Objectives

Managing Visual and Vestibular Dysfunction in the Home Diane M. Wrisley PT, PhD, NCS Sharan D. Zirges, PT, MSHA Michelle Gutierrez, PT, DSc

• By the end of this session, the participant will be able to: • Describe the anatomy and physiology of the vestibular, visual, and balance systems. • Compare and contrast different causes of visual and vestibular dysfunction. • Perform a vestibular, visual, and balance examination in the home. • Utilize examination results to determine differential diagnosis. • Perform an examination and intervention for BPPV. • Perform interventions for vestibular, visual, and balance deficits. • Apply the information learned to representative patient scenarios.

Anatomy and Physiology Review University at Buffalo PT 604

Vestibular Rehabilitation Dr. D. M. Wrisley

Peripheral Vestibular System

Hain TC, Hillman MA. Anatomy and physiology of the normal vestibular system. In Herdman SJ. (ed.) Vestibular Rehabilitation. FA Davis Co. Philadelphia. 1994:4

Visual and Vestibular Dysfunction in the Home Wrisley, Zirges, Gutierrez

Membranous Labyrinth

Kelly JP. The sense of balance. In Kandel ER, Scwartz JH, Jessell TM. (eds) Principles of Neural Science: Third Edition. Appleton and Lange. Norwalk, CN. 1991:502

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Orientation of Semicircular Canals

Anatomy of Semicircular Canal Photomicrograph of crista ampullaris and its cupula. Note that the cupula is attached to the ampullary roof. (Gacek , 2008)

Hair Cells within the semicircular canals (Schuenke, Schulte, Schumacher, and Ross, 2007)

Baloh RW, Honrubia V. Clinical Neurophysiology of the Vestibular System. FA Davis Co. Philadelphia. 1990:27.

Push – Pull Mechanism

Summary of important concepts • Semicircular Canals • • • •

Respond to angular acceleration Have a spontaneous firing rate The canals are excited by movement in their plane Are arranged in a push-pull system

Furman JM and Cass SP. Vestibular Disorders: A Case Study Approach. Oxford University Press, Oxford 2003:11

Otoliths

Anatomy of Otoliths

Furman JM and Cass SP. Vestibular Disorders: A Case Study Approach. Oxford University Press, Oxford 2003:7

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Otoliths

Summary of Important Concepts • Otoliths • • • •

Vascular Supply • Peripheral vestibular system supplied by labyrinthine artery (usually branch of anterior inferior cerebellar artery) • Labyrinth has no collateral anastomatic network • At risk for ischemic and embolic events

Respond to linear acceleration and gravity Have a spontaneous firing rate The otoliths are excited by movement within the plane of macula Push pull relationship within each otolith organ

Central and Peripheral Vestibular Pathways Cerebral Cortex Ocular Motor Nuclei (VOR Reflex)

Peripheral Vestibular Organs

Thalamus

Vestibular Nuclei

ANS (parasympathetic) Nausea/Vomiting

Cerebellum

Cervical Proprioceptors

MVST and LVST (Vestibulospinal Reflexes)

Vestibular Ocular Reflex

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Vestibular Ocular Reflex

Vestibular Spinal Reflex

Young PA, Young PH. Basic Clinical Neuroanatomy. Williams and Vestibular Rehabilitation Wilkins, Baltimore, MD. 1997:121. Dr. D. M. Wrisley

Young PA, Young PH. Basic Clinical Neuroanatomy. Williams and Wilkins, Baltimore, MD. 1997:74.

VOR Gain Adaptation

Cohen et al. Exp Brain Res 90:526, 1992

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Eye Movements • Require information about

• Head movements (vestibular information) • Visual objects (vision) • Eye movement and position (proprioceptive information) • Selection of a target (brainstem and cortical areas)

• Types of eye movements • Conjugate • Vergence • Gaze stabilization • VOR • Optokinetic reflex

• Direction of gaze • Saccades and smooth pursuit

• Accommodation Reaction: • Convergence of the eyes • Pupillary constriction • Thickening of the lens

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Optokinetic Reflex • Adjusts eye position during slow head movements

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Visual Acuity

Visual Testing

High- and Low-Contrast Visual Acuity

Melbourne Edge Test

Visual Contrast Sensitivity

Ocular Motor Function  Smooth pursuit  Smooth eye movement tracking a slowly moving discrete target  Mediated by brainstem eye fields, medial longitudinal fasciculus, and cranial nerves III, IV, and VI  Abnormalities are seen with cerebellar or brain stem lesions

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Ocular Motor Function

Ocular Motor Function

• Saccades • A quick eye movement or refixation • Mediated by frontal eye fields (voluntary saccades), brainstem reticular formation (voluntary and involuntary saccades) and cranial nerves III, IV, and VI • Abnormalities are seen with cortical, brainstem and cerebellar lesions

Ocular Motor Function • Convergence • The ability of the eyes to move symmetrically to look at objects at varying distance from the eyes • Mediated by medial rectus neurons • Abnormalities are seen with brainstem or basal ganglia lesions

Ocular Motor Function • VOR Cancellation (Fixation Suppression) • Ask the patient to look at their finger or a target that is moving with them while rotating their head or body from side to side. Note any visual vestibular nystagmus or symptoms of dizziness or nausea • Abnormalities in the presence of adequate visual acuity implies floccular dysfunction

Visual and Vestibular Dysfunction in the Home Wrisley, Zirges, Gutierrez

• Optokinetic Nystagmus • Involuntary reflexive refixation eye movements • Mediated primarily through motion sensitive neurons in retina • Free App: eyeworkout101

Ocular Motor Function • Skew Deviation (Cover/Uncover test) • • • • •

Test for ocular torsion and strabismus Ocular torsion is mediated by otolith function Strabismus is mediated by ocular muscles and central nervous system Ocular torsion may be seen with acute vestibular dysfunction Deviation of the eye may be seen with ocular muscle imbalance or central nervous system lesions

Visual Testing Lab • Visual Acuity • Visual Contrast Sensitivity • Peripheral Visual Fields • Smooth Pursuit • Saccades • Convergence • Cover/Uncover • Optokinetic Nystagmus

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Clinical Measures of Vestibular Function • Spontaneous Nystagmus

Vestibular Testing

Clinical Measures of Vestibular Function • Active and Passive VOR • Mediated by labyrinth, VIII cranial nerve, and vestibular nucleus • Active VOR • While the patient looks at a target have them move their head horizontally and then vertically at about 2 cycles/second. Look for refixation saccades, note reports of dizziness or nausea

• Passive VOR • Hold the patient’s head tipped down approximately 30 degrees, move the patient’s head horizontally and vertically at about 2 cycles/second while asking them to focus on your face. Look for refixation saccades, note reports of dizziness or nausea

• Look for repetitive fast and slow movements of the eyes in room light with and without fixation and/or with fixation suppressing goggles • Direction fixed, horizontal-rotary nystagmus is indicative of an acute asymmetry in the firing of the labyrinth, VIII cranial nerve or vestibular nucleus • The nystagmus will intensify with gaze in the direction of the fast phase

• Direction changing horizontal, vertical, torsional or pendular nystagmus is indicative of brain stem, cerebellar or cortical lesions

Clinical Measures of Vestibular Function • Dynamic Visual Acuity Longridge and Mallinson 1984 • Performed with a Snellen Eye Chart. The patient reads the lowest line comfortably with the head still and then with the head moving at 2 Hz horizontally and vertically. The number of lines of acuity lost are recorded. • Patients with bilateral vestibular dysfunction will have a loss of >5-6 lines; patients with acute unilateral vestibular loss will have a loss of >2-3 lines

• Abnormalities are indicative of vestibular dysfunction

Clinical Measures of Vestibular Function  Head Thrust (Head Impulse Test) Schubert et al 2004; Halmagyi and Curthoys 1988

Clinical Measures of Vestibular Function • Head Shake (Postheadshake nystagmus) Burgio et al 1991, Fetter 2000, Tseng and Chao 1997

 95% specificity, 35% sensitivity for detecting vestibular lesion  82% specificity, 71% sensitivity UVL, 84% sensitivity BVL Schubert et al 2004  The patient is asked to fixate on a target while the examiner moves the patients head rapidly to each side  The examiner looks for any movement of the pupil during the head thrust and a refixation saccade

• The head is tilted forward 30 degrees and the head is shaken at 2 Hz for 20 seconds. Observe for any postheadshake nystagmus either in room light or with fixation suppressing goggles. Can be repeated in vertical direction • Indicative of acute imbalance in vestibular inputs in the plane of rotation

http://library.med.utah.edu/neurologicexam/movies/cranialnerve_n_13_x2.mov

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Clinical Vestibular Evaluation

Unrecognized BPPV in the Elderly

• Positional Testing

• 100 consecutive patients referred to geriatric clinic

• Motion Sensitivity Quotient Norre and deWeerdt 1981, Smith-Wheelock et al 1991, Shepard et al 1993 • Provides an objecive score of the patient’s dizziness • The subject moves into positions that involve head and body movement • The patient reports a dizziness intensity score and the duration of the symptoms is recorded. • The symptom intensity and the duration values are added to get a score. The MSQ is calculated by multiplying the number of provoking positions by the score and dividing by 2048. 0 = no symptoms; 100 = severe dizziness in all positions • The positions can also be used for treatment

• Age range was 51-95 (mean 74) • Dizziness was reported by 61% of the older adults although they were not seeking intervention for dizziness • Balance disorders were noted in 77% of the patients • 9% of these subjects had unrecognized BPPV Oghalai JS et al, May, 2000

Dix-Hallpike Maneuver

BPPV in the Elderly • Retrospective study of 404 patients diagnosed with BPPV • Patients over 70 took longer to consult for problem • Presentation of unsteadiness, or imbalance without vertigo more common in the elderly • Effectiveness of CRM less • Higher recurrence rate Bateucas-Caetrio et al 2013

• Study of 571 75 year olds • BPPV found in 11% • Dizziness reported by 36% • People with BPPV demonstrated impaired balance and walking tests

•With the patient in long-sitting , their head is turned 45 degrees toward the ear being tested • The patient is brought back into supine with the head extended 30° over the edge of the bed.

Kollen et al 2012

Furman and Cass. New England Journal of Medicine. 1999;340:1590-1596

The Roll Test

What systems need to be checked before testing for BPPV? • Clear cervical spine • Ocular motor function • Vestibular Ocular Reflex • Vertebral artery test (?) Begin with the patient supine and the head in midline. Tilt the head up 30° in midline

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The Roll Test

Visual and Vestibular Testing Lab • Passive VOR • Head Thrust • Head Shaking • Dynamic Visual Acuity • Dix-Hallpike • Roll Test

• • • • •

Smooth Pursuit Saccades Convergence Optokinetic Nystagmus VOR Cancellation

Roll head quickly to one side, observe for nystagmus, ask patient to report symptoms

Conditions which indicate necessary referral to MD • • •

Differential Diagnosis When to refer out

Clinical decision flowchart

Visual and Vestibular Dysfunction in the Home Wrisley, Zirges, Gutierrez

• • •

Sudden or unexplained unilateral hearing loss Unexplained neurological signs Inconsistencies in clinical exam of vestibular function, history, physical exam (gait/stance), dynamic visual acuity, motion sensitivity or positional tests Exam does not reveal cause of patients problems No improvement after 30 day treatment period Unstable BP, orthostasis, low O2 saturation Which do you think would be urgent referrals?

AURICULAR OR VESTIBULAR

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NEUROLOGICAL AND OTHER

NON VESTIBULAR

NEUROLOGICAL OR VESTIBULAR

Assessment tool

Expected results if

Ocular Motor testing Smooth Pursuit Saccades Spontaneous Nystagmus

Is the vertigo…

Vestibular Ocular Reflex Testing Active and Passive VOR Head thrust

Central vestibular dysfunction

Unilateral vestibular dysfunction

Bilateral vestibular dysfunction

Frequently abnormal Frequently abnormal Frequently abnormal: Non-fatiguable Direction changing Gaze evoked Downbeat

Typically normal Typically normal Acute: frequently abnormal or present Chronic: typically normal

Typically normal Typically normal Typically normal

May be abnormal Usually normal

Abnormal if acute Abnormal with head movement in direction of lesion if acute Abnormal if acute Usually normal – may increase symptoms Abnormal if acute

Usually abnormal Usually abnormal bilaterally Usually normal Usually normal

May see non-fatiguable horizontal nystagmus if acute

Usually negative

Head Shaking VOR cancellation

Usually normal May be abnormal

Dynamic Visual Acuity

Usually normal

Dix-Hallpike Test

May see non-fatiguable nystagmus, downbeat nystagmus

Abnormal

Vestibular and Balance Intervention

CASE STUDY PAST MEDICAL HX

COMPLAINTS

TESTS

RECENT HISTORY

78 YEAR OLD FEMALE UNREMARKABLE PAST MEDICAL HISTORY

WASHING DISHES THE FLOOR AND CHAIRS STARTED MOVING

COMPLETE NEUROLOGICAL AND CARDIAC WORK UP

SEVERE COLD SINUS INFECTION 3 WEEKS PRIOR – TOOK OVER THE COUNTER MEDS

DIFFERENTIAL DIAGNOSIS AND PLAN OF CARE

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What are the indications for vestibular rehabilitation?

Objectives • By the end of this lecture the student will be able to: • Describe the theories of vestibular rehabilitation • Perform habituation exercises and adaptation exercises for vestibular disorders • Apply exercises appropriately to specific diagnoses • Modify and progress the exercise program based on patient response and develop a plan to discontinue exercises • Discuss the evidence for vestibular rehabilitation

Vestibular and Balance Impairments • Vestibular Ocular Dysfunction • Ocular Motor Dysfunction • Sensory Interaction • Motion Sensitivity • Balance and Gait Dysfunction • Sequence, timing of motor activities • Strength, ROM • Limits of stability

Impairments seen with specific diagnoses • Bilateral Peripheral Vestibular Loss • Diagnoses: idiopathic, ototoxic • Impairments: • Gaze instability • Balance Impairments • • • •

Poor use of vestibular information Inappropriate use of balance strategies Difficulty switching between strategies Inaccurate sense of limits of stability

• Abnormal perception of vertical, self or environment motion, space and motion discomfort • Poor postural alignment, head stabilization with resultant neck and back muscle tension/pain

Visual and Vestibular Dysfunction in the Home Wrisley, Zirges, Gutierrez

• Stable, non-fluctuating central or peripheral vestibular dysfunction or balance impairments • Based primarily on impairments not on diagnosis • What impairments do we identify through the vestibular evaluation?

Impairments seen with specific diagnoses • Unilateral Peripheral Vestibulopathy • Diagnoses: Acoustic Neuroma, Vestibular Neuritis, Vestibular Labyrinthitis, Meniere’s Dx • Impairments: • Gaze instability • Balance Impairments • Poor use of vestibular information • Inappropriate use of balance strategies • Difficulty switching between strategies

• Abnormal perception of vertical, self or environment motion, space and motion discomfort • Poor postural alignment, head stabilization with resultant neck and back muscle tension/pain

Impairments seen with specific diagnoses • Benign Paroxysmal Positional Vertigo • Impairments: • Abnormal perception of motion • Poor use of vestibular information for balance • Inappropriate balance strategies

• Considerations • Mechanical Problem • Repositioning must be Performed first

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Impairments seen with specific diagnoses • Central Vestibular Dysfunction • Diagnoses: CVA (i.e. Wallenberg Syndrome), MS, TBI, cerebellar dysfunction, tumor • Impairments: • Balance Impairments • • • •

Poor use of sensory information for balance Inappropriate use of balance strategies Difficulty switching between strategies Inaccurate sense of limits of stability

Treating at the Impairment Level • Goals: • • • •

Correct temporary/ changeable impairments Prevent secondary impairments Teach compensatory strategies for permanent impairments Attempt to change impairments where not known whether permanent • Refer to other health care professionals as appropriate.

• Abnormal perception of vertical, self or environment motion, space and motion discomfort • Impaired smooth pursuit, saccades

How do rehabilitation specialists treat people with balance disorder? • Based on impairments identified on evaluation and theory of vestibular compensation • Habituation Exercises • Repetition of positions that increase symptoms with aim to increase threshold at which the vestibular system responds • Cawthorne-Cooksey exercises • Norre’s exercises (from motion sensitivity test)

Habituation Exercises • Guidelines for developing and progressing exercises • Up to 4 movements are chosen from the MSQ test results • Patient performs these movements 2 or 3 times, twice a day • The movements are performed quickly enough and through enough range to produce mild to moderate symptoms with increasing rigor as the patient improves • The patient should rest between each movement for symptoms to stop • Symptoms should decrease within a minute after each exercise or within 15-30 minutes after all exercises • May take 4 weeks to see improvements, usually performed for 2 months then tapered off

Visual and Vestibular Dysfunction in the Home Wrisley, Zirges, Gutierrez

Cawthorne-Cooksey Exercises • Guidelines for developing and progressing exercises • Exercises should be performed in various positions and at various speeds • Exercises should be performed with the eyes open and closed • Patients should be trained to function in noisy and crowded environments • Patients exercised in daily group sessions

Vestibular Treatment • Ocular Motor Exercises • Saccades and Smooth Pursuit • Indications: When smooth pursuit and saccades are impaired or when the performance increases symptoms • Patients repeat the motions for 30-60 seconds 1-2 x/day

• Adaptation • Exercises designed to alter the gain of the VOR and VSR promoting central compensation for the vestibular loss • Gaze stabilization exercises • Balance exercises

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Vestibular Ocular Dysfunction • Vestibular stimulation exercises (Gaze stabilization exercises) • VOR x1 • VOR x2 • Progress from sitting through standing, increase demands of task • vary sensory conditions of task • Narrow base of support • Standing on foam • Busy visual background

Progression • What factors may influence your progression of the exercises? • The exercises will usually increase patients symptoms – how dizzy do you want your patients to get? • How will you control the increase in symptoms? • What cautions will you provide patients when you give them a home program? • When and how do you stop the exercise program?

Treatment of Otolith Dysfunction

Space and Motion Discomfort

• Isolated Otolith Dysfunction is rare • Exercises include linear acceleration: tilt and translation

• Treat any resultant space and motion discomfort or visual/vestibular mismatch

• • • • •

Bouncing on a ball Bouncing on a mini-trampoline Walking on inclines Walking on gravel Moving sleds

• Exposure therapy: exposure to gradually more complex visual environments • Gaze stabilization exercises • VOR x1, VOR x2 with busy visual backgrounds • Walking with head turns, eyes closed

Novel Vestibular Treatment • Machine based training • Biofeedback • Augmenting knowledge of results with additional sensory information • NeuroCom balance master system • Auditory biofeedback • Vibrotactile biofeedback

• Optokinetic stimulation • Sensory substitution • Auditory biofeedback • Vibrotactile biofeedback

Evidence for Vestibular Rehab

• Virtual Reality

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What are the outcomes of vestibular rehabilitation? • Improvements in impairments

• Improvements by diagnosis group • Peripheral vestibular dysfunction

• BPPV Massoud and Ireland 1996, Nuti et al 2000, Cohen and Jerabek 1999, Fujino et

• Gaze Stability Sztrum et al 1994; Badke 2004 • Subjective symptoms of dizziness Cass et al 1996; Mruzek 1995; Cowand et al 1998; Yardley et al 1998

• • • • •

What are the outcomes of vestibular rehabilitation?

Fall risk Herdman et al 2001 Postural stability Cass et al 1996; Yardley et al 1998; Asai et al 1997; Fujino et al 1996; Herdman et al 1995 Space and motion dyscomfort Whitney et al 2004 Anxiety Yardley et al 1998; Jacob et al 2001 Orientation/ perception of vertical Strupp et al 1998

Evidence to Support Vestibular Rehab • Horak et al 1992

al1994

• Unilateral Horak et al 1992; Herdman et al 1995, Mruzek et al 1995; Strupp et al 1998; Asai et al 1991; Sztrum et al 1994; Fujino et al 1996

• Bilateral Brown et al 2001 • Meniere’s Dowdal-Osborn 2002, Hahn et al 2001

• Central vestibular dysfunction • Migraine Wrisley et al 2002, Whitney et al 2000 • Cervicogenic Dizziness Karlberg et al 1996, Galm et al1998, deJong and Bles 1986, Revel et al 1991

• Anxiety Jacob et al 2001 • Head Injury Gottshall et al 2003, Herdman 1990, Telian and Shepard 1996

Evidence to Support Vestibular Rehab • Horak et al 1992

• Subjects • 25 subjects with peripheral vestibular dysfunction • Dizziness > 6 months, abnormal CDP, positional or movement related dizziness

• Treatment • Vestibular rehabilitation (VR) • Medication: meclizine or valium for 6 weeks • General strength and conditioning

• Results • SOT: significant difference in conditions 5 and 6 for VR group only • SLS: significant increase in VR group only • Trend toward decreasing dizziness in all 3 groups with largest reduction in VR group

• Outcome measures • • • •

Sensory Organization Test Single Limb Stance Positional vertigo (motion sensitivity quotient) Questionnaires – improved, no change, worse

Customized vs Generic Exercise Program

Evidence to Support Vestibular Rehab • Herdman et al 2003 • Subjects • 21 subjects with UVL (dx by EVAR and calorics – > 25 % difference)

• Treatment • Adaptation exercise and gait and balance ex • Adaptation exercises : x1 and x2 viewing (13 subjects)

• Balance and gait exercises – no head movement (8 subjects )

• Outcome measures • DVA • VAS oscillopsia

• Results • Pts who performed adaptation showed significant improvement in DVA compared to control group • Both groups improved in oscillopsia Horak et al 1992

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Vestibular Rehabilitation Improves Gaze Stability

Evidence to Support Vestibular Rehab • Szturm et al 1994 • Subjects • 23 subjects with peripheral vestibular dysfunction of < 1 year • No medications, abnormal CDP

• Treatment • Home exercise group: Cawthorne-Cooksey exercises • 3-4 times/day 15-20 minutes

• Rehab group: individualized treatment with OPK stimulation • 3x/week for 12 weeks

• Outcome Measures • CDP • VOR/OPK testing • Subjective questionnaires

• Results • Improvements in standing balance • VOR gain in rehab group • Decreased falls in rehab group Herdman et al 2003

Customized Exercise Program

Questions

Szturm et al 1994

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