 3.9

Dizzy, nonvestibular n=16

87.5 12.5

Unilateral vestibularloss n=53

11.3 88.7

Bilateral vestibularloss N=34

0 100

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DVA Scores (Herdman et al 1998)

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• Marching with eyes closed for 50

steps

• Rotation greater than 30 degrees

indicative of uncompensated

peripheral vestibular dysfunction

• Positive = indicative of UVL

Data (Jacobson 2008)

- Sensitivity: 70%

- Specificity: 59%

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Fukuda Step Test

Pre & Post Treatment


Adaptation

• VOR• VSR

Substitution

• COR• Central Pre-Programming

• Saccade Modifications

Habituation

•Limited Head or Body Movement

Canalith Repositioning

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Mechanism of Recovery and Change

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VSR

Disturbance of the dynamic VSR causes

1. Ataxic Gait

2. Wide BOS

3. Drift to one side during ambulation

VOR

• Retinal slip is the movement of the visual

image across the retina

• Requires both vision and movement

• Animal in dark without movement do not adapt.

X1 Viewing / VOR x 1

X2 Viewing / VOR x 2

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Adaptation

Vestibular System is

context and frequency

specific.

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Case 4

History: Pt. 73 y/o male seen for c/o dizziness, disequilibrium, occasional head pressure, feeling foggy, light-headed. Symptoms have been worsening over the past 3 weeks. Vitals: BP 110/60; O2 Sat - > 95%; HR 78 restingHistory: Cardiac Stent, HTN, High CholesterolMedications: > 6 medications with 5 possible drug interactionsDifferential Diagnosis: Central, Peripheral, Other?


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Neck Pain Associated?

• What if he said he had neck pain that comes on with dizziness?

• What tests and measures would you perform?

• Differential Diagnosis?

• Cardinal Signs of CGD?

• Recommended Rx?


Clinical Findings

• Vestibular:

• Cardiovascular:

• Neurological:

• Cervical:

Body on Head or Cervical

Rotatory Nystagmus Test

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Cervicogenic Vertigo

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Sharp Purser Test

97

Alleviation test for instability of transverse ligament of the dens which controls anterior translation of C1

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Joint Position Error Test

Case 5

Patient Mr. Leo - a 79 year old male, was admitted to the ER and hospitalized for septicemia. He is 3 months removed from hospitalization, and is unable to stand without a walker and without assistance. He denies dizziness & vertigo.

He currently lives in senior assisted living with his wife.

DHI – 48%

ABC- 17%

PMH: HTN; Metoprolol 12.5 mg – otherwise unremarkable


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Questions

• Based on the history what additional questions would you ask?:

• What Combination of Lab & Clinical Tests would you perform/recommend?


Physical Therapy Exam

• HIT – corrective saccades bilaterally

• DVAT - > 7 line difference

• mCTSIB – unable to perform any condition without walker

• Spontaneous Nystagmus?


Treatment Outcome

• Patient started therapy 9/2016 – Current

• Treatment Consisted Of:

• Max Therapeutic Outcome?


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Dizziness is not a disease, it is a symptom

• Most dizziness can be diagnosed with history & physical

exam alone

• Do further testing if dx unclear or red flags

• Neurologic sx’s/signs, risk factors for vascular disease

• Dix-Hallpike and Supine Roll Test to diagnose BPPV

• BPPV is the most common disorder seen in the

outpatient practice, but it is vital from practitioner to know

other etiologies. 103

Take Home Message

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“Dizziness”

Cervical Spine

Cardiovascular

Central Nervous System

Peripheral Vestibular Disorders

Pharmacology & Vestibulotoxicity

Screening For RED FLAGS

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“ I don’t have all the answers, but I am committed to the never-ending

pursuit of finding them through education, research &

collaboration”

~Mickey Shah, PT, D.Sc.

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Questions or Comments

You can find me at

[email protected]

[email protected]

www.EvidenceCEU.com

THANK YOU

References

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