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Vestibular Rehabilitation (Assessment of Vestibular Symptoms - HallPike…
Vestibular Rehabilitation
Assessment of Vestibular Symptoms - HallPike Dix
Turn head 45' to ear being tested
Lie back in 20-30 Cx Ext
Instruct pt to keep eyes open
Hold position for 60 seconds or nystagmus and vertigo to settle + 30 sec
Vertigo and nystagmus of short duration (<60s= canalithiasis)
Reversal of nystagmus on sitting up
Fatiguing nystagmus with repetition
Looking for nystagmus (eye flickers) in the direction symptoms
Treatment Options
Liberatory (Semont) Technique - Cupulothiasis Posterior SCC
Brandt-Daroff Exercises - Habituation and cupulothiasis
Exercises can be used as a self treatment to help reduce symptoms and likelihood of recurrence.
Epley Maneuver - Canalithiasis Posterior SCC
Anatomy of Vestibular System
Peripheral Vestibular Apparatus
Boney membranous labyrinths filled with fluid.
Five Sensory organs: Two otolith organs. Three semicircular canals
Otolith Organs
Semicircular Canals
Three SCC orientated orthogonality within labyrinth and functionally and anatomically paired with canals on other side. Movements in one plane will stimulate canals on both sides
Three on each side, the canals are
orthogonal (90 degrees) to each other
Functionally and anatomically paired with canals on other side, so that head movements will stimulate canals on both sides simultaneously.
Hair cells of ampullae rest on tuft of blood vessels, nerve fibers and supporting tissue called crista amullaris, which is covered by gelatinous membrane called the cupula
Sense angular acceleration or rotation movement of head
Saccule- Orientated vertically
Utricle - Orientated horizontally
Respond to linear acceleration and head tilt
Otolith organs respond to linear acceleration and
head tilt (relative to gravity)
hair cells innervated by an afferent neuron
Traduce movement into electrical signals
Resting firing rate ~100Hz
Causes a change in hair cell firing
Head movement causes deflection of stereocilia
Vestibular nerve CN V111. Transmits afferent signals from SCC and otolith organs
Central Processor
Central Nervous System
Motor Output Mechanism
Spinal cord and Cerebellum: Postural Control
Oculomotor system: Eye movements
Forebrain: Perceived Orientation
Peripheral Sensory apparatus
Saccule and Utricle
Visual, Proprioceptive, Tactile Inputs
Head motion: Linear acceleration
Head Position Gravity
Semicircular Canals
Head Motion Angular Acceleration
Central Processor
Cerebellum
Main recipient of outflow from vestibular nuclei complex
Flocculus, nodulus vermis
Error correction - comparator/integration with sensory feedback
Significant projections from cerebellum to modulate vestibular nuclear complex output
Thalamo-cortical projections
From VN complex to multi-sensory cortical areas
Parietoinsular cortex, temporo-parietal junction, hippocampus
Perception of position,/ self movement/ spatial orientation and memory
Motor Output
Vestibulo-ocular reflex
Allows for clear vision while head is moving
Induces an eye movement if equal velocity but opposite direction to head movement
Gain= eye velocity/head velocity = approx 1
Vestibulospinal reflex
maintenance of posture and balance during head movement
Sensory Integration
CNS relies on information from all available sensory systems
Relies on systems of perceptions and orientation
Postural Control for vision, somatosensory, vestibular and auditory
Neuritis/Labyrinthtis
Acute onset of
Vertigo, dyseqilibrium, oscullopsia/blurred vision, hearing loss with labytinyhitis
Initially spontaneous and aggravated by head movement improving over days to weeks
Presumed viral inflammation
May have presenting
Sensitivity/dizziness with head movements
May c/o slower movements or walking especially in the dark, or with dual tasks (head turns)
Dysequilibruim especially in the dark or visually busy environments, c/o visual blurring especially with movement
Treatment
Acute: antiemitics, vestibular suppressants, steroids
Subacute - Chronic: VR
VS.
Vestibular Migraine
General presentation
Affects 1% of general population, approx 10% of patients in dizziness clinics and 9% of patients in migraine clinics
Spontaneous or positional vertigo/giddy/dizzy lasting sec-hrs > 24 hrs
Can be vague symptoms - foggy, pressure, heavy or NQR
Light sensitive and often noise sensitive
+/- headaches and Aura
Treatment
Avoidance of triggers - diet, salt restriction and diuretics, stress, fatigue
Education and counselling
prophylatic or abortive medicine
High levels of anxiety are common.
Symptoms from attacks affect ADLS
VS.
BPPV
What is BPPV
Calcium carbonate crystals originating from the otolith organs break away and fall into the semi circular canals
The most common cana effected is the posterior SSC 85-95%
Common Characteristics
+/- postural instability/unsteady gait/falls
+/- Anxiety+++
Often more marked first thing in the morning
Bouts of vertigo lasting <60 seconds
Occurs when: Rolling, sitting <--> laying, leaning forward, looking up
Occurs with change in head position
Red Flags
Neurological Signs - inability to stand, walk, diplopia, dysarthria, dysphagia, incoordination
Sudden hearing loss
Atypical Nystagmus - Central positional vertigo - downbeat, direction changing. Central nystagmus without vertigo
Failure to respond
Those At Risk
The most common cause of vertigo in patients with peripheral vestibular dysfunction
Preceding episode of neuronitis 15-25%
History of head injury 18%
Hereditary component
Ischaemia in distribution of ant.vest artery
Post surgery (of ear or general)
Prolonged bed rest
Migraine
Meniere’s
Idiopathic
Outcome: Usually very good withing 6-12 months