Vestibular Rehabilitation:
Evaluation and Treatment
Strategies for Common
Vestibular Disorders
Burt DeWeese, PT, MCMT
Rebound Physical Therapy
Vestibular Rehab Specialist
burt@reboundphysicaltherapy.com
Background
• Graduate of Kansas State University, 1999
• Master’s in Physical Therapy from Mayo School of
Health Sciences, Rochester, MN, 2002
• Completed APTA Competency Based Certification
Course: Vestibular Rehabilitation-Emory University, 2004
• Working toward manual therapy certification through
NAIOMT – will complete level III this year
• Clinical Director at Rebound Physical Therapy,
Topeka, KS
Objectives
• Describe the anatomy and physiology of the vestibular system.
• Describe the pathophysiology of common vestibular disorders.
• Complete and interview and examination of a person with
vestibular dysfunction.
• Identify appropriate standardized assessment tools for use in
vestibular rehabilitation.
• Demonstrate skill in performing the occulomotor exam.
• Demonstrate skill in differentiating between types of BPPV.
• Identify appropriate treatment intervention with patients with
vestibular disorders.
Anatomy and
Physiology
Anatomy of the Ear
Anatomy of the Ear
• The External Ear
• External auditory canal
• Ends at the tympanic membrane
• The Middle Ear
• Space between the tympanic membrane and the
inner ear
• Contains the malleus, incus and stapes
• Transmits sound into waves inside the cochlea
• Filled with air
Anatomy of the Ear
• The Inner Ear
• Contains sensory organs for hearing and balance
• Bony labyrinth within the temporal bone
• Central portion is names the vestibule
• Saccule and Utricle
• Cochlea is anterior and vestibular portion post
• Tissue layers: bony labyrinth, perilymph,
membranous labyrinth, endolymph
The Labyrinth
• Bony Labyrinth
• Perilymph
• Between bony and
membranous labyrinth
• Membranous labyrinth
• Endolymph
• Inside membranous
labyrinth
Parnes, 2003
The Labyrinth
• 3 Semicircular Canals
• Anterior, Posterior
Horizontal
• Cochlea
• Hearing component
• Vestibule
• Saccule and Utricle
The Hair Cell
• Found in cochlea, semicircular canals, saccule and utricle
• Send in information to the vestibularcochlear system
• “Hair” of the hair cell consists of:
• Sterocilia (40-70 in one hair cell)
• Kinocilium (1 per hair cell)
Semicircular Canals
• Hair Cells
• Motion Sensors
• Always sending info
to the brain
• Kilocilia
• Deflection Towards- Excites
• Deflection Away- Inhibits
Semicircular Canals
• Provides input about
angular head velocity
• Three canals on each side
• Anterior (superior),
Posterior (inferior) &
Horizontal (lateral)
• 90 degree angle from each
other
• Horizontal canal
• 30 degree elevation
Semicircular Canals
• Mate on the opposite side
• L ant/R post, R ant/L
post
• Each semicircular canal has
a ampulla housing the
sensor organs
• Hair cells covered by
the cupula
• Both ends terminate in the
utricle
The Otoliths
• Utricle (Linear)
• Horizontal Movements
• Head Tilt
• Saccule (Linear)
• Up & Down Movements
• Otoconia “Ear Rocks”
(Calcium Carbonate Crystals)
• Hair Cells
Herdman, 2000
Vestibular Occular Reflex
• Allows clear vision through gaze stabilization
• Coordinates eye and head movements
• Sensory stimulation sends info to the brainstem
region that controls eye movement
• Example: Head left, eyes turn right while focusing on
an object
• R lat rectus/L med rectus excited and opposite
inhibited
Causes of Vertigo
Herdman, 2000
Causes of Vertigo
• BPPV
• Vestibular Neuritis
• Labyrinthitis
• Meniere's Disease
• Bilateral Vestibular Loss
• Cervicogenic Dizziness
Common Disorders
Semi-Circular
Canals
Inflammation of the
Vestibular Nerve
• Vestibular Neuritis
• Symptoms
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Sudden onset of vertigo
Nausea/vomiting
Imbalance
Sensitivity to motion
Inner Ear
• Last hours to days
• Can result in chronic dysequilibrium
• Caused by viral infection
• Treatment
Cochlea
Common Disorders
• Vestibular Labyrinthitis
• Viral or bacterial infection of
the membranous labyrinth
• Acute onset of hearing loss,
vertigo, nausea/vomiting
• Can last 1-4 days
• Will demonstrate
imbalance and
sensitivity to head
movements
Common Disorders
• Meniere’s Disease
• Increased endolymph
pressures
• Episodic
• Low frequency hearing
loss
• Tinnitus
• Can last hours to days
Common Disorders
• Fear of Falling
• Disuse Dysequilibrium
• Orthostatic Hypotension
• Cervicogenic Dizziness
• Anxiety
Common Disorders
• Central
• TBI
• CVA
• Multiple Sclerosis
Vestibular Evaluation
• Subjective component
• Thorough History
• Dizziness Handicap Inventory
• ABC confidence scale
Common Questions
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Tell me about your symptoms.
When did your symptoms begin?
How long did/does your symptoms last?
Are your current symptoms better, worse or the same?
Can you rate the severity of your symptoms 0-10/10?
Do your symptoms increase with positional changes or certain
movements?
Do you have difficulty with keeping objects in focus?
Do you have ear fullness, pressure, ringing or hearing loss?
Do you have a history of these symptoms?
Have you had any falls or unsteadiness?
Currently what meds are you taking?
Dizziness Handicap Inventory
Vestibular Evaluation
• Bedside Exam
•
Occulomotor
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•
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Smooth Pursuit
Saccades
VOR
VOR cancellation
Head Thrust/Head Shake
Upper and lower extremity screen
Cervical screen-may choose to do first
Vestibular Evaluation
• Other testing options
• Videonystagmogtaphy (VNG)
• Caloric Testing
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Test horizontal
semicircular canals
only
External auditory canal is
irrigated with warm and
cold water with head in
30 degrees flex
Significant finding 25% or more
reduction indicates a unilateral weakness
Observation Tools
• Frenzel Goggles
• Video Frenzel Lenses
• Room Light
Vestibular Evaluation
• Functional Testing
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Dynamic Gait Index-videos
Berg Balance Scale
Timed Up and Go
Static Balance Testing
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Eyes Open/Eyes Closed
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Head turns
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Firm and Foam
Dynamic Gait Index
Dynamic Gait Index
• Video
Berg Balance Scale
Timed Up and Go
• Video
Timed Up and Go (secs) (7,12,14)
Back against chair, arms on armrests –get up and
walk at comfortable place to line 3 meters away,
return to chair and sit down; repeat, take average
Age
(years)
60-69
70-79
80-89
Male
8
9
10
Female
8
9
10
Time < 10 seconds is normal
11-20 seconds is normal for frail elderly
>14 seconds indicates risk for falls
>20 seconds indicates impaired functional mobility
>30 seconds indicates dependency in most ADL and
mobility skills
Static Balance Testing
• Modified CTSIB
• Ground-Eyes open and closed
• Foam-Eyes open and closed
• ½ Tandem and Tandem
• SLS
• Computerized Dynamic Posturography
Computerized Posturogrphy
Benign Paroxysmal
Positional Vertigo
BPPV Statistics
• BPPV is the most common cause of vertigo in
patients with vestibular disorders (Bath et al,
2000)
• About 20% of all dizziness is due to BPPV
(Hain, 2010)
• About 50% of all dizziness in older people is
due to BPPV (Hain, 2010)
BPPV Defined
• Benign- It does not signify anything lifethreatening. Not malignant.
• Paroxysmal- Refers to the fact that the episodes
are brief and self-limited – "paroxysm" means
"attack."
• Positional-Change in position provokes
symptoms.
• Vertigo-Room spinning sensation.
Causes of BPPV
•“Idiopathic”-50%-70%
•Head injury- 7%-17%
•Viruses
•Vestibular neuritis- 15%
•Degeneration?
BPPV
• Nystagmus
• Non-voluntary oscillation of the eye
• Defined fast and slow phases in opposite
direction
• Fast phase defines direction of nystagmus
• Semicircular canals connected to specific eye
muscles, which dictates direction of nystagmus
• Video
BPPV – Nystagmus
• Posterior canal
• Up-beating, torsional nystagmus toward involved ear
• http://youtu.be/siL3MTNUIQI
• Anterior canal
• Down-beating, torsional nystagmus toward involved ear
• Horizontal canal
• Lateral, slight torsional nystagmus, greater toward
involved ear
• http://youtu.be/MtmkD5rDU0o
Occurrence Rates
• Percentages
• Posterior canal- 92% occurrence
• Horizontal canal- 6% occurrence
• Anterior canal- 2% occurrence
• Once patient has had BPPV, re-occurrence
rate is about 25-30%
BPPV
• Classic Symptoms
• Room spinning, nausea, imbalance
• Brief episodes of vertigo with changes in head
position relative to gravity
• Lying down in bed
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Sitting up from lying down
Rolling over in bed
Bending over
Looking up- Top Shelf Syndrome
Challenges
• Musculoskeletal restrictions
• Pain

cervical, lumbar, shoulder and hips
• Fear of falling off table in sidelying when
spinning
• Hip replacements
• Use of table/plinth
Use of Plinth
BPPV – Clinical Exam
• Dix-Hallpike Test
• 45 degree cervical
rotation
• Align canals with gravity
• Sit to supine with 20
deg of cervical
extension
• Look for nystagmus and
symptoms of vertigo
• Practice
Herdman, 2000
BPPV – Clinical Exam
• Typical Nystagmus
• Latency- before nystagmus starts
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1-30 seconds
• Direction
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Mixed up-beating, torsional nystagmus (post.)
• Duration
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Less than 1 minute
• Fatigues with repeated testing
BPPV – Clinical Exam
• All you need to know…
• Direction
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The direction of the elicited nystagmus will tell you
which canal is involved
• Duration
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Will tell you the type of BPPV
BPPV – Clinical Exam
• Two types of BPPV
• Canalithiasis (A)
• Cupulolithiasis (B)
BPPV – Canalithiasis
• Otoconia are freely
moving in the canals
• Fall to the lowest point
in canal
• Induces flow of
endolymph
• Deflection of cupula
• Fatiguing Nystagmus
• Last less than 1 min
BPPV – Canalithiasis
• Video Animation
• http://youtu.be/IHfU2cA7eRo
BPPV – Cupulolithiasis
• Otoconia are adherent
to the cupula of the
semicircular canal
• Increased density of
cupula
• Sensitive to gravity
• Persistent-last greater
than 1 min
Hain, 2010
Repositioning Procedures
Parnes, 2003
Patient Response
• Sensation of spinning
• May feel like they will fall of the table
• Clammy
• Sweating
• Nauseous
• Vomitus
Canal Alignment Reminder
• Will treat R post. canal
and L ant. canal the
same way
• Opposite eye
movement
• Post-Up beat/Rot
• Ant-Down/Rot
BPPV Treatment –
Posterior/Anterior Canals
• Canalith Repositioning
Technique
• Starting Position is
Dix-Hallpike
• Nystagmus should be
same direction in all
positions
• Practice
Liberatory or Semont Maneuver
• Used for
Cuplulolithiasis
• Posterior and Anterior
Canal
• Rotate head 45 degrees
away from affected
side
• Quick movements to
jar otoconia loose
Parnes, 2003
Case Study
• 74 yo female with past medical history of BPPV
• Slipped and fell at home
• Hit her head on the floor
• Admitted to hospital for 2 days
• Patient self report of BPPV
• Dizziness with getting in bed and rolling to the left
• Patient positive for Left Posterior Canal BPPV
• Treatment-Left CRT
Case Study
• 68 yo male with sudden onset of dizziness
• Increased with rolling over in bed and looking up
• Mild imbalance in Romberg eyes closed position
• Positive R Dix-Hallpike with persistent upbeating and
R torsional nystagmus
Case Study
• All other evaluation info was negative
• Treatment
• Semont Maneuver performed
• Then performed CRT for post canal BPPV, once
otoconia are dislodged from cupula
• Symptoms were resolved after one visit
Horizontal Canal BPPV
• How do you test? Roll Test
• Head in 30 degrees flexion
• Rotate head either direction
• Nystagmus will be lateral
• Treat the side with greater symptoms
Herdman, 2003
Horizontal Canal BPPV
• Canalithiasis
• Eyes will beat
geotropic
• Cupulolithiasis
• Eyes will beat
ageotropic
Parnes, 2003
Horizontal Canal BPPV
• Horizontal Canal CRT
• Barbeque Roll
• Head rotated to
involved side first
• Roll away from
involved side
• Keep head in 30
degrees flexion
Herdman, 2000
BPPV – Flow Chart
Horizontal Canal BPPV
• HC- Semont maneuver
• Used for
Cuplulolithiasis
• Horizontal Canal
• Head in neutral
position
• Quick movements to
jar otoconia loose
• Then perform CRT
BPPV Treatment
• Post-Treatment Instructions- typically 24 hours
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Avoid lying down until you go to bed.
Avoid up and down head movements.
Prop head up at night with pillows.
Avoid sleeping on affected side.
• Debate
Other Treatment Options
• Brandt-Daroff
• Home CRT
• Balance retraining
• Surgery-canal
plugging
Brandt-Daroff Exercises
• 3-5 cycles
• 3 times per day
• Hold position for 30
seconds after vertigo
stops
Parnes, 2003
Home CRT
• Same as CRT
• Place pillow under shoulders
• Tip head over pillow and rest on mattress
Balance Re-training
• Progress toward balance activities if the patient
continues to have imbalance.
• Will discuss balance activities in the Vestibular
Rehabilitation section.
Vestibular
Rehabilitation
Output of CNS
• Vestibulo-Ocular Reflex (VOR)
• Allows clear vision while the head is in motion.
• Vestibulo-Spinal Reflex (VSR)
• Generates compensatory body
movement in order to maintain
head and postural stability.
• Prevents Falls
Vestibular Function Testing
• Video Infrared
Recording
• Eye Movements and Head
Shake
• BPPV
• Caloric Testing
• Head and Eye
Movements
• Saccades, Smooth,
Pursuit, Head Thrust,
Slow VOR
Vestibular Testing
• Computerized Dynamic
Posturography
• Dynamic Visual Acuity
• Dynamic Gait Index
• Static Balance Testing
• Romberg, Sharpened
Romberg, SLS
• Timed Up and Go
Treatment Theory
Treatment Theory for
Dysfunctions
• Compensation
• Response to permanent vestibular lesion.
• Goals- approximate normal gaze stability and
postural control.
• CNS changes to optimize function.
• Visual input important.
• Mechanism for Compensation- Habituation
Treatment Theory
• Habituation
• Long-term reduction of a response to a noxious
stimulus.
• Repeated movements of provocative stimulus.
• Patients who move more, improve more.
• Need to provoke symptoms to reduce
symptoms.
• Examples (MSQ)
Treatment Theory
• Adaptation
• Long term changes in neuronal responses.
• Goals
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Decrease retinal slip- gaze stabilization.
Improve postural stability.
Decrease symptoms.
Decrease sensitivity.
Increase balance and function.
Treatment Exercises
• Based on Models of VOR
• Retinal Slip and Head Movements
• Main Exercises
• x1 and x2 Viewing Exercises
Viewing Exercises
Treatment Exercises
• Guidelines
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Target Seen Clearly
Head Movement +/- 30 degrees
Smooth
Continuous
Pushes Upper Limit
Treatment Exercises
• Progression
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Duration: 1-2 minutes
Frequency: 3-5x/day
Target Size: Small
Position of Head: Level, Slightly Down
Position of Patient: Sit, Stand
Target Distance: Near, Far
Compliant vs. Non-Compliant Surface
Treatment Exercises
• Active Head Movements b/t 2 Targets
• Remembered Target
• Walking Fwd/Bwd with Head Turns
• Bean Bag Toss (1 & 2)
• 180 & 360 Degree Turns
• Ball Against Wall
• Walk in Circle with Ball Toss
Treatment Exercises
• Sit to Stand with head turns
• Wobble board with head turns
• Hurdles with ball toss
• Obstacle course
• Stairs
Balance Re-training
• Romberg
• ½ Romberg
• Full Romberg
• On ground and on foam
• Add head turns
Home Exercise Program
• All the previous discussed exercises
• Can modify as needed
• Can create any exercise incorporating head and
eye movements
• Include balance activities.
Billing
• PT evaluation- 97001
• Neuromuscular Re-ed-97112
• Canalith Repositioning-95992
• One unit per day
• Therapeutic Activity-97530
Treatment Frequency
• 1-3 times per week
• Can take up to 8-12 weeks
• Most often 4 weeks length of treatment
• BPPV only: 1-3 visits
• If BPPV and neuritis
• Treat BPPV first, once resolved, treat neuritis
and balance disorders
Any Questions?
Bibliography
• Herdman, Susan. Vestibular Rehabilitation. Philadelphia: F.A.
Davis Company, 2000.
• Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of
benign paroxysmal positional vertigo (BPPV). CMAJ 2003;
169:7 681-693.
• http://www.dizziness-andbalance.com/disorders/bppv/bppv.html. Timothy Hain, MD.
Benign Paroxysmal Positional Vertigo. July 19, 2010.
• Vestibular Rehabilitation: A Competency Based Course. Emory
University. Atlanta, Georgia.
Thank You!