Brenda S. Howard, DHSc, OTROT Process III

*An Occupation-based Approach to Vestibular Rehabilitation and Balance

*Learning Objectives

*Recognize the role of Occupational Therapy in Vestibular Rehabilitation*Understand types of vestibular dysfunction: central, peripheral, BPPV*Identify clients who may benefit*Relate current evidence in fall prevention to the need to further research

*What is balance?

*The Vestibular System

*The Inner Ear Labyrinth *Vestibular Nerve*Vestibular Nuclei*Vestibular Projections

*Central Connections• Vestibulo-ocular reflex• Vestibulo-spinal reflex• Vestibulo-collic reflex• Autonomic connections• Limbic connections

*What do patients report when they have a vestibular

impairment? Vertigo a sense of movement where there

is no movement; an illusion of movement

(Herdman, 2007; Herdman & Clendaniel, 2007)

*What do patients report when they have a vestibular

impairment? Dizziness a combination of vertigo,

lightheadedness, and imbalance

(Herdman, 2007; Herdman & Clendaniel, 2007)

*What do patients report when they have a vestibular

impairment? Vision Hearing Nausea

(Herdman, 2007; Herdman & Clendaniel, 2007)

*What do patients report when they have a vestibular

impairment? Cognition Balance, Coordination Emotions

(Herdman, 2007; Herdman & Clendaniel, 2007)

*Causes of Vestibular

Dysfunction

*Peripheral*Benign Paroxysmal Positional Vertigo (BPPV)*Unilateral Vestibular Hypofunction (UVH)*Bilateral Vestibular Hypofunction (BVH) *Ménière's Disease

*Central*CVA*Migraine*Concussion

(Herdman, 2007; Herdman & Clendaniel, 2007)

* What can go wrong? Peripheral causes of vertigo

* Unilateral Vestibular Hypofunction

* Peripheral Vestibular Asymmetry * Labyrinthitis* Vestibular Neuronitis* Vestibular Infarct* Vestibular Schwannoma/Acoustic

Neuroma(Herdman, 2007; Herdman & Clendaniel, 2007)

* Peripheral Vertigo History and Symptoms

Sudden onset (illness, trauma, or unknown)

Constant dizziness, provoked by motion (especially head and body turns)

(Herdman, 2007; Herdman & Clendaniel, 2007)

* Peripheral Vertigo History and Symptoms

Discomfort with watching movement or patterns

Mild-Moderate Imbalance

(Herdman, 2007; Herdman & Clendaniel, 2007)

* Peripheral Vertigo History and Symptoms

Horizontal unidirectional gaze-evoked nystagmus

http://www.youtube.com/watch?v=YntJiBCz3pA

(Herdman, 2007; Herdman & Clendaniel, 2007)

*Gaze-Evoked Nystagmus –

Alexander’s Law*http://www.youtube.com/watch?v=mghGeKkNBzQ

* Bilateral Vestibular Hypofunction

Not dizzy Off balance No balance in the dark Oscillopsia (“things bounce visually”)

* Bilateral Vestibular Hypofunction

Dynamic Visual Acuity loss of greater than 6 lines Immediate fall Romberg eyes closed on compliant

surface

Causes: Chemotherapy, ototoxic antibiotics, autoimmune

* BPPV (Benign Paroxysmal Positional

Vertigo) Etiology:

Otoliths in semicircular canal Cupula deflects more than usual

(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)

* BPPV Posterior canal: 95% of cases

(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)

* BPPV Symptoms Dizziness with position changes Lying flat, rolling over, sit up, stand up, bend

over, look up “Top Shelf or “Dentist Office” vertigo Strong spinning for less than one minute May have “leftover” symptoms for hours

Seniors may describe symptoms differently; rocking, tilting, passing out

(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)

*BPPV Nystagmus:

*http://www.youtube.com/watch?v=gyvSmTlGu2k

*(This video shows examples of many kinds of BPPV; we are going to concern ourselves with Posterior Canal BPPV only because it is the most common – 95%)

*BPPV is Designated by:*Canal

*Right or left*Anterior (Superior)*Posterior *Horizontal

*Otolith Position*Canalithiasis*Cupulolithiasis

* What can go wrong? Central Causes of Vertigo

• Migraine Associated Vertigo (MAV), Vestibular Migraine

• Post-Concussive Disorder• CVA (cerebellar, pontine)

(Herdman, 2007; Herdman & Clendaniel, 2007)

* Vestibular Migraine• May or may not have headache

• May have vertigo without migraine• Headache may be low grade but

persistent• A history of migraines (or persistent headaches)

(Herdman, 2007; Herdman & Clendaniel, 2007)

* Vestibular Migraine• Symptoms similar to a unilateral vestibular loss but

with no objective findings on VNG• Motion, light, and sound sensitive

(Herdman, 2007; Herdman & Clendaniel, 2007)

* Vestibular Migraine• May be episodic • Or may “wax and wane”• Typically responds better to balance and gentle

habituation exercises

(Herdman, 2007; Herdman & Clendaniel, 2007)

*Post Concussive Disorder Central AND Peripheral

Concussion Labyrinth trauma BPPV

Cognition Headache – post-concussive migraines Imbalance Motion sensitive, visually sensitive

(Herdman, 2007; Herdman & Clendaniel, 2007)

*CVA – Cerebellar, Pontine*Diplopia, dysmetria, dysarthria

*“Constant hum” of vertigo*Pursuits/Saccades*Subjective visual vertical*Direction-changing nystagmus

*http://www.youtube.com/watch?v=jeYe-SMMW9k

(Herdman, 2007; Herdman & Clendaniel, 2007)

*Diagnostic Tests Medical Tests: MRI, CT, cardiac Audiology Tests:

Audiogram VNG/ENG Rotary Chair Positional Testing including Dix Hallpike VEMP Computerized Dynamic Posturography (CDP)

*Peripheral vs. Central*Severe nausea*Mild imbalance*Hearing loss common*Oscillopsia

*Moderate nausea*Severe imbalance*Rare hearing loss*Diplopia

*Peripheral vs. Central

*Neuro symptoms rare*Rapid compensation*Horizontal nystagmus (or rotary nystagmus – BPPV)

*Neuro symptoms common*Slow compensation*Vertical and direction changing nystagmus

* Non-Vestibular Causes of Vertigo

*Cardiac*Orthostatic hypotension*Low blood pressure*Hypoglycemia*Cervicogenic

* Non-Vestibular Causes of Vertigo

*Medication*Anemia*Psychogenic*Imbalance of Aging/ Multifactorial Imbalance

*Imbalance of aging

*Visual changes*Sensation through feet*Orthopedic impairments*Slower reaction time*Muscle weakness*Blood pressure*Mental status changes*Behavioral choices

*Evaluation

*History*Sensorimotor*Static and Dynamic Balance*Oculomotor*Motion sensitivity*Positional changes

*Vestibular Therapy Evaluation*History

Detailed description of symptoms Past Medical History, Medications Occupational Profile – the “so what” Questionnaires*Dizziness Handicap Inventory (Jacobson, et al., 1990)*ABC Scale (Whitney, et al, 1999)

*Oculomotor Exam*Pursuits*Saccades*Gaze Evoked Nystagmus*Slow Head Rotation*Eye-Head to Periphery*Dynamic Visual Acuity (DVA) – using logMAR chart (Herdman et al., 2003)

* How is Vestibular Rehabilitation Occupation-Based?

• Vestibular function underlies all human activity

• Vestibular impairment impacts all occupations

• Occupational Therapy Perspective• Remediate vestibular function• Compensate for safety• Environmental modification

*Questions?

*References* Akin, F., & Davenport, M. (2003). Validity and reliability of the Motion

Sensitivity Test. Journal of Rehabilitation Research and Development, 40(5), 415-422.

* American Geriatrics Society & British Geriatrics Society (AGS/BGS). (2010). Clinical practice guideline: Prevention of falls in older persons. Journal of the American Geriatrics Society (special article). Retrieved May 17, 2013 from http://www.americangeriatrics.org/health_care_professionals/clinical_practice/ clinical_guidelines_recommendations/2010/

* Clendaniel, R. (2010). The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary results [sic] [Abstract]. Journal of Neurologic Physical Therapy, 34(2), 111-116.

* Cohen, H. (2011). Assessment of functional outcomes in patients with vestibular disorders after rehabilitation. Neurorehabilitation, 29, 173-178.

* Cohen, H., Blatchly, C., & L., Laurie. (1993). A study of the Clinical Test of Sensory Interaction and Balance. Physical Therapy Journal, 73, 346-351.

* Cohen, H., Burkhardt, A., Cronin, G., & McGuire, M. (2006). Specialized knowledge and skills in adult vestibular rehabilitation for occupational therapy practice. American Journal of Occupational Therapy, 60(6), 669-678.

* Cohen, H., Kane-Wineland, M., Miller, V., & Hatfield, C. (1995). Occupation and visual/vestibular interaction in vestibular rehabilitation. Otolaryngology-Head and Neck Surgery, 112(4), 526-532.

* Cohen, H., Gottshall, K., Graziano, M., Malmstrom, E., Sharpe, M., & Whitney, S. (2011). International guidelines for education in vestibular rehabilitation therapy. Journal of Vestibular Research, 21, 243-250.

* Cronin, G. & Steenerson, R. (2011). Disequilibrium of aging: Response to a 3-month program of vestibular therapy. Physical & Occupational Therapy in Geriatrics, 29(2), 148-155

* Cronin, G. (June 14-15, 2013). Vestibular Rehabilitation: Treatment Intensive (course manual). Philadelphia, PA: Education Resources, Inc.

* Epley, J. (1992). The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngology-Head and Neck Surgery, 107(3), 399-404.

* Epley, J. (1995). Positional vertigo related to semicircular canalithiasis. Otolaryngology-Head and Neck Surgery,112(1), 154-161.

* Hain, T. Dizziness, imbalance, and hearing disorders. Retrieved on June 30, 2013 from http://www.dizziness-and-balance.com/disorders/index.html

* Haven, L. (2011, Summer/Fall). VEDA produces benchmark study to help reduce suffering. On the Level: Quarterly Newsletter of the Vestibular Disorders Association, 28(3-4), 1-8.

* Helminski, J., Zee, D., Janssen, I., & Hain, T. (2010). Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Physical Therapy Journal, 90(5), 663-678.

* Herdman, S.(Ed.). (2007). Vestibular Rehabilitation (3rd ed.). Philadelphia: FA Davis Co.

* Herdman, S. & Clendaniel, R. (March 13-17, 2007). Vestibular Rehabilitation: A competency-based course (course manual). Atlanta, Georgia: Department of Rehabilitation Medicine, Emory University School of Medicine and American Physical Therapy Association.

* Herdman, S., Schubert, M., Das, V., & Tusa, R. (2003). Recovery of dynamic visual acuity in unilateral vestibular hypofunction. Archives of Otolaryngology-Head and Neck Surgery, 129, 819-824.

* Hernandez, D. & Rose, D. (2008). Predicting which older adults will or will not fall using the Fullerton Advanced Balance scale. Archives of Physical Medicine and Rehabilitation, 89(12), 2309-2315.

* Indiana Professional Licensing Agency Occupational Therapy Committee (IPLA). (2011). Occupational Therapy Committee: Laws and Regulations: A compilation of the Indiana Code and Indiana Administrative Code. Retrieved from http://www.in.gov/pla/files/OTC.2011_EDITION.pdf

* Jacobson, G., Newman C., Hunter, L., et al. (1990). The development of the dizziness handicap inventory. Archives of Otolaryntology-Head and Neck Surgery, 116, 424-427.

* Shepherd, N. & Telian, S. (1995). Programmatic vestibular rehabilitation. Otolaryngology-Head and Neck Surgery, 112, 173.

* Shumway-Cook, A., & Horak, F. (1986). Assessing the influence of sensory interaction of balance: suggestion from the field. Physical Therapy Journal, 66, 1548-1550.

* Vestibular Disorders Association (VEDA). Living with a vestibular disorder. Retrieved on June 30, 2013 from http://vestibular.org/living-vestibular-disorder

*Whitney, S., Hudak, M., & Marchetti, G. (1999). The Activities-specific Balance Confidence scale and the Dizziness Handicap Inventory: A comparison. Journal of Vestibular Research,9, 253-259.

*Whitney, S., Hudak, M., & Marchetti, G. (2000). The dynamic gait index relates to self-reported fall history in individuals with vestibular dysfunction. Journal of Vestibular Research, 80, 896-903.

*Whitney, S. & Sparto, P. (2011). Principles of vestibular physical therapy rehabilitation. Neurorehabilitation, 29, 157-166.

*Wrisley, D. & Kumar, N. (2010). Functional gait assessment: Concurrent, discriminative, and predictive validity in community-dwelling older adults. Physical Therapy Journal, 90, 761-773.