PVL – may be bilateral or unilateral
CVL – may be bilateral or unilateral
Pathophysiology:
 Peripheral sensory apparatus and / or vestibular nerve
 BPPV: canalithiasis, cupulolithiasis
 Perilymphatic fistula
 Labyrinthitis
 Neuronitis
 Meniere’s
 Acoustic neuroma
 Postconcussive Syndrome
Pathophysiology:
 CNS lesion impairs natural compensatory process
 Vascular disorders: ischemic, bleeding
 Long white fiber tracts
 Demyelinating disease
 TBI
 CVA
 Cerebellar trauma
 Tumor
Impairments:
 Distorted vestibular function – BPPV
 Fluctuating vestibular function
 Sudden vertigo
 Motion sensitivity
 Dysequilibrium
 + DVA with nystagmus
 Decreased VOR
 + Sensory Organization Test (SOT)
 Decreased Limits of Stability (LOS)
 Abnormal gait, especially with head turns
 Anxiety
 Hearing loss / Tinnitus
 Tullios sign (sound-induced vertigo or nystagmus or
both)
 Hennebert's sign (nystagmus owing to applied pressure
in the external auditory canal)
 Nausea, dizziness
 + caloric test, + ENG
Impairments:
 Dizziness regardless of activity or position
 Decreased sensory intergration
 Dysequilibrium
 Abnormal gait, with head turns
 Motion Sensitivity
 Continuous vertigo with / without nystagmus  Refer to
Neurologist
 Decreased smooth pursuit
 Lateropulsion
 Ocular Tilt Reaction (OTR) pathological triad
 HIGH VOR Gain
 Head Thrust is negative
 Loss of VOR Cancellation
 Asymmetrical Optokinetic response
 Abnormal Subjective Visual Vertical (SVV)
 Abnormal convergence
 Direction changing nystagmus
 Vertical nystagmus (downbeating)
 Vertigo with unilateral lesion at vestibular nuclei
 saccades
 lightheadedness
 decreased righting reaction
 ataxic gait
 decreased sensory integration
 lateropulsion
 oscillopsia
 neck pain secondary to reflexive compensation
 anxiety depression
Management:
• Canalith Repositioning Maneuvers
 For persistent cases  Brandt Daroff as Habituation
 Motion Sensitivity drills
 Increase activity level
 Anxiety – coping management
 CRMS
 Brandt-Daroff exercises
 Liberatory maneuver
 Gaze stabilization
 Postural stabilization
 Reconditioning
Management:
SUBSTITUTION
 Facilitate CNS compensation
 Force use of vestibular, somatosensory, propioceptive
systems
 CAREFUL Habituation (treating ABOVE the lesion
level)
 Cawthorn-Cooksey Exercises: vestibular hypofunction
 Sensory Integration
 Motion Sensitivity drills
 Saccadic, smooth pursuit tracking,
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Ocular ROM
DVA – Dynamic Visual Acuity
Retrain VSR – for postural stability (static balance,
dynamic equilibrium, perturbations, motor strategies
Retrain Gaze Stabilization (VORx1, VORx2, VOR
Cancellation)
Motion Sensitivity Quotient
Conditioning exercises
Flexibility
Anxiety / coping management
Walking program (conditioning and improve gaze
stabilization)
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UVL
BVL
Pathophysiology:
 Lesion to peripheral sensory apparatus and / or vestib
nuclei in pons
 Labryinthitis
 Perilymph fistula
 Acoustic neuroma
 Meniere’s disease
 Head trauma / labyrinthine concussion
 Vestibular neuritis
 Surgical procedure
Pathophysiology:
 Ototoxicity
 Bilateral infections
 Age-related degeneration
 Meningitis
Impairments:
Spontaneous nystagmus with acute lesion
 Must make diff dx of vertigo from episodic cause, eg
Meniere’s, migraine
 + Head Thrust (saccade to side of lesion)
 decreased VOR Gain
 + Dynamic Visual Acuity (DVA) sign
 + CTSIB
 + Sensory Organization Test (SOT)
 + Fukuda
 Abnormal gait: LOB, head turns, deviation to side
 Dysequilibrium
 Decreased Single Limb Stance (SLS), Sharpened
Romberg (Tandem)
 Hearing loss, progressive, unilateral
 nystagmus
 postural instability
 tinnitus
 sudden vertigo, nausea
 + head shake
 + caloric test
 Dysequilibrium
 visual complaints
 decreased head / trunk rotation with gait
 anxiety, depression
Impairments:
 No nystagmus
 No vertigo
 Dysequilibrium
 VOR abnormal with severe Gaze Instability
 Decreased Single Limb Stance (SLS), Romberg and
Sharpened Romberg (Tandem)
 + Head Thrust occurring bilaterally
 + Dynamic Visual Acuity (DVA) sign
 + Fukuda
 + CTSIB
 + Tandem Walk (EO)
 Abnormal gait: head turns
 hearing loss
 oscillopsia
 postural instability; rigidity
 lightheadedness
 nausea
 wide base gait
Management:
ADAPTATION, Recovery, Substitution, Habituation (if
chronic)
 VOR exercises
 Gaze stabilization ex.
 Retrain VSR (Vestibulospinal Reflex); postural
stabilization
 Gait training
 Flexibility
 Conditioning
 Anxiety – coping management
 Increase motion tolerance
 Watchful waiting
 Meniere’s: salt restriction
 Post op exercise (neuroma excision, etc.)
Management:
 SUBSTITUTION (for complete lesion), ADAPTATION
(for incomplete lesion), Habituation is NOT appropriate
 Potentiate Cervical Ocular Reflex (COR)
 Use modified saccades
 Central pre-programming
 Enhance visual input, eg, spotting
 Somatosensory input
 Alternative strategies for Gaze Stabilization & Postural
Control
 Goal: improve functional abilities rather than
improvement of vestibular damage (if severe or complete
lesion).
 Pt. education:
o avoidance strategies
o preplanning
o appropriate shoes, floors, lighting
 Flexibility
 Conditioning
 Tai Chi, pool exercises
 Functional Actitivites ( ADL, IADL)
In making a differential diagnosis, remember that PVL/CVL and UVL/BLV form a matrix.
PVL
UVL
BVL
CVL