Anatomy and Physiology
Vestibular Training
The 90 Minute Guide
SCC: rotational movement.
Saccule: Linear movement
Utricle: gravity movement
Otolinths: “crystals”
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By Jillian Fontana, PT, DPT, CTRS
Updated 8/22/14
Objectives
• Brief review of the Anatomy and Physiology of
the Vestibular System
• Identify and appraise the difference between
central disorders, peripheral disorders and BPPV
through patient’s History and Special Tests.
• Identify effective treatment based upon positive
tests and differential diagnosis.
• Navigate a cheat sheet to assist you in practice.
Functions of the Vestibular System
Senses and perceives body position and self-motion.
Enables gaze stability.
Statically aligns the head and body to vertical.
Detects the direction of gravity and helps to maintain
the orientation of the whole body to vertical (Postural
Stability)
• Selects appropriate sensory cues for postural
orientation in different sensory environments.
• Assists in controlling the position of the body’s center
of mass both for static positions and dynamic
movements.
• Stabilizes the head during postural movements.
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From Heather Dillon Anderson’s Vestibular Rehab lecture PT, DPT,
NCS
Quick Reminders: Terms to Know
Anatomy and Physiology
• http://www.youtube.com/watch?v=BbKU0Ab
bARg
• This video illustrates a quick review of the
vestibular system.
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Nystagmus – “a term to describe fast, uncontrollable movements of the
eyes that may be:
– Side to side (horizontal nystagmus)
– Up and down (vertical nystagmus)
– Rotary (rotary or torsional nystagmus)”
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Vertigo: “a sensation of motion in which the individual or the individual's
surroundings seem to whirl dizzily” http://www.merriam-webster.com/dictionary/vertigo
Vertigo vs. Light headedness
– “Spinning” vs. “floating”
Aural Fullness: feeling of ears needing to pop like descending from
airplane
Oscillopsia: objects moving in visual field
Tinnitus: ringing in the ear
VOR – Vestibular Ocular Reflex
http://www.nlm.nih.gov/medlineplus/ency/article/003037.htm
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Quick Reminder: Concepts to Know
Vestibular Exam: History
• Essential to categorize sx -
• Alexander’s Law;
• “Jerk nystagmus worsens when gazing in the direction
of the fast component.” If it switches direction it is a
central disorder.
http://medical-dictionary.thefreedictionary.com/Alexander+law
• http://www.youtube.com/watch?v=mghGeKkNBzQ
• Vestibular Crisis:
• Sudden dizziness, loss of balance, nausea, vertigo
lasting 1-4 days associated with head motion. (Patient
upstairs this past week was in vestibular crisis)
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• Characteristics and timing of Sx important
– Frequency
– Length?
– Triggers?
• Explore Psych Component (H/o panic attacks, recent
increase in stress? )
• Anything ruled out? (MRI, Neurology/Cardiac work-up)
Examination
• The key to determining type of dysfunction is the
interview.
• Red Flags?
– New onset of Sx which may represent stroke (dysphagia,
diplopia, dysarthria)
– Constant, unremitting symptoms
– Progressive/worsening symptoms
– Patients without any previous medical tests (if you cannot
produce any symptoms)
• Previous Tests? Previous Treatment?
• Reminder: Your patient may not be able to tolerate a
complete examination in one session.
true vertigo vs. dizzy
Light-headedness vs. spinning
Episodic-spontaneous vs. motion provoked?
Continuous exacerbations?
Other sx: Panic attacks? Headaches? Mood Swings?
Vestibular - Examination
• Differential Diagnosis:
– Orthostatic Hypotension
• B.P supine sitting standing
– Wait 5 minutes between each reading (Dr. D)
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Hyperventilation
Vasovagal Attack – (vagus nerve stimulated – brief syncope)
Cardiac Dysfunction
Anxiety/Panic Attacks
Lab values (hypoglycemia or hyponatremia [low NA+])
Drug Toxicity (Dilantin causes nystagmus)
The Big Four Problems
• Unilateral Vestibular Hypofunction (Peripheral
Disorder)
• Bilateral Vestibular Hypofunction (Peripheral
Disorder)
• BPPV (Peripheral Disorder)
• Central Vestibular Disorder (CVD)
Need to differentiate which of these the patient has for effective treatment.
Reminder: One patient can have more than one of these at the same time.
(For example, BPPV common in women beginning in 4th and 5th decades of
life. A 49 year old female may have an underlying BPPV and then have a
pontine stroke leading to positive results for both BPPV and CVD.
Central
• Causes:
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Brainstem and cerebellar lesions
Demyelinating diseases
Epilepsy
Head injury
Motion Sickness
Structural Malformation (Arnold Chiari)
Post Concussive Syndrome
Trauma
Tumor (Posterior Cerebrum or Cerebellar)
Vascular insufficiency
Vestibular migraine
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Central
• Hx:
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Persistent
Other Sx and complaints
Vague Symptoms
Symptoms occur more often and are more lingering.
• Tests:
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Smooth Pursuit
Saccades
VOR Cancellation
Slow VOR
Gaze Stabilization (Can be Peripheral or Central – Central
does NOT follow Alexander’s Law)
Peripheral Dysfunction
• Three types:
– Unilateral Vestibular Hypofunction
– Bilateral Vestibular Hypofunction
– BPPV (technically a Peripheral Disorder but think
of it as an entirely different entity)
Central
Peripheral
• History:
• Findings:
– Purely horizontal or vertical nystagmus
– Nystagmus that changes direction (does not
follow Alexander’s Law)
– Often diffuse balance difficulty
– Unremitting positional nystagmus (peripheral
disorders nystagmus with stop in 2-3 minutes)
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Involves vertigo (“spins”)
Sx triggered by change in head position or head movement
Sx fluctuate
Sudden onset
Can include vestibular crisis
• Tests:
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Head Thrust
Head Shaking
Dynamic Visual Acuity
Gaze Stability – follows Alexander's Law
Central
• Plan of Care
– 1-3 visits per week for 8 – 15 weeks (depending
on setting and co-morbidities)
– Goals:
• Habituation exercises for rehabilitation of system.
• Substitution exercises in case of permanent disaiblity.
– D/C:
• HEP
• modifications for lifestyle and safety.
– Prognosis:
• Dependent upon severity.
Peripheral
• Causes:
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Barotrauma
BPPV
Cervical vertigo/cervicogenic dizziness
Meniere’s Disease
Perilymphatic fistula
Ototoxic drugs
Toxic chemicals
Tumor (Acoustic neuroma or vestibular schwaroma)
Vestibular Neuritis
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Peripheral
• Findings:
– Nystagmus follows Alexander’s Law
– Impaired VOR (key for peripheral dysfunction)
– BPPV
Peripheral –
Bilateral Vestibular Hypofunction:
• Treatment:
– Determine if this is a complete loss or incomplete loss.
• Complete loss = Substitution Exercises
• For incomplete loss Return to unilateral treatment.
– Gait Training
– Functional Activities
• Will have difficulty flying planes, riding bikes or swimming (especially in
murky water).
• Utilize night lights at home.
– Bilateral Complete Loss will not get better
• Teach to move slower, limit head and body movement.
• Move eyes, then head and finally turn body when turning.
• Train remaining balance systems (somatosensory and vision)
Peripheral –
Unilateral Vestibular Hypofunction
• Treatment:
– Adaptation – retraining of the system
• Goal: gaze stability to see clearly with head movement and
“postural control under static and dynamic conditions”
• VOR x 1 VOR x 2 (know how to progress)
• Balance Exercises, Functional Activities and HEP
– Motion Sensitivity:
• Can use Motion Sensitivity Quotient to determine symptoms
that provoke individual patient.
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Sx should last less than a minute.
Do not perform another movement until Symptoms dissipate.
Change speeds of movements.
Do not overstimulate.
Unilateral Peripheral
• POC:
– Approximately 1-2 visits per week for 4 to 8 weeks
– Goal: Rehabilitation of system
– D/C:
• HEP
• Activities involving head motion
• Prognosis:
– Excellent prognosis
– Return to PLOF
Peripheral –
Bilateral Vestibular Hypofunction
• POC:
– 1-3 visits/week for 8 – 15 weeks
– Goal of substitution for missing vestibular system
and training visual/somatosensory systems.
– D/C:
• Will most likely need modifications of lifestyle for safety
– Night lights, reflective stickers for stairs.
• Prognosis:
– Fair to return to PLOF.
Peripheral:
Benign Paroxysmal Positional Vertigo (BPPV)
• Considered a “Peripheral nystagmus but best
to think of it as a third entity”
• Fun Facts:
– If it is truly BPPV, nystagmus with stop.
– 48% of those with otologic cause of dizziness is
BPPV
– Found in approx ½ population over 65 y/o.
– Most individuals require 3-5 physician visits before
they are properly diagnosed.
– Sx remit with one treatment approx. 85% of time.
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Peripheral - BPPV
Peripheral - BPPV
• Clinical Assessment:
• Occurs when the “crystals” are displaced into
the semi-circular canals.
• This gives a false sense of vertigo secondary to
head position and can cause dizziness and
nausea.
• Can be spontaneously
• May follow head trauma, labyrinthitis or
ischemia in the vestibular system.
– Dix-Hallpike (Test for Anterior and Posterior Canals)
– Sidelying Test (Test for Ant/Post canals for patients
unable to handle cervical extension)
– Notes:
Peripheral - BPPV
Peripheral - BPPV
• Physiology: (6 types) – Must distinguish to
treat correctly.
– Cupulotithiasis: The otoconia are held to the
cupula of one of the SCC.
• Anterior Canal
• Posterior Canal
• Horizontal Canal
– Canalithiasis: The otoconia are free floating in the
canals within the endolymph.
• Anterior Canal
• Posterior Canal
• Horizontal Canal
Peripheral - BPPV
• Classic Symptoms:
– Brief episodes of vertigo (true spinning) – typically less
than 1 minute – may be longer with trauma.
– Associate with changes in head position relative to
gravity.
• Lying down, raising from horizontal orientation, rolling over
in bed.
• Bending over
• Looking up.
• Associated Symptoms:
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Sense of imbalance (>50% of patients)
General Motion Sensitivity
Anxiety
Restriction of Movement
• Typical Nystagmus
– Latency of 1 – 30 seconds. (if it occurs right away, it is probably
not BPPV)
– Duration generally < 1-2 minutes
» Canalithiasis < 60 seconds
» Cupulolithiasis > 60 seconds.
– Fatigues – If it does not fatigue it is not BPPV.
– Involved side will have stronger nystagmus and patient will c/o
vertigo.
• Eye Movements for Anterior and Posterior Canal :
– Posterior: canalith or cupulolisthiasis torsional
nystagmus toward involved side (99% downward ear)
and up-beating.
– Anterior : canalith or cupulolisthiasis torsional
nystagmus toward involved side (99% downward ear)
and down-beating.
– Central Disorder = Positional nystagmus occurs
immediately and does not fatigue! Symptoms do not
decrease with repeated maneuvers.
Peripheral - BPPV
• Treatment in Anterior and Posterior Canals: (Canal and Cup)
– Goal: Return otoconia to the vestibule via vestibular maneuvers.
– Determine which canal is involved to perform the correct
manuever.
– Re-test if time allows.
– Pt. Education is KEY! –
• Provide post-maneuver instructions is essential to successful treatment.
– Follow up with patient after 48 hours to 1 week.
– Progress to balance training and habituation if needed.
– Encourage pt. to return to daily activity involving head motion after
precautionary period is reached.
– Treat BPPV 1st – once you fix this other co-morbidities won’t be as
bad (i.e. balance or anxiety)
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Peripheral - BPPV
• Treatment Maneuvers:
– Ant/Post Canalithiasis:
• Best: Canal Repositioning Technique (CRT) (AKA
Modified Epley or Canal Repositioning Maneuver (CRM)
• Other options:
– Brandt-Daroff exercises
– Self CRT
– Ant/Post Cupulolithiasis:
• Best = Liberatory Maneuver
• Other option = Brandt- Daroff Exercise
Peripheral - BPPV
• Treatment of Horizontal Canalithiasis
– Bar-B-Que Roll / Log Roll
• AKA Lempert Maneuver or modified CRT
– Forced Prolonged Position (FPP): Patient
instructed to lie in sidelying with unaffected ear
down for 8 – 12 hours – Best practice to use FPP
following BBQ roll.
– Liberatory maneuver (AKA Appiani)
• Treatment of Horizontal Cupulolithiasis:
– Rapid BBQ roll
– Liberatory maneuver for horz. Cup (AKA Casani)
Peripheral - BPPV
• Post Maneuver:
– Instructions:
• Avoid sleeping on involved side
• Sleep with an extra pillow
• Avoid extreme head positions.
– Protocol:
• Provide patient education regarding BPPV. The more they
understand, the better outcomes you have.
• If BPPV is bilateral, completely treat one side before
addressing other.
• Teach self CRT or Brandt-Daroff exercises if appropriate.
• Address secondary issues after BPPV addressed (balance,
central dysfunction, etc.)
Peripheral - BPPV
• Post Maneuver Instructions
– Do not bend over, move head up or down or tilt
head to either side for rest of day.
– Avoid sleeping on involved side
– Sleep with an extra pillow
– Avoid extreme head positions.
Peripheral - BPPV
• Evaluating Horizontal Canal (Lateral Canal) BPPV:
– Evaluation: Roll Test
– Horizontal Canalithiasis: (Horizontal Geotrophic)
• Nystagmus beats toward downward ear/ground* most
common.
• You will see nystagmus when testing both ears.
• Involved side will have stronger nystagmus.
• Nystagmus fatigues.
– Horizontal Cupulolithiasis (Horizontal Ageotrophic)
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Nystagmus beats away from downward ear
You will see nystagmus when testing both ears.
Involved side will have weaker response.
Nystagmus persists. (Exception to the Rule: Only test in which
nystagmus persists and it does not mean central disorder)
Vestibular - Evaluation
• Other Tests: Can be used with Central, BPPV and Peripheral signs.
– Balance Tests and Measures:
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Static Standing: NBOS, Rhomberg, SLS, etc.
Sensory Integration: Modfied CTSIB
Reactive Balance: Nudge or posterior tug test
Reduction in limits of stability: functional reach < 10”
Anticipatory Balance: picking up objects, getting out of chairs.
– FGA, DGI, modified CTSIB, BERG, 10 meter walk test.
– Outcome Measures:
• Motion Sensitivity Quotient (MSQ)
• Dizziness Handicap Inventory (DHI)
• Activities-Specific Balance Confidence Scale (ABC)
– Fuduka Step* - The cheat test – This will tell you which side the
impairment is on. Patient will turn to side of impairment with
vestibular impairment. If they move more than 20 inches, they are
unable to ambulate in the dark.
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Vestibular Lab: Eval
1. Occular ROM/Smooth Pursuit (Central)
– Pen 18 – 24” from face – Have patient follow with
eyes, without moving head.
– Test in all planes (horizontal, vertical and diagonal).
– Watch both eyes move together (smoothly) through
full ROM.
– Abnormal: eyes moving in jerking or saccadic fashion,
eyes not staying together, decreased ROM, nystagmus
(note presence of nystagmus and direction)
– Reminder: have patient focus on cap of
highlighter/marker to give a single point
Vestibular Lab: Eval
5. Slow VOR (central test)
– Grasp patients head with both hands on either side of
temples – (do not grab jaw) – flex patient’s head 20 – 30
degrees.
– Instruct patient to focus on target (your nose) and slowly
rotate patient’s head from side to side and then up and
down. 4 Hz or 20 head turns in 10 seconds.
– Watch to make sure your patient’s eyes maintain gaze on
target.
– Normal Result: Patient able to focus on therapists nose.
– Abnormal Test: Patient cannot maintain gaze or closes
eyes, c/o of dizziness.
Vestibular Lab: Eval
2) Gaze Holding (central or peripheral)
– Hold pen at approx. 25% before end or range and
observe for nystagmus in all directions.
– Do not go to end range – This can cause nystagmus
normally (false positive)
– Abnormal Test: Direction changing nystagmus or
purely vertical nystagmus is a central sign.
– Abnormal test: Horizontal nystagmus consistently
beating in same direction with increased intensity
toward direction of nystagmus (Alexander’s Law) =
peripheral sign.
Vestibular Lab: Eval
6. Rapid VOR/Halgami Head Thrust (peripheral test)
– Begin with slow VOR.
– Without telling patient, rapidly thrust patient’s head to
one side and hold.
– Watch to make sure patient’s eyes maintain gaze on target
(therapist’s nose).
– Resume slow VOR and then randomly perform head
thrusts to either side (multiple times each for
confirmation) – Do no make a pattern so patients do not
have a false negative with anticipating your movements.
– Normal result: Pt. will maintain gaze fixation/ no c/o of
dizziness.
– Abnormal result: Unable to maintain gaze or saccade seen
to correct gaze. Note side head thrust in – this is the
involved side.
Vestibular Lab: Eval
Vestibular Lab: Eval
3. Vergence (Central Test)
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Hold pen approx. 24” in front of patient and ask to focus on
pen while you move it toward their nose.
Normal: Eyes should converge and pupils constrict – double
vision is normal near nose.
Abnormal result: Eyes moving at different speeds (possible CN
injury).
4. Saccades: (Central Test)
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Hold 2 pens (or pen and therapist nose) one centered and
other approx. 6 – 10 inches horizontally, vertically and
diagnoally.
Ask patient to look from one target to another testing all
directions and repeating several times.
Normal: Eyes should move smoothly between targets without
stopping or overshooting.
Abnormal Result: More than 2 eye movements required to get
to target or over shooting or under shooting target consistently.
7. VOR Suppression/Cancellation Test (central)
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Ask the patient to fixate and track a small target that
moves synchronously with head movement.
Normal: subjects eyes stay focused on target without
difficulty.
Abnormal: “catch-up” saccades or nystagmus –
unable to suppress VOR reflex.
8. Dynamic Visual Acuity Test (Peripheral Test)
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Have the patient read an eye chart with clinician
performing a slow VOR on patient.
Normal: 1 -2 line difference in acuity or no change.
Abnormal: A 3 or more line decline
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Vestibular Lab: Eval
9. Dix-Hallpike (BPPV)
– Passively turn patient’s head 45 degrees while
sitting in long sitting.
– Move patient into supine with head extended
rapidly.
– Nystagmus seen 1 - ~30 seconds after positional
movement. Vertigo and nystagmus will fatigue if
truly BPPV.
Vestibular Lab: Treatment
• Adaptation continued:
– Gaze stabilization
• Use with impaired smooth pursuit or saccades.
• Have patient practice whichever tests are impaired
multiple times per day.
• What you may see in my charts:
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Circles Sheet
b, p, q, d sheet
Where’s Waldo?
How to progress?
Vestibular Lab: Eval
10. Roll Test (BPPV)
– Perform head thrust in supine with head flexed
approximately 20 – 30 degrees.
– Horizontal Canalithiasis: (Horizontal Geotrophic)
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Nystagmus beats toward downward ear/ground* most common.
You will see nystagmus when testing both ears.
Involved side will have stronger nystagmus.
Nystagmus fatigues.
– Horizontal Cupulolithiasis (Horizontal Ageotrophic)
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Nystagmus beats away from downward ear
You will see nystagmus when testing both ears.
Involved side will have weaker response.
Nystagmus persists. (Exception to the Rule: Only test in which
nystagmus persists and it does not mean central disorder)
Vestibular Lab
• Substitution
• For use when adaptation does not work or bilateral complete loss.
– Imaginary Target Viewing:
• Focus on a target close eyes turn head open eyes Focus on new target.
• Repeat in multiple directions.
– Viewing Between 2 Targets:
• To focus on new object, look with eyes first then head then body (if needed)
• Repeat in different directions.
• Progress: add walking, unstable surfaces, etc.
Vestibular Lab: Treatment
Vestibular Lab
• Adaptation Exercises:
– VOR x 1
• Can be used with Unilateral Vestibular Hypofunction or incomplete
bilateral hypofunction.
• Pt. flexes head 30 degrees and focus on thumb approximately 3
feet away.
• Pt turns head as if shaking head no (horizontally) to each side.
• Repeat Vertically. (as if shaking head yes)
• Goal to perform quickly (approximately 4 times a second.)
– How to adapt:
• Vary speed of movement (too hard go slower), vary distance.
• Progression: add foam, change position of feet, walking, etc.
• Habituation:
– Base of what provides symptoms for patient (can
use MSQ to help)
– Start with tolerable exercises
– Repeating motion should improve tolerance of
that situation.
– Progress based on response/patient tolerance.
– VOR x 2
• Same conditions as VOR x 1 except add target to move in opposite
direction as head 4x per second.
• Repeat vertically.
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Balance Activities
• Squats on BOSU Squats on Dynadiscs
(progress with eyes closed)
• ½ roll leg swivels (progress to eyes closed)
• ABCs [NBOS SLS Airex NBOS Airex
SLS Eyes closed (EC) NBOS EC SLS Airex EC NBOS Airex EC SLS]
• Ball Toss [ NBOS SLS Airex NBOS Airex
SLS]
Case Study Negative
• Smooth Pursuit
• Vergance
• Sacaddes
• Gaze Stability
• Slow VOR
• Head thrust
• VOR Supression
BPPV Treatment Maneuvers
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Canalith Repositioning Technique*
Self CRT
Brand-Daroff Exercises for BPPV
Semont or Liberatory Maneuver
BBQ Roll/Log Roll
How I would treat
• CRT or Epley
• VOR x 1 VOR x 2
• Balance Ther Ex
– Remember: 28 year old dancer – start fairly high
up
• Probably start with eyes open vs. closed since she
moved up 4 feet with eyes closed.
References
Case Study
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28 y/o female
H/o frequent ear infections as child, failing hearing tests for low sounds in
teens, dizziness disturbances with changes in head position.
Does not like swimming secondary to pain in ear when submerged in
water.
Balance generally good to general pop, however, patient was a dance
minor and reports had worst balance in program. (habituation)
Reports occasionally has headaches and at times has sensitivity to sound.
Can have nausea with headaches associated with loud noises.
Cannot remember the last time she hasn’t had aural fullness in left ear.
+ for tinnitus in Left 1-2 times a week, occasionally will have it in right.
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What are you leaning towards based on history?
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Positive
• Fuduka step – 4 feet
forward and 45 degree left
turn.
• Rapid VOR – reports
dizziness after 10 seconds.
• Dynamic Visual Acuity –
change greater than 3 lines.
• And test on next slide.
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Heather Dillon Anderson, PT, DPT, NCS 4 weeks of notes from Neumann University/ Good Shepherd
Penn Partners Vestibular Specialist
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Referenced Following Lectures:
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Vestibular Rehabilitation 5/19/2012 PT 737
Vestibular Examination and Interventions 6/2/2012 PT 737
Evaluating and Treating BPPV 6/9/12 PT 737
Vestibular Lab 1: 6/2/2012 PT 737
Vestibular Lab 2: Vestibular BPPV Lab 6/9/2012. PT 737
Various websites included in slides for definitions only.
Youtube for vestibular anatomy videos and Alexander’s Law videos.
Herdman, Susan. Vestibular Rehabilitation. Third Edition. Philadelphia, PA. FA Davis Co, 2007.
Farrel, L. Peripheral Versus Central Disorders. Neurology Section Fact Sheet. American Physical
Therapy Association. www.APTA.org Accessed 1/31/14.
Lowrie, M. Vestibular Disease: Anatomy, Physiology and Clinical Signs. Compendium: Continuting
Education for Veterinarians”. July 2012.
Umphred, Darcy. Neurologic Rehabilitation, fourth edition. Mosby, St. Louis, MI. 2001.
Zapanta, P. Vestibular Rehabilitation. Emedicine.medscape.com/article/883878-overview. Accessed
1/31/14. Updated March 12, 2012.
Thompson, T and Amedee, R. Vertigo: A Review of Common Peripheral and Central Vestibular
Disorders. Ochsner Journal. 2009 Spring; 9(1): 20-26.
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