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Vestibular Disorders
Chad Lairamore, PT, PhD
Physical TherapyUniversity of Central Arkansas
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Incidence Dizziness
5.5% or 15 million peopleyear
!ne of most common complaints todoctors "ith increasin# a#e
$ain reason to see $D for those 5 andover
&% of those "ith initial complaints have
no resol'tion in ( "eeks )*% "ith persistent dizzinessreport
rec'rrent symptoms +eyond * months
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Pro+lems in "hich of the follo"in# areas"o'ld !T ca'se verti#o and di--iness
A. Peripheral vesti+'lar system
/. Central vesti+'lar system
C. Cere+ell'mD. 0nner ear
E. Lower extremity peripheral
nervous system
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Anatomy of the ear
!'ter ar Pinna
Tra#'s
2ternal A'ditory Canal 3meat's4
Tympanic mem+rane
'nction6 Collect 7 direct so'nd "aves
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!'ter ar Patholo#ies
Perforated eardr'm
Ca'ses6 2plosions, tra'ma,ac'te middle ear infections
Can +e s'r#ically corrected
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$iddle ar
Components6
A'ditory !ssicles6 $alle's, 0nc's, 8tapes
Tensor tympani 7 8tapedi's m'scles.
'stachian t'+e
'nction6 Comm'nicates so'nd "aves viavi+ration to inner ear
Patholo#ies6 $iddle ear infections
The middle ear is dry, 'stachian t'+e drainsanythin# o't of the middle ear
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0nner ar
/ony 7 $em+rano's La+yrinth6 Utricle, 8acc'le, 8emicirc'lar canals,
cochlea
9o'nd and oval "indo"s Areas "here the tiss'e is thinner, can +e
r'pt'red easily, "hich "ill ca'se symptoms.
Perilymph 3s'rro'nds semicirc'larcanal4, ndolymph 3:'id inside Utricle,
8acc'le, semic'rc'lar canals4
'nction6 Sensory info forequilibrium and hearin
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0nner ar Patholo#ies
/eni#n Paro2ysmal Positional ;erti#o3/PP;4
La+yrithitis
$eniere
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Anatomy of Central ;esti+'lar
8ystem
Central ;esti+'lar 8ystem Areas "ithin the +rain that comm'nicate "ith and
inte#rate vesti+'lar information.
/rain stem
Controls vesti+'lar re:e2es ;esti+'lar corte2, Thalam's, 9etic'lar ormation
Aro'sal
A"areness of the +ody
Discrimination +et"een movement of environment vs. self
Cere+ell'm
!aintain vestibulo"ocular re#ex $V%&'
Post're
Coordination
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Central ;esti+'lar 8ystem
2tensive connections +et"een vesti+'lar n'clei andretic'lar formation, thalam's and cere+ell'm
;esti+'lar system contri+'tes to aro'sal, conscio'sa"areness of +ody, a+ility to discriminate +et"eenmovement of self and environment.
=hat happens if a pt does not o+tain an 'pri#htpositionThink a+o't retic'lar formation.
!rthostatic hypertension can happen.
Pts. =ill +e "oo-y #ettin# 'p +'t is not al"ays related toorthostatic hypertension.
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Central ;esti+'lar Cont.
Cere+ellar connections
(elp maintain calibration of Vestibulo"%cular &e#ex
Contri+'te to post're in static and dynamic
0n:'ence coordination of lim+ movement
;esti+'lo>!c'lar 9e:e2 3;!94
$aintains sta+ility of an ima#e on thefovea of the retina d'rin# rapid head
movements 9apid movement of the eye opposite the
direction of head movement
video
http://www.youtube.com/watch?v=j_R0LcPnZ_whttp://www.youtube.com/watch?v=j_R0LcPnZ_w7/25/2019 1- Vestibular Disorders 1-13-16
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Patholo#y
Central system
/rainstem infarctiono 8ymptoms6 Transient cl'msiness, =eakness, Loss
of vision, Diplopia, Drop attacks, Dysarthria
Cere+ellar infarctiono A0CA
$ay ca'se verti#o, also associated "ith hearin# loss
Lesion here mimics a peripheral disorder
o P0CA infarcts Ac'te, severe verti#o, mimickin# la+yrinthine d-
o ;erte+ral artery infarct6 typically only e?ects thecere+ell'm 3perf'se cere+ellar iss'es like ata2ia,etc.4
T/0 "ith la+yrinthine or sk'll fract'reo A+normal central processin# res'ltin# in verti#o
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Patholo#y Central 8ystem
;erte+ro+asilar ins'@ciency Posterior circ'lation s'pplies +lood to +rainstem,
cere+ell'm and peripheral vesti+'larapparat'sverte+ro+asilar ins'@ciency 3;/04
Drop attacks, transient +lindness, dysarthria ot as common.
$'ltiple 8clerosis 3$84 Demyelinatin# disease
Can a?ect C ;0006 ca'sin# identical symptoms as'nilateral peripheral vesti+'lar hypof'nction 3$90re'ired for d24
Aco'stic ne'roma, menin#ioma, metastatic
t'mor, or hematoma in the posterior fossa
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$edical Treatment for Central
Disorders
$ana#e as those "itho'taccompanyin# symptoms ofdyse'ili+ri'm
8'r#ical 9emoval of t'mors
PT to incl'de6 Adaptation 7 fall prevention strate#ies
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Anatomy of Peripheral ;esti+'lar 8ystem
Peripheral ;esti+'lar 8ystem3located "ithin the inner ear4
* primary f'nctions 3Associated "ith
;!94 8ta+ili-ation of vis'al ima#es on the fovea of
the retina d'rin# head movement to allo"clear vision
$aintain post'ral sta+ility, especially "ithhead movement
Provide info for spatial orientation
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Anatomy Peripheral ;esti+'lar8ystem
ach ear has6
) Semicircular canals $S**' Anterior, posterior, hori-ontal
B06 anterior is also called s'perior
ori-ontal canal is also called lateral
+ otolith orans
8acc'le Utricle
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8emicirc'lar Canals
ach has acontralateralcoplanar mate
ori-ontal
8CC pair Posterior and
contralateralanterior 8CC
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8emicirc'lar Canals
ndolymph l'id that moves freely "ithin the
canals
Amp'lla nlar#ement at one end of the
8CC
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8emicirc'lar Canals
C'p'la6 "ithin amp'lla elatino's +arrier
Contains sensory hair cells and proEectin#
cilia 8tereocilia 3small4 and Finocilia 3lar#er4
$ovement of the cilia Ca'se an e2citation or inhi+ition in the hair cell
"hich in t'rn leads to a depolari-ation orhyperpolari-ation of a?erent vesti+'lar nerves.
Dependant 'pon direction of motion 8terocilia to"ard Finocilia6 e2citation
8terocilia a"ay from Finocilia6 inhi+ition
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C'p'la is a#elatino's or#an
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8emicirc'lar Canals
9espond to motion ino"n plane +est
Coplanar pair6 p'sh>p'll dynamic
/rain detectsmovement +y
comparin# ( 8CC
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!tolith !r#ans
8acc'le 7 Utricle Linear acceleration
8tatic head tilt
!tolyth 8ensory hair cells proEect into #elatino's
material
!toconia 3ear rocks4
Utricle e2citation
ori-ontal linear acceleration andor statichead tilt
8acc'lar e2citation ;ertical linear acceleration
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!toconia and 'nderlyin#hair cells
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0f a person t'rns their head to the90T. =hat vesti+'lar or#an "as
primarily activated
A. sacc'le
/. 'triclesC. anterior canal
D. posterior canal
E. horizontalcanal
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Patholo#yUnilateral Peripheral system
/eni#n Paro2ysmal Positional ;erti#o 3/PP;4
Displacement of otoconia
5& G &% of the cases are idiopathic
Under the a#e of Hfty tra'ma s'ch as a fall, T/0, or "hiplash inE'ry
!ver the a#e of Hfty De#eneration or dehydration of the #elatino's
mem+rane
$i#rate into 8CC ree :o"in# in the endolympth > canalithiasis
or adhere to c'p'la G c'p'lolithiasis
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A (5 yr old is +ein# treated for "hiplash after
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A (5 yr old is +ein# treated for "hiplash aftera car accident. 8he reports neck pain andintermittent di--iness "ith head movements.
=hat is the +est co'rse of action
A. Teach the patient to limit all neckran#e of motion.
/. 9efer her to a physician for a centralvesti+'lar disorder
C. Treat her "hiplash hopin# that the
di--iness "ill s'+side on its o"nD. ,reat her whiplash and evaluate
her for a peripheral vestibulardisorder
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Patholo#y
Unilateral Peripheral system
;esti+'lar ne'ronitisTypically ca'sed +y a viral infection
0f assoc. "ith hearin# lossentire la+yrinth
ass'med to +e involved
Labyrinthitis ;erti#o provoked +y head movement, +'t not
necessarily head position
Ac'tely
8'dden severe verti#o, 7;, no hearin loss orfacial wea-ness
Typically resolves in I 1 "eek
Physician may prescri+e anti>viral meds
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Patholo#y
Unilateral Peripheral system
9amsay 'nt syndrome 3viral infection4 orm of la+rynthitis
erpes -oster 3chicken po24 in e2ternal ear
;000 and ;00 C a?ected, facial "eakness, hearin#loss, verti#o
Tends to resolve on its o"n, can +e treated "ithantivirals.
Post>Tra'matic ;erti#o 0mmediately follo"in# head tra'ma
9espond "ell to repositionin# techni'esand vesti+'lar e2ercise most nota+ly for ;!9
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Patholo#y
ilateral /eripheral systems
Dr'# To2icity
8econdary e?ect
Amino#lycosidesJconcentrated in endo and perilymph :'ids,
e2posin# hair cells to hi#h concentrations Streptomycin 0 entamycin most detrimental
Can a?ect the hair cells
9eport pro#ressive 'nsteadiness, especially "ith decreased vis'alinp't
/ilateral loss of vesti+'lar f'nction, l'ct'atin# attacks of verti#o3depends 'pon symmetry of hypof'nction4, tinnit's, :'ct'atin#hearin# loss and ill>descri+ed a'ral sensations of f'llness
8pontaneo's recovery in ho'rs to "eeks "hen the dr'# isdiscontin'ed
Bo' are a PT st'dent in ac'te care Bo' are treatin#
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Bo' are a PT st'dent in ac'te care. Bo' are treatin#a K& yo male patient "ho has an endocarditis andis takin# 8treptomycin. The patient complains oflosin# his +alance and hearin# a hi#h pitchedso'nd. 0f yo' "ant to impress yo'r C0, yo' "o'lds'##est6
A. A disc'ssion "ith the $D re#ardin# possi+le$eniere
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Patholo#y
/ilateral Peripheral systems
$eniere5&
Pro#ressive hearin# loss and tinit's "ith fre'ency of attacks
Comes and #oes, #ets "orse over time. 5&% +ecome +ilateral
earin# loss pro#resses to moderate de#ree and sta+ili-es
$edically mana#ed +y controllin# :'id intake
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$edical $ana#ement
Dru ,ype 2ame Indications
Antihistamine andAnticholiner#ic
$ecli-ineM Antivert Ac'te ;est. e'ritisLa+yrinthitis9amsay>'nt
Phenothia-ine Phener#an Ac'te ;est. e'ritis
La+yrinthitis9amsay>'nt
Anti>in:ammatory Prednisone Ac'te ;est. e'ritisLa+yrinthitis9amsay>'nt
Antiviral Acyclovir 9amsay>'nt
Dont have to memorize this chart.
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N'estion6 A person "ith symmetrical+ilateral vesti+'lar dysf'nction "ill
likely !T e2perience
1.Vertio and nystamus
,his is usually a unilateral 3 centralproblem
/. Tinnit's and f'llness in the ears
C. Unsteadiness
D. earin# loss
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ysta#m's
ysta#m's D'e to im+alance in tonic Hrin# rate of
vesti+'lar ne'rons
amed for fast component of eye movement Us'ally a central patholo#y.
ye movement that typically occ'r6 Com+ined hori-ontal and rotational 3torsional4
8in#le planarJhori-ontal or vertical
Direction chan#in#
Discernin# peripheral vs central
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Discernin# peripheral vs centralpatholo#y +ased on nysta#m's
Symptom or Sin /eripheral *entralysta#m's direction $i2ed plane 3hori-ontal
and torsionalDirection chan#in#,varia+le
?ect of H2ation onnysta#m's
Decreases 8ame or increases
ati#a+ility Bes o
D'ration3sin#le episode4
Less than 1 min'te 8ymptoms may persist
0ntensity of si#ns andsymptoms
8evere verti#o, markednysta#m's, systemic
symptoms s'ch asna'sea
Us'ally mild verti#o,less intense nysta#m's,
rare nausea
/alance $ay +e mild O5& yearsof a#e5& may have 34
9om+er#
34 9om+er#, deviateL9 d'rin# #ait
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ysta#m's video
ori-ontal and rotationalnysta#m's
ori-ontal nysta#m's
;ertical nysta#m's
=hat is the di?erence +et"eenthe di?erent types ofnysta#m's
http://www.youtube.com/watch?v=fBDXQchKapU&feature=relatedhttp://www.youtube.com/watch?v=fBDXQchKapU&feature=relatedhttp://www.youtube.com/watch?v=PNSK8q40ax0&feature=fvwhttp://www.youtube.com/watch?v=_KtMS7hx5c4http://www.youtube.com/watch?v=_KtMS7hx5c4http://www.youtube.com/watch?v=_KtMS7hx5c4http://www.youtube.com/watch?v=PNSK8q40ax0&feature=fvwhttp://www.youtube.com/watch?v=PNSK8q40ax0&feature=fvwhttp://www.youtube.com/watch?v=fBDXQchKapU&feature=relatedhttp://www.youtube.com/watch?v=fBDXQchKapU&feature=related7/25/2019 1- Vestibular Disorders 1-13-16
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8ymptoms associated "ith centralvs peripheral patholo#y
*entral /atholoy /eripheral /atholoy
Ata2ia often seen Ata2ia mild or not present
A+normal smooth p'rs'its anda+normal saccadic eyemovements
8mooth p'rs'its and saccades's'ally normal. Positional testin#may prod'ce nysta#m's
Do not typically incl'de hearin#loss
$ay incl'de hearin# loss, f'llnessin ears, tinnit's
Ac'te verti#o is not 's'allys'ppressed +y vis'al H2ation
Ac'te verti#o is 's'ally moreintense, +'t can +e s'ppressed"ith vis'al H2ation
yes oscillate at e'al speeds3pend'lar nysta#m's4
ysta#m's e2hi+its slo" and fastphase 3Eerk nysta#m's4
P're persistent verticalnysta#m's re#ardless ofpositional testin#
8pontaneo's hori-ontalnysta#m's
Bo'
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Bo' re takin# the history of a Q5 yo female"ho is active. 8he presents "ith6 verti#o"ith movement, na'sea and vomitin#, and
nysta#m's "ith head movements. =hich ofthe follo"in# do yo' !T e2pect to Hndd'rin# yo'r e2amination6
A. A positive 9om+er#/. A fati#'in# nysta#m's
*.1taxia
All others are Peripheral,a'sea is mostly peripheral,and rare in central
D. ormal smooth p'rs'its
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Case 8t'dy 1
Bo'r patient has complaints of intermittent severedi--iness. The symptoms are a##ravated +yrollin# over in +ed and #ettin# 'p in the mornin#.
=hen o+servin# the patient yo' notice a torsional
hori-ontal nysta#m's "ith head movement thats'+sides after K5 seconds
The patient states that foc'sin# on an o+Eectmakes the di--iness +etter.
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0s the lesion likely central orperipheral
1. Central
+./eripheral
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=hat is a likely dia#nosis
A. ;esti+'lar ne'ronitis 3no hearin#
loss or facial "eakness4. //V
Intermittent
C. $eniere
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0f the patient has persistentsymptoms after m'ltiple
treatments "hat sho'ld +er'led o't
1. entamycin
to2icity(. /PP;
*. $eniere
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Case 8t'dy (
Bo'r patient is admitted "ith a dia#nosis of/PP; from a local physician. =heno+servin# the patient yo' note an irre#'lar
vertical nysta#m's that is persistent. The patient states that he is al"ays a little
di--y and is havin# di@c'lty foc'sin# hisvision.
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0s the physician dia#nosiscorrect
1. Bes
+. 2o
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=here is the lesion likelylocated
1. Posterior canal
(. Anterior canal
). *entral vestibular system
K. Peripheral vesti+'lar system
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Case 8t'dy *
Bo'r patient has complaints of intermittentdi--iness "ith a feelin# of f'llness andrin#in# in +oth ears, also mild hearin# loss.
The symptoms have persisted on and o?for m'ltiple years 3only lastin# 1>( ho'rs4.
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=hat is the likely dia#nosis
1. ;esti+'larne'ronitis
(. /PP;
*. $eniere
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8ho'ld a physician +econs'lted
5. 6es(. o
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N'estions
9eadin# Assi#nment !
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