Vestibular rehabilitation - acpin

Anne Rodger
ACPIN Conference and AGM
10/03/2012

Ves$bular Rehabilita$on
5 -­‐10% normal population experience vertigo at some
point – incidence increases with age
BPPV lifetime prevalence of 2.4% (Bhattacharyya et al
2008)

Dynamic systems framework
postural control (PC)
Integration
Task – What postural
demand
Environment:
Individual:
Cognitive: including
internal models of body,
attention, confidence etc
Sensory: Integration, to
determine position and
motion of body in space:
vision, proprioception and
vestibular systems)
Motor commands to
control the body in space
Shumway-­‐Cook and Woollacott
2007)
Strategies to adapt to varying
task and environmental
demands.
Individual
Motor
Sensory
cognition
Task
PC
Environment

Balance emerges …
processing
(sensory and musculoskeletal
systems)
Input
output

Ves$bular system
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When it goes wrong

?
How much of a problem is vestibular dysfunction in an
elderly population?
How much of a problem is it in MS? Is this a central of
peripheral issue?
How much of an problem is it in TBI or posterior fossa
tumours?
Do YOU always assess vestibular function in these groups?

Elderly -­‐ Un-­‐Diagnosed and Under
treated?
Dizziness is very common (Lawson et al 2008)
1/3 people over the age of 65 fall annually -­‐ rises with age. (Liston et al
2011)
Vestibular function declines with age.
50% of people in their 60s are unable to maintain balance when only
vestibular cues are present (rises with age ~70% for over 70s and 85%
for over 80s (Liston et al 2011)
Most elderly fallers attend Geriatricians / falls service not ENT
73% older adults referred for falls assessment had vestibular
impairment (Liston et al 2011)
50% all dizziness in older people is due to BPPV (Oghalai et al 2000)

MS – A central or peripheral
problem?
50% pwMS report vertigo at some point (Karatas 2008)
Most common cause of vertigo in pwMS -­‐ 52%= BPPV with
32% brainstem (Frohman et al 2000)
BPPV = the cause in 60% (in Frohman 2003)
83% pwRRMS tested had vestibular pathology of peripheral
aetiology, ONLY 3% had central symptoms (Zeigelboim et al
2008).
In MS customised VR shown to improve fatigue, balance
function and perceived disability compared to control groups
receiving strength or endurance training (Herbert et al 2011)

TBI & posterior fossa tumours
BPPV is most common cause of dizziness post TBI -­‐
only 8% are Central (Luxon and Davies 1995).
Central / Peripheral – need an accurate diagnosis. Dix
Hall-­‐Pike, eye movements
Commonly undiagnosed?
Posterior fossa tumours – vertigo and reduced balance
common.

What is Ves$bular Rehabilita$on
(VR)?
Canalith repositioning
Exercises
adaptation exercises for gaze stabilization
habituation exercises
substitution training for visual or somatosensory input
postural control exercises
fall prevention training
patient and family education.
VR effective but variable results -­‐ 60%–85% improvement
(Cass et al 1996, Topuz et al 2004)

Subjec$ve Assessment -­‐
Onset – gradual, recent, longstanding
Duration
How they describe symptoms
Frequency/irritability, severity
Precipitating factors
Functional context
Level of control over symptoms
Psychological state

Objec$ve assessment
Visual:
Observation at rest; smooth pursuit, saccades, VOR and
VOR with head thrusts, VOR suppression
Physical:
Balance
Posture
Sensation/Proprioception
Movement patterns, posture, muscle strength, range of
movement-­‐particularly of neck, how they interact, gait
Symptom provoking movements – bending, turning etc
Visual provoking movements

Other Causes of Dizziness
VBI
Postural Hypotension
Hyperventilation and
Anxiety
Thyroid
Medications
Anaemia
Cardiac problems -­‐
arrhthmias etc
Vasovagal Attacks
Hypoglycaemia
Psychiatric
­Therefore a detailed
history needs to be
taken.

Outcome measures
Subjective:
Dizziness Handicap Index (DHI)
Vestibular Disorders of Daily Living Scale (VADL) (Cohen 2000)
Vertigo Symptom Scale VSS (Yardley et al 1992)
VAS (Visual Analogue Scales)
Functional:
Timed Get Up and Go
Berg Balance
Timed Ten Metre Walk
Dynamic Gait Index
VOR
Dynamic Visual Acuity (DVA)
Sensory Integration
(mCTSIB) (Modified Clinical Test of Sensory Integration of Balance (Wrisley et
al 2004, Whitney et al 2004))
Motion Sensitivity / Movement Triggers
MST (Motion Sensitivity Test (Akin and Davenport 2003)

Physiotherapy Treatment
Aim to
Reduce dizziness
Improve gaze stability
Improve postural stability
Improve functional abilities
By encouraging compensation, whereby symptoms
progressively lessen, by a variety of mechanisms
Spontaneous
Adaptation (neural plasticity) – enhancing VOR and VSR so less input is
required
Substitution, prediction and other cognitive strategies (Herdman 1994).
Compensation through Habituation

Mechanisms of recovery
Spontaneous
Occurs by a lessening of the static dysfunction
Corresponds with recovery of firing rate of the
vestibular nucleus
Often occurs in first few days -­‐ weeks
Enhanced by movement and delayed by inactivity
Partial or full recovery

Mechanism of recovery: Adapta$on/
plas$city
Ability of the V.S. to make long term changes in the
neuronal response to an input
Adaptation is induced by retinal slip (movement of image
across retina)
Retinal slip sends an error signal, which brain tries to
minimise -­‐ by increasing the gain on the vestibular
responses (Girardi & Konrad 1998) = Re-­‐Calibration
Repetition increases the adaptation (Girardi & Konrad 1998)
Context specific to:
frequency of head movement
directional plane of movement
target distance

Adapta$on exercises
Aim to increase the gain of the VOR. (Girardi & Konrad 1998)
Increase the tolerance to head movement.
head movement, eyes focus on object (= x1)
Head and object move, whilst focussing on object (= x2)
Change distance, speed, direction, background, postural demands.
Should train for 1 -­‐2 minutes
Repeat 3-­‐5 times a day
Context specific
Herdman 2002)
Virre & Sitarz 2002 found good results for 2 x 30 minutes
sessions for a week subjects looking at moving images on a
computer

Mechanisms of recovery Subs$tu$on.
Primarily for bilateral disorders
Other strategies replace the lost vestibular
function (visual and somatosensory)
A number of reflexes can be optimised
COR which operates at low frequency (under 0.1) can partially
compensate by increasing its range-­‐ up to 0.3Hz (Herdman 1997)
VCR (vestibulo-­‐collic reflex) aligns head to gravitational vertical
and the CCR (cervico-­‐collic reflex) aligns head to the body, can
increase their influence in posturally challenging circumstances or
in balance problems (Guitton et al 1986)

Subs$tu$on Con$nued
Performance of saccadic eye movements to help
regain the target
Use of visual and somatosensory cues
Advice on safety at night, swimming etc
Strategies based on prediction or anticipation (Zee
2000)
Strategies ineffective for
fast, unexpected movements
or when the cues are inaccurate / not available

Mechanisms of recovery
Habitua$on
A reduction of a ‘pathological’ response to a
stimulus brought about by repeated exposure to
that stimulus (movement or posture)
Desensitisation -­‐ eventually the stimulus has to be
stronger in order to be symptomatic (Girardi & Konrad
1998)
Repetition – vital for LTP (Shumway-­‐Cook and Woolacott
2001)

Habitua$on exercises
Tailoring vertigo producing manoeuvres within an
ADL setting, or getting patient to repeat postures
or symptom producing activities.
Cawthorne-­‐Cooksey Exercises (CCE)
Brandt Daroff
?outdated or poorly evaluated

Visual Ver$go
Symptoms provoked or aggravated by specific visual
contexts, (supermarkets, driving or movement of
objects) (Guerraz et al 2001)
Patients have an abnormally large perceptual and
postural responses to disorientating visual
environments
Treatment needs to involve visual motion
desensitisation – e.g. repeated optokinetic stimulation
High tech: Planetarium or low tech: DVD (Pavlou 2006,
2010)

Summary
Vestibular dysfunction is common.
In neurological patients the vestibular dysfunction is not
necessarily from Central origin.
Physiotherapists have an important role; success comes
from: hard sell based on an accurate comprehensive
assessment and tailored treatment plan
-­‐ If in doubt: Encourage movement and visual movement

Ques$ons?
anne.rodger@uclh.nhs.uk

References
Bhattacharyya, N; Baugh, R; Orvidas, L; et al (2008). Clinical
practice guideline: Benign paroxysmal positional vertigo.
Otolaryngology–Head and Neck Surgery 139, S47-­‐S81
Cass, S. Borello-­‐France, D. Furman, J. 1996. ‘Functional
outcome of vestibular rehabilitation in patients with abnormal
sensory-­‐organisation testing’ American Journal of Otology 17:
581-­‐ 94
Frohman E, Zhang H, Dewey R, Hawker K, Racke M, Frohman T
(2000). Vertigo in MS: utility of positional and particle
repositioning manoeuvres. Neurology, 55(10), 1566-­‐9.
Frohman E; Kramer P; Dewey R; Kramer L; Frohman T. (2003).
Benign paroxysmal positioning vertigo in multiple sclerosis:
diagnosis, pathophysiology and therapeutic techniques Multiple
Sclerosis, 1 June, vol. 9, no. 3, pp. 250-­‐255(6)

References 2
Girardi, M. Konrad, H (1998). ‘Vestibular rehabilitation
therapy for the patient with dizziness and balance disorders’.
Orl-­‐Head and Neck Nursing. Fall Volume 16, no. 4 13-­‐ 22.
Guerraz, M. et al (2001) ‘Visual vertigo: symptom assessment,
spatial orientation and postural control’ Brain 124 (8): 1646-­‐1656
Guitton, D. Kearney, R. Wereley, N. Peterson, B. (1986).
‘Visual, vestibular and voluntary contributions to human head
stabilisation’ Experimental Brain Research. 64: 59-­‐69
Hebert, J: Corboy,J; Manago, M: Schenkman, M. (2011) Effects of
vestibular rehabilitation on multiple sclerosis-­‐related fatigue
and upright postural control: a randomized controlled trial.
Phys Ther. Aug;91(8):1166-­‐83
Herdman, S (1994). Vestibular Rehabilitation’. F.A. Davis Co.
Phildelphia
Herdman, S. (1997). ‘Advances in the treatment of vestibular
disorders’. Physical Therapy 77: 602-­‐618
Herdman, S & Whitney S. 2007 Interventions for the patient
with vestibular hypofunction, chapter 20 in Vestibular
Rehabilitation. Susan Herdman Third Edition FA Davies
Company Philadelphia.

References 3
Karatas, M (2008). Central vertigo and dizziness: epidemiology,
differential diagnosis and common causes. The Neuologist, 14 (6):
355-­‐364)
Lawson, J. Bamiou, D. Cohen, H. & Newton, J. (2008) Positional
vertigo in a falls service Age Ageing 37 (5): 585-­‐588.
Liston, M; Bamiou, D; Martin, F;Luxon, L; Pavlou, M. (2011) Vestibular
function in unexplained falls. Abstract for British Society of Neuro-­otology.
Luxon, L & Davies, R. 1995. ‘Handbook of Vestibular Rehabilitation.
Oghalai, J. S., et al. (2000). "Unrecognized benign paroxysmal
positional vertigo in elderly patients." Otolaryngol Head Neck Surg
122(5): 630-­‐4
Pavlou, M. (2010) The Use of Optokinetic Stimulation in Vestibular
Rehabilitation. Journal of Neurologic Physical Therapy: Volume 34 -­‐
Issue 2 -­‐ pp 105-­‐110

References 4
Pavlou, M. Davies, R. Bronstein, A. (2006). The assessment of
increased sensitivity to visual stimuli in patients with chronic
Dizziness. Journal of Vestibular Research 16 223–231
Shumway-­‐Cook A, Woollacott M (2007) Motor Control Theory and
Practical Applications Third Ed Lippincott Williams and Wilkins
Philadelphia.
Topuz O, Ardic F, Sarhus M, Ogman G, (2004) Efficacy of vestibular
rehabilitation on chronic unilateral vestibular dysfunction Clinical
Rehabilitation18(1):76-­‐83.
Zee, D 2000 ‘Vestibular Adaptation’ in Vestibular Rehabilitation Susan
Herdman (2 nd Ed) Contemporary Perspectives in Rehabilitation. F A
Davis Company. Philidelphia
Zeigelboim, B; Arruda, W; Mangabeira-­‐Albernaz, P. et al. (2008).
Vestibular Findings in Relapsing, Remitting Multiple Sclerosis: A
Study of Thirty Patients International Tinnitus Journal, Vol. 14, No. 2,
139–145