CB: Objective Findings 11/5/2013. Management of Atypical Vestibular Disorders: Beyond BPPV, Vestibular Neuritis, and Acoustic Neuroma

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1 Management of Atypical Vestibular Disorders: Beyond BPPV, Vestibular Neuritis, and Acoustic Neuroma CSM 2014 Las Vegas Rachel D. Trommelen, PT, DPT, NCS Laura Morris, PT, NCS Janene Holmberg, PT, DPT, NCS Objectives Upon completion of this presentation, the learner will be able to 1) Articulate the pathophysiology of selected atypical vestibular disorders 2) Articulate theoretical mechanisms that would support management of atypical vestibular disorders with vestibular rehabilitation 3) Select appropriate tests and measures to identify impairments of body structure and/or function, activity limitations, and participation limitations 4) Identify strategies used by experts the field to reduce symptoms of dizziness, improve balance control, and optimize function in patients with atypical vestibular disorders 5) Identify options for management of patient with atypical vestibular disorders which have little or no evidence based support. 6.) Articulate future direction of research into the effectiveness of vestibular rehabilitation with atypical vestibular disorders Why this topic? Case 1: CB Referral from neurotologist: MAD vs. Meniere s Pt. is a 49 y/o female presenting with gradual onset of dizziness, nausea, and imbalance past 6 months. Symptoms progressively worsening over time PMHx: Migraines (daily past few months, severe a few times, hormonal relationship, sensitivity to smells, lights, sounds), PMDD Medications: Seasonique, Ambien CR. ENT placed patient on betahistine and diazide CB CB: Objective Findings Symptoms Gradual worsening 0/10 at present and best, 10/10 at worst (off medications, even when wearing sunglasses) Tempo: Hours Frequency: 1 2 times per week, but nauseous daily Description: Wooziness unsettled unsteady Blurry vision at distance Imbalance and near falls, no falls Pressure and ringing, bilaterally ears (intermittent) Oculomotor Findings All beside tests negative except positive left head thrust, VOR dysfunction VOR testing positive in sitting, elicited mild symptoms Hallpike Dix and rolls tests negative bilaterally VNG findings: Abnormal ECoG in left ear (suggestive of hydrops), abnormal VEMP left ear with oscillopsia Balance/Gait ABC: 73% Static Balance: mctsib, SLS, Romberg, and Sharp Romberg EO 30. Romberg EC 30, Sharp Romberg EC 15 Functional Gait Assessment: 27/30 Gait speed: 3.85 ft/sec DHI: PANAS: Negative for anxiety/depression Oscillopsia VAS: 6.5 cm, 5.8 cm, and 7.5 cm respectively for sitting, walking, and driving 1

2 Function and Participation Limitations Mother to 17 y/o son Owns a boutique shop Lives in 1 story home Can t walk in a dark room, more careful on a ladder, lingers in bed longer, more symptom at work Limiting driving: Let s friends drive, uncomfortable driving longer distances Patient goals: Feel Better CB: Clinical Impression Presentation c/w MAD vs. Meniere s Should benefit from VRT for vestibular adaptation, habituation, and balance training Intervention Superior Semi Circular Canal Dehiscence VOR and balance exercises for 2 weeks. Minimal improvements, but limited compliance with HEP week 1 CT scan revealed Superior Semicircular Canal Dehiscence (SSCD) MD recommended surgical treatment, thus patient D/C ed from PT Returned to PT approximately 4 month post surgery Small hole develops in the temporal bone, and the superior semicircular canal moves into that hole Genetic Trauma Causes an abnormal communication between superior semicircular canal and brain Created a third mobile window which causes increased sensitivity to sound and pressure changes First described by Minor and colleagues in 1998 Chein, 2011 Pfammatter, canal dehiscence scd SSCD SSCD: CT Scan Image Signs Vertical and torsional eye movements with sound or pressure induced symptoms CT scan abnormalities VEMPs lower in affected ear May see Weber test positive to affected ear Autophony Symptoms Oscillopsia & Dizziness induced by loud sounds 59% of patients will report history of symptoms with vigorous valsalva Chien, 2011 Chien, 2011 Computed tomography images demonstrating a superior canal that is dehiscent (a and b) and one that is intact (c and d). The dehiscent superior canal is from a 39 year old man with superior canal dehiscence syndrome. The patient developed sound induced vertigo and oscillopsia. Dehiscence of the bone over the right superior semicircular canal was confirmed at surgery. (a) Multiplanar reformation in the plane of the superior semicircular canal demonstrates dehiscence of bone (arrow) over the right superior canal. (b) Multiplanar reformation orthogonal to the plane of the superior semicircular canal demonstrates dehiscence of bone (arrow) over the right superior canal. (c) Multiplanar reformation in the plane of the superior semicircular canal in a normal temporal bone CT in shown for comparison. The bony covering of the superior canal (arrow) is intact. (d) Multiplanar reformation orthogonal to the plane of the superior semicircular canal in a normal temporal bone CT. The bony covering of the superior canal (arrow) is intact. 2

3 SSCD: Clinical Classification Cochlearvestibular signs and symptoms (78%) Signs described above in most patients Attributed to larger size (6 mm or greater) Cochlear signs and symptoms (15%) Conductive and mixed hearing loss Small dehiscence (1 2 mm) Vestibular Signs and symptoms (7%) Dizziness, loss of balance, and torsional nystagmus with valsalva Small Dehiscence (1.5 1 mm) Pfammatter, 2010 SSCD: Does Size Matter? Symptom description VEMPs: Larger lesion produced lower VEMPs Larger lesions more often has positive findings of Tullio phenomenon, Hennebert sign, and/or valsalva However the pattern of these findings is different for dehiscences of all sizes Pfammatter, 2010 Treatment Options Post Surgical Management Conservative Management: Avoidance of symptom provoking activity Surgical Management Repair through middle cranial fossa approach Plugging canal Transmastoid approach All surgical approaches affective in reducing or eliminating vestibular and auditory symptoms Chien, 2011 S/p Canal Plugging with middle cranial fossa approach Post Op testing for unilateral hypofunction Tested immediately post op (1 7 days) and 6 29 weeks post op Identified by positive head thrust test (performed with camera analysis 38% presented with hypofunction in immediate post op period, 11% at 6 week f/u Conclusion: More often immediate post op, typically resolves. Larger dehiscence increases risk of vestibular hypofunction NO mention of vestibular rehabilitation Agrawal, 2009 CB: Re eval Findings CB Symptoms Symptoms gradually improving 0/10 at present and best, 5/10 at worst (with bending and head and eye movements) Tempo: seconds Frequency: whenever completing provoking movements Description: Wooziness top heavy wobbly Blurry vision when walking with head turns Imbalance and with no falls or near falls Ringing intermittently Functional Limitations Less cooking, increased fatigue Not working (closed store) Not driving Process of moving Gained 30 lbs since PT discharge, wants to start fitness routing with trainer for weight loss Patient goals: To be able to drive and less wooziness Re eval Findings Balance/Gait ABC: 62% Static Balance: mctsib, SLS, Romberg, and Sharp Romberg EO 30. Romberg EC 30, Sharp Romberg EC 15 Functional Gait Assessment: 23/30 Gait speed: 3.23 ft/sec DHI: PANAS: Negative for anxiety/depression Oscillopsia VAS: 1.0 cm, 1.2 cm, and 4.2 cm respectively for sitting, walking, and driving Interventions VOR: sitting, standing, romberg, walking forwards, walking forwards and backwards Balance training: Gait with head and body turns, static standing balance in variety of positions with EC and/or foam Optokinetic Stimulation: Youtube videos initially and progression to stimulating body environments Habituation: Turns, with and without ball toss 10 visits over 10 weeks 3

4 Outcomes: CB Case 2: GC Initial ABC: 62% FGA: 23/30 Gait speed: 3.23 ft/sec Activity and participation limitations Outcomes ABC: 86.9% FGA: 29/30 Gait Speed: 3.89 ft/sec Activity and participation Patient able to drive 15 minutes without symptoms Able to work out with trainer at gym without symptoms Resumed all ADL s and household chores without dizziness Patient is a 41 y/o female presenting from neurotologist with dx of vestibular neuritis and history of migraine variant Patient complains of baseline motion sensitivity Sudden vestibular crisis event in February/March 2010, diagnosed with labrynthitis. Resolved with acupuncture Symptoms came back May 2013 mildly, but progressed to severe after bending over. Severe for a few days then decreased Reports HA after episode PMHx: C section, Psorasis inner ear, migraine disorder Migraine Hx: Last migraine a few years ago. Reports mild HA few per month GC GC: Objective Findings Symptoms Gradual improvement 2/10 at present and best, 10/10 at worst (episode in may) Tempo: Constant Description: Bobble head and Interia Self reported oscillopsia Imbalance and near falls, no falls Pulsatile sensation in inner ear: MD attributed to debris in ear Oculomotor Findings All beside tests negative except positive right head thrust, VOR dysfunction VOR testing positive in sitting, elicited mild symptoms Hallpike Dix and rolls tests negative bilaterally ENG findings: Rotational chair revealed subtle signs of uncompensated vestibulopathy with decreased VOR phase change and left asymmetry. VEMPs, calorics, and other VNG negative Balance/Gait ABC: 80% Static Balance: mctsib, SLS and Sharp Romberg EO/EC 30 Functional Gait Assessment: 26/30 Gait speed: 3.57 ft/sec Situational Vertigo Questionnaire: 2.35 DHI: 40/100 PANAS: Negative for anxiety/depression Oscillopsia VAS: 1.0cm, 0.5 cm, and 1.8 cm respectively for sitting, walking, and driving Function and Participation Limitations Wife, mother to 3 y/o son Plans to start work as school RN (6 hrs/day) in 3 4 weeks Lives in 2 story home Stopped walking and doing yoga Limiting driving Patient goals: Not to be dizzy GC: Clinical Impression Didn t fit vestibular neuritis or Meniere s Peripheral unilateral weakness Appeared stable Let s start a program and monitor 4

5 Intervention Outcomes: GC VOR and balance exercises for 2 weeks. Reports improvement Day before vacation (2 weeks to Brazil), patient received results of CT revealing SSCD Patient continued exercises as able during vacation Follow up with MD while patient on vacation: opting for conservative management Continuation of full VOR and balance exercise progression followed by 4 weeks of optokinetic stimulation program Total time: 8 sessions over 9 weeks Initial DHI: 40/100 ABC: 81% FGA: 26/30 SVQ: 2.35 Activity and participation limitations Outcomes DHI: 6/100 ABC: 92.5% FGA: 30/30 SVQ: 2.35 Activity and participation Able to care for son without difficulties or symptoms Able to complete all work/home tasks without difficulty Return to Yoga and walking for exercise Reports no dizziness X 1 week, no limitations in daily life Hindsight is 20/20 Paid more attention to auditory symptoms Symptoms with bending could be due to valsalva and not only movement itself Case Study: Bill 54 y.o. high school math teacher Underwent aortic aneurysm repair Resulted in rare saccadic eye movement disorder (Solomon 2008, Eggers 2008) Presented with symptoms of dizziness, imbalance, inability to read Case Study: Bill Clinical Assessment VOR intact Smooth pursuit intact VOR suppression intact Vergence intact VERY slow saccades 5

6 Objective outcome assessment Unable to complete King-Devick testing Used timed reading sample instead Initial, monthly to record progress Saccadic eye task with two targets 3 feet apart, pt. arm s length away, head and eye movement required Initially, 7 seconds to right, 4 to left Assessment Gait Functional Gait Assessment 18/30= risk for falls Difficulty with head turns in gait, turning around, obstacle negotiation Static balance WNL Dynamic balance Head turns in standing caused marked postural instability Functional Impairment Unable to read Unable to drive ADLs slow, increased energy required Buttoning shirt Finding desired object Entering room Difficulty assessing environment Community environments Required assist due to impairment in visual scanning Intervention Utilize intact systems Target following during gait, visual scanning Rapid head turn with blink for compensatory technique Saccadic training Large words for reading Visual scanning simple Used peripheral vision to manage complex environments Compensatory mechanism Progression Smaller fonts, increased time for reading Head turns in gait Dynamic standing balance tasks Somatosensory feedback Reaching Head/eye movement Sitting driving simulation Busy background for visual scanning Grocery store- find soup cans 6

7 Outcomes Total of 14 weeks, 2x/week initially, then 1x/week Returned to work as teacher, with assistant teacher Hallways at school still problematic Able to read at functional speed Much slower than his suspected prior speed Saccadic task 1.5 seconds to right, 1 second to left Still very slow but marked improvement Outcomes Balance- better than before Static and dynamic Functional Gait Assessment (FGA) improved from 18/30 to 28/30 Head turns still mildly impaired Exercising regularly at gym Hopes to drive eventually (?) Why such success? Determination How can I keep doing what I was doing before? WORK, physically active lifestyle Positive outlook/ sense of humor Discipline to keep doing BORING exercises/tasks Supportive wife/kids Management Considerations Classes of eye movements Saccades Smooth pursuit Vergence Vestibulo ocular reflex Optokinetic system Compensation vs. recovery? Is impairment permanent or has potential for improvement? Balanced approach Use of compensatory techniques to help function in the short term Neuromuscular re education to improve vestibular and/or oculomotor function Be aware of the mechanism that you are employing Management Considerations Classes of eye movements Saccades Smooth pursuit Vergence Vestibulo ocular reflex Optokinetic system 7

8 Compensation vs. recovery? Is impairment permanent or has potential for improvement? Balanced approach Use of compensatory techniques to help function in the short term Neuromuscular re education to improve vestibular and/or oculomotor function Be aware of the mechanism that you are employing References Chien WW, Carey JP, Minor LB. Canal dehiscence. Current Opin in Neurol. 2011;24: Pfammatter A et al. A superior semicircular canal dehiscence syndrome multicenter study: Is there an association between size and symptoms? Otol Neurotol. 2010;31: Argawal Y, Migliaccio AA, Minor LB, Carey. Vestibular hypofunction in the initial postoperative period after surgical treatment of superior semicircular canal dehiscence. Otology & Neurotology. 2009;30: