Why do we care about Dizziness? Because Dizzy People Fall. 5/25/2016. Downloaded from 1. Vestibular Rehabilitation.

Transcription

1 Vestibular Rehabilitation Valerie Johnson, PT, DPT Vestibular Rehab Specialist Objectives Functional Anatomy Review Basic Function of the Vestibular and Human Balance System Central vs. Peripheral Signs & Symptoms & Pathophysiology Central vs. Peripheral Pathologies & Disorders The Patient Interview- obtaining subjective clues Vestibular Examination and Positional Testing Vestibular Rehabilitation Techniques and Canalith Repositioning Patient Education Case Studies Resources for professionals and patients Why do we care about Dizziness? Because Dizzy People Fall. In fact, persons who reported dizziness had a 12 fold increase in the chance of reporting a fall(agrawal Y et al 2009) Why? Downloaded from 1

2 Dizziness A Non-specific, Primary Care Dilemma. PCPs see the majority of patients reporting dizziness (Micromedical Technologies Issue 21 Summer/ Fall) 1998) Dizziness is the 3 rd leading complaint to PCPs. However, the incidence of dizziness (and falls) rises steadily with age, making dizziness the leading complaint to PCPs for patients over 75 years of age. Getting a Diagnosis is Enough To Make Anyone s Head Spin 50% of dizzy patients do not receive a diagnosis from PCP Only 4% of dizzy patients are referred to specialists by their PCP. (Sloan 1989) The average number of providers an individual sees for dizziness is 7 when a vestibular disorder is not considered. Almost 40% of dizzy patients have seen 4 or more physicians when a vestibular dx is considered. Dizzy patients resort to over-utilizing the healthcare system resulting in high direct and indirect costs, unnecessary testing, and loss faith in the medical system. Impact of Dizziness on the Population 40% of those > 40 y/o will have a dizziness disorder in their lifetime. 70% of undiagnosed patients are issued Meclizine by PCP to manage dizziness, however Meclizine is not an appropriate treatment of chronic dysequilibrium, imbalance, or lightheadedness. (Physicians Desk Reference 1999) Downloaded from 2

3 Dizziness vs. vertigo vs. lightheadedness vs. Dysequilibrium What does that mean anyway? Lets take a closer look Dizziness Is An Umbrella Term Dizziness is difficult to describe Symptom descriptors are often vague and mean different things to different people People will use dizziness to describe vertigo and vice versa Vertigo Perception of motion (usually spinning) Vertigo A sensation, perception, or illusion of spinning or rotation of one s self or environment, even with eyes closed Nystagmus- involuntary back and forth or rotary movements of the eyes A distinct symptom often confused with other types of dizziness Most likely due to peripheral vestibular involvement However further investigation is warranted to rule out CNS involvement in the physical exam Asymmetrical neural tone Often associated with nausea, vomiting, and imbalance Downloaded from 3

4 Multifactorial Dysequilibrium Geriatric Syndrome? Poor balance and instability in the elderly The specific cause of these complaints is often not obvious to the examiner Imbalance is often multifactorial and presents with no single clinical abnormality What do PCPs need to do? Identify known fall risk factors and red flags Know what questions to ask regarding symptoms and triggers. Know when to refer to a specialist Motor Output Motor Neurons (reflexive pathways) Vestibular Nuclei Cerebellum I feel drunk! Multi-factorial Dysequilibrium Definition A sense of unsteadiness or imbalance typically exacerbated by movement or environmental influences (may be associated with nausea) Usually complicated by a gradual, age related loss in vestibular function in conjunction with other factors Downloaded from 4

5 Why Do We Care About Multi-factorial Dysequilibrium? Because They Fall! Individuals with dysequilibrium over 75 years old fell 4 times more frequently than controls. And 2/3rds of subjects fell at least once a year.(kerber et al 1988) The Patient Interview Research suggests that 60% of making an accurate diagnosis is reliant upon subjective clues from the interview. Do you Frequently feel unusually hot, cold, numb, or tingly in your feet or toes? Sense of touch is an important contributor to balance and orientation. Stretch receptors in the legs, feet, ankles, toes, and fingers provide sensory FB for balance. Tendency to fall backward Assess for Peripheral Neuropathy Downloaded from 5

6 Impaired Sensory Inputs for Balance Continued. Difficulty walking in the dark, on uneven surfaces such as gravel, or on a sloped walkway? Impaired Sensory Inputs for Balance Q) Do you have difficulty walking over gravel or a sloped walkway? Do you experience instability when moving your head or changing directions when walking? Q) Do you feel uneasy or unsteady when walking down the isle of a supermarket or in an area congested with people? A) Symptomatic in areas with limited or overwhelming visual cues Asking about dizziness A lot like asking about pain Onset Nature Intensity Duration (acute and residual) Frequency Aggravating factors (dizziness always has a trigger) Easing factors Get a thorough case history. Get some suspicions of what you think may be causing dizziness/ imbalance Confirm with physical examination Downloaded from 6

7 Ask For Subjective Clues About Dizziness Do you see the room spinning or have a spinning sensation? Vertigo Is the spinning inside your head? Or do you feel dizzy with head movements or when changing directions while walking? Vertigo or Vestibular Ocular Reflex (VOR) Dysfunction Do you feel faint-like? Worse with upright? Exertion? Lightheadedness, pre-syncope Is it more unsteady on your feet? Do you feel drunk-like? Is your instability movement related, worse in certain environments such as a grocery store, or associated with any nausea? Imbalance or Multi-factorial Dysequilibrium Do you see objects or the horizon bouncing when you are moving or walking? Oscillopsia 2* Bilateral Vestibular Loss Assessing Sensory Inputs for Balance Sensory Organization Balance Training Eyes Open/ Eyes Closed Visual Suppression- i.e. sunglasses Visual overwhelm/ distraction- Disco Balll Head movements Varied BOS Varied surfaces Firm Foam Inclines/ Declines Shuttle board Rockerboards ½ foam rollers Downloaded from 7

8 VOR Dynamic Visual Acuity Testing Pt 10 feet from Snellen eye chart reading lowest line possible (>50% accuracy) with head still (Static Visual Acuity- SVA) Examiner moves pt s head in horiz. Plane at 2Hz, +/- 15* (+) test of a DVA change>2 lines from SVA indicates fall risk during walking Funtion Stabilize an image on the retina during head movement Gaze stabilization during head movement Abnormal VOR- know factor for fall risk and indicator or recent falls Vestibular Inputs for Gaze Stabilization VOR VOR functions to cause eye movements that are equal and opposite to head movements VOR Stabilization Exercises Look at the X and shake your head Downloaded from 8

9 Common Factors Underlying Gait, Balance, and Dizziness Disorders Sensory Deficits Peripheral Neuropathy- Impaired proprioception Gait Characteristics- Unsteady, Uncoordinated Visual deficits Gait Characteristics- Tentative, uncertain Vestibular pathology- 30%-65% of dizzy patients presenting to PCP Gait Characteristics- Unsteady, weaving esp. when changing directions or moving head Usually multifactorial Sensory Conflict Sensory Overwhelm Vascular Causes of Dizziness Arrhythmias OH VAI Symptoms w/ combined cervical extension & rotation 5 D s Diplopia Dysphagia Dysarthria Drop Attacks Dizziness Downloaded from 9

10 Testing Vascular Causes of Dizziness Consecutive Positional BP Assessment- Drop in Systolic BP>20 or Diastolic BP >10 following transitions to upright significant for OH (orthostatic HTN) Supine BP Sitting BP Standing Initial BP Standing 1 minute BP Standing 3 minute BP Vestibular Disorders This is how it works Sensory hair cells convert rotational and translational head motion into electrical signals These messages are sent to neural structures that control eye and postural muscles, resulting in orientation of the head and body in space (VSR) as well as coordinated eye and head movement (VOR). Maintains stable vision and upright posture through reflexive spinal and ocular motor pathways. Downloaded from 10

11 Vestibular System Anatomy- Peripheral 5 Sensory Organs (labyrinthine structures) 3 Semicircular canals- ant, post, horiz 2 Otolith organs- utricle and saccule 2 Otolith Structures Peripheral Vestibular Sensory Organs Informs CNS about linear motion (acceleration) 1) Utricle- Horizontal Linear Motion *Acceleration 2) Saccule- Vertical Linear Motion *Acceleration The otoliths detect static tilt with respect to gravity Hair cells with overlying gelatinous membrane that contain otoconia Otoconia Calcium Carbonate Crystals ear rocks Causes the Maculae (sensory component) to be sensitive to gravity Do you. Experience dizziness or a spinning sensation when you lie down, tilt your head back, or roll over in bed? Downloaded from 11

12 BPPV (Benign Paroxysmal Positional Vertigo) Definition: Brief, episodic vertigo and instability triggered by head position changes with respect to gravity. Most common inner ear disorder Also easiest form of vertigo to treat. Semi-Circular Canals Couples head motions and hair cell movement (push+/pull-) Informs CNS about angular motion/ acceleration Coordinates head and eye movement Allows us to perceive the 3D environment we live in BPPV Pathophysiology Patient education Canalithiasis: Otoconia are swimming freely in the canal before settling into the most gravity dependent portion of the canal. Result- brief, intense bursts of vertigo/ nystagmus lasting usu <30-60 sec. Cupulolithiasis- Otoconia are stuck to the cupula thus increasing the density of the cupula and making it sensitive to gravity Result- longer duration of intense vertigo/ nystagmus Downloaded from 12

13 Why me? BPPV Risk Factors Head/ neck trauma- leading cause Women x2 more likely Migraine x4 more likely Age BPPV relapses Post-Surgical Prolonged bed rest Inner ear infections Osteoporosis Associated with BPPV Positional Testing Dix HallpikeTesting Supine Roll Testing 38 Downloaded from 13

14 Dix Hallpike Test for the L posterior Canal Canalith Epley Repositioning Manuever for the Left Posterior Canal Keep in Mind Risk for transference from the posterior canal to the horizontal canal during Epley Repositioning Manuever. Downloaded from 14

15 Horizontal Canal BPPV- Supine Roll Test - Harder to treat - Usually more intense symptom wise -N/V, running into walls, etc.- Cupulolithiasis vs. Canalithiasis What do you see? What do you do? Horizontal Canalithiasis Supine Roll Test- Horizontal Canalithiasis Geotropic Nystagmus = fast phase toward the ground Duration < 1minute Tx: Roll away from the most symptomatic side in a step wise fashion for two minutes for each position QE fig7.jpg&imgrefurl= vxxgku_bvbbhy9xzijxv7gqfg14=&h=518&w=600&sz=53&hl=en&start=0&zo om=1&tbnid=ikgtd0mcpcxxfm:&tbnh=157&tbnw=182&prev=/images%3fq%3dbbq%2broll%2bbppv%26um%3d1%26hl%3den%26client%3dfirefox- a%26sa%3dn%26rls%3dorg.mozilla:en- US:official%26biw%3D1280%26bih%3D845%26tbs%3Disch:1&um=1&itbs=1&iact=rc&dur=460&ei=UN2YTJXXNaLknQef9_j8Dg&oei=UN2YTJXXNaLknQef9_j8D g&esq=1&page=1&ndsp=25&ved=1t:429,r:0,s:0&tx=149&ty=90 Downloaded from 15

16 What do you see? What do you do? Horizontal Canal Cupulolithiasis Horizontal Canal Cupulolithiasis- the affected side is the side where the nystagmus is less intense Ageotropic Nystagmus Duration= 2+ Minutes TX: short sitting to side lying (toward the affected ear), hold 2 minutes>>> Rotate C-spine down toward table 90*, hold 2 minutes then return to short sitting Anterior Canal BPPV- Rare Dix Hallpike revealed down beating rotary nystagmus Tx: Sitting C-spine rot 45* to contra-lesional side x 15 seconds>>> Supine 45* C-spine rot + 45* C-spine extension x2 min>>> Supine C-spine rot 45*, C-spine ext 0* x 1 min>>> Sitting C-spine rot 0*, C-spine flex 30* Vestibular Neuritis or Labyrinthisis Downloaded from 16

17 Inner Ear Infection Q) Did you experience a room spinning sensation (vertigo) lasting for days? with residual movement related nausea, intolerance, or instability? (Not to be confused with: Otitis Media (middle ear infection): acute or infection; painful; bacterial) Resulting in unilateral vestibular loss/weakness and/or hearing loss Almost always viral; almost never returns to the same ear 49 Inner Ear Infection Cont Key Characteristics: Vestibular Neuritis: sudden onset; hours to days; nausea/ vomiting; Typically follow other illnesses, stressful events and even head trauma NO hearing loss Vestibular Labyrinthitis: same as above WITH hearing loss Residual movement related intolerance, nausea, instability Hearing loss will become permanent if steroids are not issued within 72 hours of initial onset. Remarkably Plastic Vestibular System Downloaded from 17

18 Unilateral Vestibular Loss (UVL) Tx: VOR Stabilization We need to encourage vestibular stimulation to promote CNS compensation in the recovery from vestibular injury/ disease and to to combat vestibular loss due to aging. However, the brain must become aware that the asymmetry exists in order for the brain to compensate (highly plastic) to recover symptoms. Vestibular suppressant or central sedative meds inhibit this critic compensatory process. Acute vestibular induced vertigo due to tonic asymmetry may benefit from a vestibular suppressant in the acute phase (3-5 days) by reducing the activity in the vestibular nuclei and cerebellum. Ototoxicity resulting in Bilateral Vestibular Loss (BVL) Unsteadiness (w/out vertigo) after receiving high dosages of antibiotics by IV, cancer treating drugs, or other ototoxins Oscillopsia- bouncing vision Bilateral Vestibular Loss (BVL) Permanent hair cell death Head thrust and DVA Testing Testing for Unilateral Vestibular Loss (UVL) and BVL Head Thrust Testing (+) positive if >2 line difference Dynamic Visual Acuity Testing Downloaded from 18

19 Quick review: The Labyrinthine Structures Meniere s DZ, Endolymphatic Hydrops, and Fistulas Bony Labyrinth Perilymph High Na/ Low K Membranous Labyrinth Endolymph High K/ Low Na Same specific gravity of cupula Meniere s Disease Definition: Decreased ability to regulate the electrolyte balance of the endolymph. Considered a disease or syndrome and is typically progressive Key Characteristics: low frequency hearing loss, fluctuating hearing loss, fluctuating fullness/pressure in the ears, fluctuating tinnitus (noises in the ear), and or violent spells of vertigo that are usually followed by unsteadiness, fatigue, malaise, or nausea. Attack Duration: minutes to hours followed by exhaustion Residual HL (typically in low frequencies), residual imbalance Conservative diet/ lifestyle mgmt, diuretics, abx injections 56 Meniere s Disease DDX Do you experience reoccurring episodes of vertigo, fluctuation of fullness/ pressure/ tinitis, and hearing changes (beginning in one ear) that are increasing in frequency? Downloaded from 19

20 Meniere s Dz Vestibular Rehab Between attacks! Or Following gentamicin injections. Goal: maximize vestibular inputs for balance and promote CNS compensation for new baseline Every attack permanently damages the hearing and balance nerves Hearing loss accumulates over time Unilateral Vestibular nerve damage can be compensated for by the CNS About 50% of cases will develop bilat. Meniere s DZ Diet, Lifestyle, and Medical Management for Meniere s Disease Goal: Stop the Attacks! Treatment aimed at stabilizing the inner ear fluid Medical Mgmt: Usu. A mild diuretic to eliminate excess fluid + potassium supplementation Gentamicin Injections Stress Management Decrease salt intake Allergy management Hearing aids specifically fitted for MD have different programs to accommodate fluctuations in hearing Endolymphatic Hydrops vs Meniere s Disease Not progressive. No low frequency hearing loss. Downloaded from 20

21 Fistula & SCDS Acoustic Neuroma Acoustic Neuroma Benign tumor most commonly associated w/hearing loss & tinnitus ON ONE SIDE than can progress to dizziness and/or unsteadiness, unilat. facial droop as well 62 Mal de Debarquement Syndrome Downloaded from 21

22 Chronic Subjective Dizziness AKA PPPD Primary diagnostic criteria: based on subjective history Symptoms increase with postural changes Sensitivity to a variety of visual stimuli- visual patterns especially walking over busy patterns, complex environments, focused precision visual tasks (reading), sensitivity to visual motion head movements, sensation of self movement, sensation of movement in the head that is difficult to describe Persistenten, nonvertigenous dizziness, unsteadiness at least 50% of the day for at least 3 months Signs: typically aren t any, diagnostic testing is generally normal May have been characterized as aphysiologic in the past Commonly have a H/o of neuro-otologic event, usually peripheral vestibular event that has since compensated A H/o anxiety and/or depression May have a migraine or vestibular migraine component Cervicogenic Dizziness Where is my head? Dizziness usually associated with neck pain No diagnostic tests to confirm Diagnosis Treatment joint position re-training Postural Re-eduation Manual Therapy Psychogenic or a-physiological Disorders of Gait and Balance Presentations vary and usually don t fit pattern for known disorders... Extreme Anxiety/Phobia: exaggeration caution with abduction of arms as if walking on ice Hysterical Gait: gyrations, wastage of muscular energy (astasia-abasia), slow motion & dramatic fluctuations over time =tdpvnobwezo Downloaded from 22

23 Do you Feel like you can t walk in a straight line or are pulled to one side when walking? Or Feel like your feet just won t go where you want them to go? Cerebellar dysfunction results in slow of inappropriate reactions to self movement or external stimuli Cerebellar disorders often masquerade as vestibular disorders Central vs. Peripheral Vestibular pathways Vestibular Nuclear Complex Primary Processor Located primarily in the Pons with extensions into Medulla Cerebellum Provides feedback and regulates eye/body/head movement Generates motor outputs to stabilize vision and posture space Medications for Dizziness If underlying etiology for dizziness is due to central involvement, then suppressing the vestibular system with medication will make it that much harder for this person to function Ex. Cerebellar stroke pts need their vestibular system more than ever, so keep it awake. Downloaded from 23

24 Neurological Causes of Dizziness 1) PICA Infarct/ Webber s Syndrome Valcular supply to Lateral Medullary Region of the Brain Stem 2) AICA- Dorsolateral Pontomedullary Infarct Vascular Supply to Inferior Cerebellum, Pontomedullary region of the brainstem, Membranous Labyrinth 3) Cerebellar Infarct 4) Migraine Associated Vertigo (MAV) 5) TBI and Concussions 6) Tornado Epilepsy - focal discharge at the vestibular cortex, uncommon Cerebellar Involvement Symptoms Do you Feel like you can t walk in a straight line or are pulled to one side when walking? Or Feel like your feet just won t go where you want them to go? Signs Dysmetria Dysdiadochokinesia Ataxia Abnormal oculomotor exam Abnormal Oculomotor Exam smooth pursuits and sacades Abnormal Smooth pursuits gqcgzsswplk Abnormal VOR cancellation Abnormal Saccades Overshooting/ undershooting visual targets Downloaded from 24

25 Tonic Ocular Tilt Reactions- Central Vestibular Disorder Vertical Vestibular Ocular Reflex (VOR) coordinates head and eye movements in the Roll Plane Objectve: Ex.)Upper brainstem lesions (Brand & Dieterich 1987) Ex.) Webber s (lateral medullary) Syndrome (Brand & Dieterich 1987) 1) Skew Eye Deviations with cover/ cross cover test (hypotropia of the undermost eye)- assess eye alignment 2) Ocular torsion 3) Head tilt Subjective: Vertical Diplopia or (SVV) Subjective Visual Vertical (Bucket Test) >3* off vertical DISORDERS OF GAIT: CEREBELLAR GAIT ATAXIA Wide based gait Lateral instability of trunk Poor accuracy of foot placement Decompensation of balance with tandem walking Early feature is often difficulty maintaining balance when changing directions Common causes include stroke, TBI, tumor, ETOH, & neurodegenerative disease Cerebellar Ataxia Gait Testing for Central Vestibular Disorders HINTS Test Item Cluster100% sensitive; 96% specific for patients at risk for stroke presenting to the ER with acute onset of vertigo Johns Hopkins HINTS (-) negative Head Impulse (+) positive direction changing gaze evoked Nystagmus (+) positive Test of Skew Via Cover Cross Cover Testing Downloaded from 25

26 Post-Concussion Syndrome What is a concussion? Head trauma resulting from a direct blow to the head or other body part May not involve LOC Disturbance in normal brain function No structural damage per MRI or CT Post concussion Syndrome- a prolonged recovery from a concussion Post Concussion Syndrome Symptoms Definition- No skull fx or Intra Cerebral Hemorrhage, LOC<2 hours Symptoms Persistent HAs (25%) or Vestibular Migraines (41% Anxiety (19%) Insomnia (15%) Dizziness (14%) Other: fatigue, poor concentration, memory disorder, irritability, Spatial disorientation (19%) Emotional Lability Imbalance Confusion Weakness N/T Nausea/ vomiting Everything seems like it s in slow motion Vision changes- blurring, diplopia, etc. Downloaded from 26

27 Signs of Post Concussion Syndrome Impaired oculomotor exam Impaired balance exam Impaired VOR Post traumatic Meniere s Disease/ Endolymphatic Hydrops Reduced tolerance for complex sensory environments Post traumatic Positional Vertigo (28%) Post traumatic Hearing Loss Post traumatic whiplash Post traumatic seizure disorder High Risk Populations for PCS Children and Adolescents Younger= worse prognosis Women Female soccer players Family h/o Alzheimer s/ dementia Post Concussion Syndrome Management Baseline Testing- Ideally pre and post concussion including Neuro-cog Strict Bedrest for 2 weeks- (as if they had the flu) Maintain regular sleep/ wake schedule Do not want to raise the heart rate during a metabolic crisis in the brain Eliminate mental, physical, & emotional stress, minimize visual/ auditory stimuli If symptoms persist after two weeks of strict bed-rest then initiate Vestibular Rehab Downloaded from 27

28 Initiate Vestibular Rehab AS TOLERATED Re-assess and compare with baseline testing VOR Stabilization Exercises Sensory Organization Balance Activities Visually track objects in front of a busy background/ VOR cancellation Oculomotor re-eduation Brock strings Convergence/ Divergency Near/ Fare Accommodation Return to sport protocol 1 st - No activity 2 nd. Light Aerobic Exercise- walking, stationary cycling at 50-64% HR max, balance/ vision/ eye-head coordination as tolerated 3 rd. Moderate Aerobic Exercise or Sport Specific training at 65-76% HR max, balance/ vision/ eye-head coordination as tolerated 4 th. Non-contact, more aggressive, sport specific training drills. Plyometrics, balance/ vision/ eye-head coordination as tolerated 5 th. Full contact/ 100% job demands once cleared medically through practice or part-time 6 th. Return to PLOF and/ or Game Day Vestibular Migraine/ Migraine Associated Vertigo Neurological Event, usually striking young adults or children Etiology- thought to be result of vascular trigger resulting in altered neuronal activity Vestibular migraines- VEMP testing suggests utricle (anterior vestibular artery and sup. Portion of vestibular nn involved DDX: subjective reports, MRI may r/o something serious Symptoms may include pain, photosensitivity, phonosensitivity, N/V, visual disturbances, aura 40% have some accompanying vestibular syndrome Disruption in balance, dizziness, vertigo Onset: may be pre/during/post migraine or occur independently Downloaded from 28

29 Vestibular Migraine Treatment/ Management Vestibular and/or painful migraines are treated/ managed the same. First, ID and eliminate Diet and Lifestyle triggers If that doesn t work, refer to neurologist or HA specialist for further investigation, medical mgmt, medication, IV infusions, Brain MRI Refer for stress mgmt CBT or Biofeedback Mindfulness meditation Intense CV exercise Program 4-5xweek x % HRM Classic Triggers Hormone fluctuations, barometric pressure/ weather changes, foods, stress, sleep disturbances, hunger, dehydration Migraine Dietary Triggers All the good stuff Coffee, Tea,. Caffeine Chocolate ETOH- esp. red wine, brandy, craft brews, port, sherry, scotch, gin, or bourbon Nitrates- smoked, cured, processed meats Aged Cheeses MSG, aspertame Sour cream, yogurt, buttermilk Medications And so on.. Migraine Sufferers Benign recurrent vertigo in adults Paroxysmal vertigo in children Adults with migraines are x4 more likely to get BPPV Avg age yrs 50% of sufferers go undiagnosed or mismanaged Downloaded from 29

30 Red Flags Ramsey Hunt Shingles Sudden hearing loss Central Signs (+) VOR Cancellation- inability to suppress to VOR (+) positive saccades and smooth pursuits testing Spontaneous nystagmus Pure rotary nystagmus Pure horizontal or vertical nystagmus, Down beating nystagmus with lateral gaze Vestibular Testing Closing Thoughts The more you know, the more you don t know You just get more comfortable with not knowing. Know how and when to look for red flags Know when to refer Downloaded from 30

31 GAIT AND BALANCE EVALUATION Patient Interview- searching for subjective clues Positional Testing: Dix Hallpike & Supine Roll testing BPPV Sensory Organization and Static Balance Testing MCSIB or Romberg firm/foam eyes open vs. eyes closed with sensation to vibration testing at the medial malleolus DVA & Head Thrust Testing- VOR stability Oculomotor Exam- Smooth Pursuits and Saccades Thank you! Additional Resources: Vestibular.org materials for professionals patient handouts APTA vestibular SIG podcasts Downloaded from 31