Vestibular Rehabilitation:Examination and Treatment

Jeff Walter PT, DPT, NCS

Referral Process• Majority of patients present with symptoms,

not a medical diagnosis

• Specialist vs. Primary Care

• Misdiagnosis is common

Medical History: Systems Review

• Neurological: Stroke, Multiple Sclerosis, Migraine, Seizure, CHI, Cervical Cord Compression

• Cardiovascular: Arrhythmias, Orthostatic Hypotension

• Endocrine: Diabetes (neuropathy, retinopathy, stroke-risk factor)

• Orthopedic: Arthritis (neck / spine), RA, AnkylosingSpondylitis

• Psychological: Anxiety, Panic

Laboratory Testing

• Audiogram• ENG / VNG: includes caloric testing • MRI: brain imaging• MRA: vascular imaging• Cardiac Testing• Rotary Chair: optimal test to determine

bilateral vestibular function• Posturography: utilized to assess for

aphysiologic sway

Terminology

• Vertigo

• Imbalance

• Oscillopsia

• Disequilibrium

• Lightheadedness

History

• Type of dizziness

• Spontaneous vs. motion induced

• Duration

• Frequency

• Provocative factors

• Auditory complaints

• Falls

Identify axis around which symptoms are provoked

Red Flags (remember the D’s)

• Decline in hearing

• Dysarthria

• Discoordination

• Diplopia

• Decreased mentation and urinary incontinence

• Decline in strength/weight

• Decreased consciousness

• Dysfunction of cranial nerves

Examination

Auditory screen

• “Weber Test” for unilateral hearing loss: vibrating tuning fork placed on top of head, if sound lateralizes test is positive for ipsilateral conductive loss or contralateral nerve- type deafness. 512 Hz fork is optimal.

Gaze Stability Assessment

• Spontaneous Nystagmus

• Gaze evoked Nystagmus

• Pursuit

• Saccades

• Static vs. Dynamic Visual Acuity

• Head Impulse Test

• Post Head-Shaking induced Nystagmus

• Hyperventilation induced dizziness/nystagmus

Methods of blocking fixation

• Frenzel lenses

• Video infrared camera

• Ophthalmoscope

Suppliers

• Frenzel Lenses

– Baxter (cat # Au5050)

– ICS Medical

– Nagashima

– Bausch and Lomb (same as Baxter)

– US Neurologicals

• Video

– Micromedical 217-483-2122

– Iscan: 617-273-4455

– SMI http://www.smi.de

– Neurokinetics http://neurokinetics.com/

– ICS/GNO 847-534-2150

– Synapsis 512-301-9890

Spontaneous Nystagmus

• Peripheral– Mixed

horizontal/torsional

– Present with acute lesions, rarely with chronic stable lesions

– More prominent with fixation removed

• Central

– Vertical or torsional

– Acute or chronic

– More prominent with fixation present

Pursuit

• Abnormal pursuit is a common sign of central dysfunction

• Impairment not strongly localizing:

– Advanced age

– Brainstem disorders

– Cerebellar disorders

– Congenital nystagmus

– Drug ingestion

– Inattention

Gaze evoked nystagmus

• Gaze held left, right, up and down at 20-30 degrees from centered resting position

• Observe for nystagmus with and without fixation

Gaze-Evoked Nystagmus

• Peripheral dysfunction

– Uni-directional

– More prominent with fixation removed

• Central dysfunction

– Direction changing

– More prominent with fixation present

Gaze-Evoked Nystagmus

• Causes of Gaze-evoked nystagmus (GEN)

– Medication / Substance Abuse (ETOH, sedatives, anti-convulsants)

– Brainstem or cerebellar disorder

– Congenital nystagmus

Alexander’s Law = “peripheral vestibular origin nystagmus increases in intensity with gaze directed toward the fast phase”

1st degree nystagmus- present only in gaze towards fast phase

2nd degree nystagmus- present in primary gaze and stronger in gaze towards fast phase

3rd degree nystagmus- present in all gazes, strongest in gaze towards fast phase

Saccades

• Assess volitional horizontal saccades with special attention to

– Amplitude?

– Duration?

– Synchrony?

• Dysfunction indicative of central involvement (pons or cerebellum)