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Navigating the Dizzy Patient: Ready, Set, Treat!

Andréa Kristoff, MPTCertified Vestibular Rehabilitation Therapist

35% of adults aged 40 years or older in the US –approximately 69 million Americans -have experienced some form of vestibular dysfunction. A further 4% (8 million) American adults report chronic balance problems.

Prevalence and Incidence

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An additional 1.1% (2.4 million) report a chronic problem with dizziness alone.

80% of adults aged 65 years and older have experienced dizziness.

BPPV, the most common vestibular disorder, is the cause of approximately 50% of dizziness in older people.

Overall, vertigo from a vestibular problem accounts for 1/3rd

of all dizziness and vertigo symptoms reported.

3 Equilibrium/Sensory Systems: Vestibular System

Balance - Sensory Input Systems

Vest bula Syste Visual System Somatosensory System/Proprioception

CNS – integrates sensory input and produces motor control response

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Labyrinth Cochlea

Anatomy of Vestibular System

Cochlea Vestibular organs

1. Semicircular Canals2. Otolith organ

a.Utricleb.Saccule

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Sensory One’s perception of motion and orientation

Function of the Vestibular System

Angular acceleration Linear acceleration Positional sense in relation to gravity

Motor Providing a clear visual image of surroundings by

controlling eye movement Equilibrium and postural maintenance

Input Involved

Provides internal reference, telling brain where head is in space, direction of motion, and acceleration

Vestibular System

acceleration. Gravity is detected by the Otolith organs Otolith: Utricle and Saccule – both gravity

detectors sensitive to linear acceleration Velocity detection by the Semicircular Canals Semicircular Canals (SCC): Anterior (Superior),

Horizontal (Lateral), and Posterior

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Vestibular system includes parts of inner ear and brain that process sensory info involved with

Vestibular System (cont)

controlling balance and eye movements. If disease or injury damages these processing areas, vestibular disorders can result.

Consider Reflexes: VOR and VSR

BPPV: Posterior and Horizontal (Anterior)V tib l N iti /L b thiti

Vestibular DisordersMost Common Diagnoses

Vestibular Neuritis/Labrynthitis Meniere’s Disease Vestibular Migraine Superior Canal Dehiscence (SCD)/Perilymph

Fistula Vestibular Schwannoma/Acoustic Neuroma

In therapy clinic and in home Vertebral Artery Test - screen

Clinical Testing

Balance/Gait/Sensory integration: Romberg/Sharpened Romberg, mCTSIB, BERG, DGI, 5 Rep Sit to Stand, 30 secs Sit<-> Stand, TUG, BEST test, Fukuda Stepping Test

Vestibular/Central testing at MABI VNG, VEMP, DVA, ECochG, Posturography – Audiology

and/or ENT Other: Rotary Chair, ENG

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Romberg’s Test: Ask the patient to stand with their feet together (touching if possible). Then ask the patient to close their eyes. Remain close to the patient and prepare to

Romberg/Sharpened Romberg

catch them if they begin to sway or demonstrate loss of spatial orientation.

Test Difficulty

Feet Together Eyes Open Easy

Feet Together Eyes Closed Harder

Sharpened

Tandem Stance Eyes Open Harder Yet

Tandem Stance Eyes Closed Most Difficult

This test is designed to assess how well an individual is utilizing sensory inputs when one or

Modified Clinical Test for Sensory Interaction on Balance (mCTSIB)

g y pmore sensory systems are compromised, restricted or impaired.

4 conditions to test

Condition One: All sensory systems (i.e., vision, somatosensory, and vestibular) are available for

mCTSIB Condition One

y, )maintaining balance.

Eyes Open, Firm Surface 3 Trials Time: /30 seconds

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Condition Two: Vision has been removed and the older adult must rely on the somatosensory and

mCTSIB Condition Two

y yvestibular systems to balance.

Eyes Closed, Firm Surface 3 Trials Time: /30secs

Condition Three: Input from the somatosensory system has been compromised, which requires

mCTSIB Condition Three

y p , qreliance on the use of vision and the vestibular system to balance.

Eyes Open, Foam Surface 3 Trials Time: /30secs

Condition Four: Both vision and somatosensory systems have been restricted, which requires

mCTSIB Condition Four

y , qreliance on the vestibular inputs to maintain postural stability/balance.

Eyes Closed, Foam Surface 3 Trials Time: /30 secs

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To start the test, stand in the middle of a room. Place a small piece of tape on the floor in front of your toes to mark your starting position

Fukuda Stepping Test

your starting position. Close both eyes, hold your arms out stretched directly in

front of you, start stepping in place as if you were taking a brisk walk. Make sure someone is watching you so you do not bump into anything in the room.

Remain walking in place for 50 to 100 steps. After stepping, open your eyes and determine how much your body rotated to one side or the other.

Assessing the Results Place a small piece of tape on the floor along the front

of your toes and compare the angle of this line with

Fukuda (cont)

of your toes, and compare the angle of this line with your original line.

If you have taken only 50 steps, then an angle of 30 degrees or more may indicate vestibular weakness to the side your body deviated.

If you performed for 100 steps, an angle greater than 45 degrees indicates single sided vestibular weakness on the side to which your body turned while doing the test.

Benign Paroxysmal Positional Vertigo Most common cause of vertigo, a false sensation of

i i #1 f di i i 60

Benign Paroxysmal Positional Vertigo

spinning. #1 cause of dizziness in 60+yo Key Symptoms:

Sudden, intense vertigo with head motions Short duration, yet latent onset Rotary-torsional nystagmus beating upward and towards

affected ear in posterior BPPV Diaphoresis and emesis Mild postural instability between attacks

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Dix-Hallpike Test can be performed to determine the presence of posterior canal Benign Paroxysmal Positional Vertigo (BPPV). Observe Nystagmus

BPPV (cont)

Observe Nystagmus Negative result: no nystagmusPositive result: torsional nystagmusHorizontal nystagmus can indicate horizontal canal BPPV

Treat with maneuvers: Semont Liberatory, Epley CanalithRepositioning for posterior, Gans; Hybrid for horizontal

The presence of vertigo alone does not suggest a positive finding

Nystagmus

Torsional

BPPV (cont)

o s o al

Horizontal

Up/Down beating

Epley Maneuverfor Posterior BPPV

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Supine Roll for Horizontal BPPV

History of falls

Imbalance/unsteadiness

Visual-Spatial deficits

Vertigo

Indications for other testing

Vertigo

Recurrent dizziness

Tests offered at MABI: VNG, ENG, DVA, Calorics, VEMP,

ECochG

Other Tests available: vHIT, Rotary Chair

While VNG is considered the primary test of vestibular function, VNG alone is not enough to assess the etiology of dizzy/imbalance symptoms. Instead, VNG should be used in conjunction with a complete medical evaluation to rule out other co-morbitites including cardiovascular, metabolic, neurologic and neuromuscular dysfunction.

Videonystagmography (VNG)

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Treatment for Unilateral and Bilateral Peripheral Vestibular Dysfunctions (better than for Meniere’s,

VBRT – Vestibular and Balance Rehabilitation Therapy

y ( ,MAV, CNS disorders)

Recommend VBRT for 2-3x/week for 8-12 weeks

Gaze Stabilization - VOR Other: smooth pursuit, saccades, VOR opposition, VOR

cancelation

Vestibular and Balance Treatments

cancelation Balance

Static – Ft apart, together, partial tandem, full tandem, SLB -on varied surfaces (foam, pebbles, mulch)

Dynamic – moving surfaces (rocker boards, mini-trampoline), with UE motions (magnet moving, Body Blade, pick up items)

LE strength/coordination Step taps, step ups, stairs, ramps, 4 square stepping

Gait Gaze stabilization, head/eye turns (horiz and vertical),

VBRT Treatments (cont)

cognitive tasking, obstacles (over, around, tapping)

Cognitive Tasking Letter reading, puzzles (word search, mazes, hidden

objects)

Visual Perturbations Lasers, black and white pattern boards, glasses

(red/green, holy, patched)

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Unrelenting and/or worsening symptoms, changes in symptoms (severe vertigo, oscillopsia)

When to Refer Out

y p ( g , p ) Need MD Rx like any outpatient referral – prefer

evaluate and treat for Dizziness/Balance/Vertigo orders for testing and treatment.

Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults. Arch Intern Med. 2009; 169(10): 938-944.

Ator GA. Vertigo-Evaluation and Treatment in the Elderly.

Fife TD Iverson DJ Lempert T Furman JM Baloh RW Tusa RJ Hain TC Herdman S Morrow MJ

References

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurol. 2008; 70: 2067-2074.

Herdman, S. (2007). Vestibular rehabilitation (3rd ed.). Philadelphia: F.A. Davis.

Vestibular Seminars. (n.d.). Retrieved March 2015, from http://www.vestibularseminars.com

Information about dizziness, balance and hearing. (n.d.). Retrieved March 2015, from http://www.dizziness-and-balance.com

The American Institute of Balance. Leader in Vestibular Studies and Equilibrium Disorders. Largo, FL. USA. (n.d.). Retrieved March 2015, from http://www.dizzy.com

Vestibular Disorders Association. (n.d.). Retrieved March 2015, from http://www.vestibular.org

http://scienceisbeauty.tumblr.com/post/49201644148/anatomy-of-vestibular-apparatus-source-chapter

http://www.cmej.org.za/index.php/cmej/article/view/2450/2537

Goulson, A. M., McPherson, J. H., Shepard, N. T. (2016). Background and Introduction to whole-body rotational testing. In: Jacobson GP, Shepard NT, editors. Balance function assessment and management. San Diego: Plural Publishing; 2016. p. 347–64.

Whole-Body Rotational Testing. In Jacobson, G. P., Shepard, N. T. (Eds.), Balance Function, Assessment and Management (pp 225-250) San Diego CA: Plural Publishing

References (cont)

Assessment and Management (pp.225 250). San Diego, CA: Plural Publishing.

Lithgow, B., & Fang, Q. (n.d.). Typical ABR response [Digital image]. Retrieved September 15, 2016, from http://www.eng.monash.edu.au/non-cms/ecse/ieee/ieeebio1999/p50.htm

McCaslin, D. L. & Jocobsen, G. P. (2016). Vestibular Evoked Myogenic Potentials (VEMPs). In Jacobson, G. P., Shepard, N. T. (Eds.), Balance Function, Assessment and Management (pp.225-250). San Diego, CA: Plural Publishing.

Neuhauser HK, Radtke A, von Brevern M et al. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168(19):2118–2124.

Schoonhoven, R. (2006). Responses from the cochlea: Cochlear Microphonic, Summating Potential, and Compound Action Potential. In Burkard, R. F., Don, M., Eggermont, J. J. (Eds.), Auditory Evoked Potentials: Basic Principles and Clinical Application (pp. 180-195). Philadelphia, PA: Lippincott, Williams & Wilkins.

National Institute on Deafness and Other Communication Disorders (NIDCD). Strategic Plan (FY 2006-2008). Available at: www.nidcd.nih.gov/StaticResources/about/plans/strategic/strategic06-08.pdf.

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Barin, K. (2016). Interpretation and Usefulness of Caloric Testing. In Jacobson, G. P., Shepard, N. T. (Eds.), Balance Function, Assessment and Management (pp.225-250). San Diego, CA: Plural Publishing.

Burkard, R. F., & Don, M. (2006). The Auditory Brainstem Response. In Burkard, R. F., Don, M.,

References (cont)

( ) y pEggermont, J. J. (Eds.), Auditory Evoked Potentials: Basic Principles and Clinical Application (pp. 180-195). Philadelphia, PA: Lippincott, Williams & Wilkins.

Curthoys, I. S., MacDougall, H. G., McGarvie, L. A., Weber, L. A., Weber, K. P., Szmulewicz, D., Manzari, L., Burgess, A. M., Halmalgyi, G. M. (2016). The Video Head Impluse Test (vHIT). In Jacobson, G. P., Shepard, N. T. (Eds.), Balance Function, Assessment and Management (pp.225-250). San Diego, CA: Plural Publishing.

Assessment and Management (pp.225-250). San Diego, CA: Plural Publishing.

Shepard, N. T., Schubert, M. C. (2016). Background and Technique of Ocular Motor Testing. In Jacobson, G. P., Shepard, N. T. (Eds.), Balance Function, Assessment and Management (pp.225-250). San Diego, CA: Plural Publishing.

Shepard, N. T., Schubert, M. C., Eggers, D. Z. (2016). Interpretation and Usefulness of Ocular Motility Testing. In Jacobson, G. P., Shepard, N. T. (Eds.), Balance Function.

Gans, R.E. (2014). Introduction to VNG. Personal Collection of R.E. Gan, The American Institute of Balance, Largo, FL.

Thank you for allowing me to come and speak on Vestibular Disorders and Treatments!

Questions?

Andréa Kristoff, MPT Certified Vestibular Rehabilitation Therapist Mid America Balance Institute

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