Welcome to Fall CE Event 2015

Transcription

1 Welcome to Fall CE Event 2015

2 Basic Vestibular Function, Examination Procedures, Diagnosis, and Intervention Mark Amos, BA, DC, DACNB, FABVR

3 What s It About? Fall prevention 6 million people/ year Balance disorders and dizziness in top 3 complaints among elderly Falls leading cause of death and disability in elderly 85% of falls are vestibular

4 Who Falls? Over 55 years old Someone who has fallen and develops fear of falling History of head or neck trauma Should be evaluated

5 Anatomy and Physiology of Vertigo and Balance Humans have a very complex system to maintain balance and eye position The system relies on vestibular, visual, and proprioceptive input This input is translated into neurological signals

6 Things to Remember Intensity of movement determines intensity of signal Vestibular system is capable of self regulation of sensitivity

7 Localization Vertigo (feeling of motion) is cortical disruption in interpreting spatial orientation Nystagmus results from direction specific imbalance of VOR Postural imbalance results from inappropriate activation of vestibulospinal pathways

8 Localization Autonomic symptoms (nausea, vomiting, anxiety) results from activation of the vestibulo-autonomic pathways

9 Visual System What needs to be said? Get new glasses Get checked for cataracts Get checked for glaucoma

10 Proprioceptive System Moving joints it s what we do Decreased motion = decreased input Restored motion = increased input More later with cervicogenic vertigo

11 Vestibular System Works with the other two Weakness in one will lead to compensation by the others

12 Example A diabetic patient with peripheral neuropathy Cannot feel his legs or feet Decreased proprioception Walks by looking at his feet Turn off the lights and see what happens

13 Vestibular Rehabilitation Certain exercises and maneuvers can correct or mitigate vestibular disturbance That s what we will explore today

14 2 Vestibular Sensations Otolithic System Linear acceleration Static head position Canal System Rotational acceleration

15 Why Review Anatomy? Understanding anatomy leads to understanding of pathology Understanding pathology leads to understanding of treatment The why s and how s

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20 How It Works The hair cells stick straight up The hairs are ion channels In the upright position they are closed Note the channels are connected

21 How It Works The hairs deflect with motion of the macula or cupula The connections open the ion channels Ions rush into the channels and depolarize the cell

22 How It Works The hair cells stick straight up The hairs are ion channels In the upright position they are closed Note the channels are connected

23 How It Works When the kinocilium bends the opposite direction it makes it harder to open the channel and depolarize the cell Inhibition

24 Otolithic System Utricle- horizontal acceleration Saccule- vertical acceleration Utilize otoliths

25 Otolith System Macula Calcium Carbonate Otoliths Vestibular Nerve

26 Otolith System Head Motion! (+) Vestibular Nerve

27 Otolith System!Head Motion (-) Vestibular Nerve

28 Bear 1996

29 Purves 2001.

30 Canals 3 canals- angular acceleration 90º orientation Ampulla Cupula

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32 Semicircular Canal Ampulla Cupula Hair Crista Amullaris Vestibular Nerve

33 Semicircular Canal Ampulla Cupula Endolymph Flow! (+) Crista Amullaris Vestibular Nerve

34 Semicircular Canal Ampulla Cupula (-) Endolymph! Flow Crista Amullaris Vestibular Nerve

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37 Top View Anterior Canal Horizontal Canal Posterior Canal

38 Anterior and Posterior Canals Anterior canal activates when the head moves FORWARD and lateral Posterior canal activates when the head moves BACK and lateral

39 Lesions

40 Cervicogenic Vertigo Whiplash or cervical trauma Affects COR cervico-ocular reflexes Affects CSR cervicospinal reflexes Involves muscle spasm May be confused with BPPV Subluxation indicators apply Upper cervical Horizontal canal orientation Cervical mechanoreceptors develop before vestibular

41 3 Basic Types Bilateral peripheral loss- patient has feeling of up and down head movement while walking, gait instability, increased difficulty with darkness and uneven ground Acute/subacute unilateral loss- causes imbalance in tone, vertigo, body positioning, nystagmus, autonomic symptoms

42 3 Basic Types Paroxysmal stimulation- short attacks of vertigo

43 Two Locations Peripheral vestibular lesion Central vestibular lesion

44 Peripheral vs. Central Peripheral Intermittent Motion provoked Cause nausea Consistent nystagmus Central Constant (usually) Not motion dependent Only fluctuates in intensity Variable nystagmus

45 Peripheral Lesions BPPV Neuritis Labyrinthitis Meniere disease Fistula-dehiscience Nerve compression Bilateral vestibular loss

46 BPPV Benign paroxysmal positional vertigo Results from head/neck trauma Medication use Dislodges otolithis from the utricle and saccule into the semicircular canals

47 BPPV 2 models Canalolithiasis Cupulolithiasis Otolithic debris causes extreme vertigo, nausea with head position

48 Normal Canal Function Head Motion Endolymph!

49 Canalithisiasis Canaliths

50 Canalolithiasis Responds well to repositioning maneuvers Purpose is to move the crystals out of the canal

51 Normal Canal Function Head Motion Endolymph!

52 Cupulolithiasis Cupulolithiasis

53 Cupulolithiasis Does not respond to canalith repositioning Responds well to a liberatory maneuver to break it free

54 BPPV 3 canals 3 forms 90%, 9%, 1% Posterior, horizontal, anterior

55 Vestibular Neuritis Acute unilateral viral infection Usually superior portion of vestibular nerve (anterior and lateral canals) Associated with GI or upper respiratory infection Lasts hours

56 Labyrinthitis Infection of the membranous labyrinth Often with upper respiratory infection Dizziness with hearing loss Gradual return to function (months)

57 Meniere Disease Endolymphatic hydrops Overproduction of endolymph Feeling of fullness in the ear Ringing + vertigo Newer information shows correlation with autoimmune disorders and migraine

58 Meniere Disease Does not respond well to vestibular rehabilitation Intermittent Episodes may last minutes to hours Standard treatment is salt restriction and /or surgery

59 Meniere Disease Patient will experience fullness of the ear and ringing The there is a sudden change as the membranes rupture Tumarkin otolithic crisis

60 Meniere Disease

61 Fistula/Dehiscience Head or neck trauma Tears an opening in the membranous labyrinth results in new window and decreased pressure Changing pressure or loud noise causes vertigo

62 Fistula/Dehiscience

63 Nerve Compression Will often involve hearing loss Often affects facial nerve and trigeminal nerve All three emerge at the cerebellopontine angle

64 Acoustic Neuroma

65 Bilateral Vestibular Loss Often medicinal/toxic (mycin drugs) May be autoimmune May be infectious May be longstanding Meniere May or may not involve hearing Often has oscillopsia and gait ataxia

66 Central Lesions Stroke/degeneration/scarring Constant Ischemia Hyperventilation Low cardiac output Possible low blood sugar

67 Medulla Lesion Habituation is the key System will decrease sensitivity Chiropractic is a piece of this puzzle Increase input Normalize function Cawthorn Cooksey exercises

68 Hyperventilation The exception to the constant rule May be intermittent Often with fear of falling leading to anxiety attack Anxiety attack leads to hyperventilation which leads to fall

69 How? Capillaries have chemoreceptors for carbon dioxide More carbon dioxide in the blood means more capillary dilation Less carbon dioxide in blood means less capillary dilation and ischemia

70 How? Decreased CO2 means heart and brainstem ischemia Brainstem ischemia leads to dizziness and anxiety and panic and hyperventilation

71 How? Decreased CO2 means heart and brainstem ischemia Heart ischemia leads to angina and therefore panic attack over heart attack and hyperventilation

72 Hyperventilation

73 History Considerations

74 BPPV Vestibular Neuritis Labyrinthitis Meniere's Disease Fistula Dehiscience Nerve Compression Bilateral Loss Vertigo Yes Yes Yes Yes Yes Yes No Nystagmus Yes Yes Yes Yes Yes Yes No Duration 30 sec- 2 min hours Months 30 min- 24 hours Seconds Seconds to minutes Periodic Nausea Yes Yes Yes Yes No Yes No Specificity Onset with position Acute onset w/ viral inf Acute onset w/ viral inf Fullness and tinnitis Tullio or pressure Frequent tinnitis Severe gait ataxia Hearing Loss No No Yes Yes No Yes Possible Precipitating Action Postural change None None None Valsalva Increased ICP Facial weakness Drugs

75 Evaluation

76 CTSIB Clinical Test of Sensory Organization in Balance Foam Dome Test 6 conditions Help reveal which has failed: vision, proprioception, vestibular

77 Sensory Organization Test Condition 1 Stable platform Eyes open Utilizes all 3 sensory modalities

78 Sensory Organization Test Condition 2 Stable platform Eyes closed Relies on somatosensory and vestibular

79 Sensory Organization Test Condition 3 Stable platform Eyes open Environment movesprovides false sense of motion Patient MUST suppress vision and rely on somatosensory input and vestibular input

80 Sensory Organization Test Condition 4 Unstable platform Eyes open Patient must rely on vestibular and visual input

81 Sensory Organization Test Condition 5 Unstable platform Eyes closed Patient must rely solely on vestibular input

82 Sensory Organization Test Condition 6 Unstable platform Moving environment Patient must rely entirely on vestibular input

83 Positional Head in extension + rotation Vertebral artery Cervicogenic Posterior canal

84 Cervicogenic Test Patient seated in a spinning stool Stabilize patient s head Rotate patient with head horizontal Dizziness = Cervical problem Do what we do best

85 Vertebrobasilar Artery Test Have patient seated leaning forward Neck is in extension Have patient rotate head to one side then hold 30 seconds Repeat to other side and hold Hautant test

86 Eye Movement Testing Observe nystagmus while stationary Pursuit Saccade Vestibulo-ocular reflex VOR

87 Pursuit!!!Cardinal fields of gaze!! H pattern + convergence!!patient should follow smoothly to all positions

88 !!Hold fingers 14 apart!!1-2 in front of patient!!patient goes to one side on command!!back to neutral!!go to side on command Saccade!

89 Vestibulo-ocular Reflex!!!Ask the patient to fixate on doctor!!doctor slowly turns head side to side!!patient should maintain fixation on doctor!!head Thrust Test!!Test VOR a little faster

90 Dizziness Simulation Battery Designed to reproduce dizziness The portion of the test reproducing dizziness is the cause and then may be addressed Helps aid the patient in understanding the cause

91 Dizziness Simulation Battery Seating vs. standing blood pressure Carotid sinus reflex Valsalva test or Tullio Hyperventilation provocative test Hallpike Dix maneuver Lateral canal maneuver Anterior canal test

92 Hallpike Dix Maneuver Patient s head is turned 45º This sets the posterior canal parallel to the table

93 Hallpike Dix Maneuver Patient is quickly lowered back to a head off the table position This view shows testing the right posterior canal Nystagmus indicates BPPV

94 Hallpike Dix Movie!

95 Top View Anterior Canal Horizontal Canal Posterior Canal

96 Hallpike Dix Position Anterior Canal Posterior Canal

97 Hallpike Dix Maneuver The test focuses on the posterior canal by putting it in a gravity dependent position Patient complains of dizziness or develops nystagmus to make the test (+)

98 Hallpike Dix (+)!!!Patient is leaned back in the right posterior canal position!!eyes will beat upward and right

99 Nystagmus Will point toward the affected ear Hallpike Dix will give the plane of the problem Observation of nystagmus will reveal whether it is the posterior canal or the OPPOSITE anterior canal

100 Horizontal Canal Testing Lay patient supine Flex head 30º Turn head side to side Nystagmus toward the affected ear will reveal which horizontal canal is involved

101 Horizontal Canal Movie!!!The video shows a purely horizontal nystagmus!!the position places the horizontal canal in a purely vertical orientation

102 Treatment

103 Based Upon Cause Cervicogenic = adjustment Orthostatic = send patient back to MD Fistula = rest in bed for several days until it heals, possible surgery VBAI = light force adjustment, doppler unltrsound, MRA Infection- re-evaluate and VRT as needed

104 Hyperventilation Breathing exercises Lots available on line 10 breaths/ minute in 2, hold 2, out 2 Andrew Weil 4, 7, 8 Work to six breaths per minute Start 5 minutes work up to 1/2 hour

105 BPPV Cupulolithiasis = liberatory maneuvers (Semont) Canalolithiasis = repositioning maneuvers Epley, Lempert????? = Brandt Daroff

106 Semont Maneuver To liberate the stuck on cupulolithiasis Preloads endolymph Then slams the head opposite Washes the crystals off the cupula

107 Semont s Maneuver

108 Posterior Canal Semont!!!Starts like Hallpike!!Turning head lines up the posterior canal with direction of motion!!fall and wait 2-3 minutes!!flip and wait 5 minutes!!important to slam patient into table repetitively

109 Horizontal Semont!!!Clears the horizontal canal by liberating crystals off the cupula

110 Epley s Maneuver Specific to posterior canal Also will clear opposite anterior canal Starts with Hallpike-Dix position Moves free floating otoliths through the canal to drop out into the vestibule Hold each position 30 seconds or until dizziness/nystagmus stops

111 Epley s Maneuver

112 Epley Video!

113 Vertigone Movie!

114 DizzyFix

115 Bar-B-Que Roll Lempert maneuver Clears horizontal canal Put the patient on a spit

116 Lempert s Maneuver

117 Bar-B-Que Roll Movie!!!Starts with affected ear down!!then is a 450º roll to the opposite side

118 Anterior Canal!!!This is the rarest form!!patients often have confusing contradictory symptoms

119 Brandt Daroff Maneuver This is the WTF maneuver If all else fails maneuver Promotes habituation Fall and stay there until the dizziness stops Then go the other way

120 Brandt Daroff Maneuver

121 Brandt Daroff Movie!!!This is used also in conjunction with other maneuvers to promote habituation.

122 Central Lesion Cawthorn Cooksey Exercise Starts with eyes Then head moves Then seated Then standing

123 Cawthorn Cooksey Exercise In Bed Supine Eye movements done slow then quick Gazing up and down Gazing side to side Accommodation 3 feet to 1 foot Head movements done slow, then quick, eyes open, then closed Flexion extension Rotation

124 Cawthorn Cooksey Exercise Sitting Bed exercises 1-5 Shoulder shrugging and circles Bend forward to pick up objects from the ground

125 Cawthorn Cooksey Exercise Standing Bed exercises 1-5 Sitting exercise 6 Sitting to standing eyes open and closed Doing same with a turn Throwing ball hand to hand above eye level Throwing a ball hand to hand below the knees

126 Cawthorn Cooksey Exercise While moving Circle round a person while playing catch Walking with eyes open and closed Walking up and down a slope eyes open and closed Walk up and down steps eyes open then closed Performing stooping, stretching and aiming motions

127 Vestibular Rehabilitative Therapy (VRT) Main types Gaze stabilization Adaptation exercises Substitution exercises

128 Gaze Stabilization Just as it says Do pursuit exercises Track moving target side to side, up and down Do Saccade exercises Look from side to side, up and down Do VOR exercises Look at stationary target move head side to side and up and down

129 Gaze Stabilization!!!Combine the above!!x2 viewing- move target and head in opposite directions!!okn plus

130 Adaptation Exercises For unilateral vestibular loss Main goal is to restore VOR Use Gaze stabilization exercises Use head moving exercises Walking with head turns Walking on foam

131 Substitution Exercises For bilateral vestibular lesion No restoration of of VOR (no V) These train patients to use vision and mechanoreception in place of VOR Exercises include 1 leg stand, sit to stand, balance beam, foam walk Patients also need balance hygiene

132 Documentation WHO is gearing more toward quality of life Describes how a balance disorder may turn into a handicap This underscores the importance of rehabilitation

133 Documentation The patient perception of the problem is the handicap or disability Even the patient who has been rehabilitated with no symptoms may be disabled by fear of falling or recurrence Documentation = patient education? Documentation = psychological recovery?

134 Documentation Activities-Specific Balance Confidence Scale Dizziness handicap inventory Vertigo score card

135 Activities-Specific Balance Confidence Scale Powers and Myers, Patients are asked to fill in one of the following percentages for each individual question. Even if the patient does not perform the activity now, the patient should consider the activity and assign a confidence rating. A rating of 100% indicates certainty that unsteadiness or loss of balance will not result from that activity. If an aid is usually used to perform the activity, rate the activity as though performing with the aid. 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No Confidence Complete Confidence 1. Walking around the house. 2. Walking up and down stairs inside the home. 3. Picking up a slipper or something from the floor 4. Reaching at eye level. 5. Reaching overhead while standing on toes. 6. Reaching overhead while standing on a chair. 7. Sweeping the floor. 8. Walking outside to a nearby car. 9. Getting in and out of a car or other transportation. 10. Walking across a parking lot. 11. Walking up and down a ramp. 12. Walking in a crowded area where people walk rapidly past you. 13. Being bumped while walking in a crowd. 14. Using an escalator while holding the railing. 15. Using an escalator while holding packages without holding the railing. 16. Walking on slippery floors or icy sidewalks. Total Average Score (< 68% = low mobility, increased fear)

136 Dizziness Handicap Inventory Patient Name: Date: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please answer "Yes," "No," or "Sometimes" to each question by writing the corresponding letter in the blanks to the right of the questions. Answer each question as it pertains to your dizziness or unsteadiness only. Y = Yes S = Sometimes N = No Physical 1. Does looking up increase your problem? Emotional 2. Because of your problem do you feel frustrated? Functional 3. Because of your problem, do you restrict your travel for business or recreation? Physical 4. Does walking down the aisle of a supermarket increase your problem? Functional 5. Because of your problem, do you have difficulty getting into, or out of bed? 6. Does your problem significantly restrict your participation in social activities such Functional as going out to dinner, going to movies, dancing, or to parties? Functional 7. Because of your problem, do you have trouble reading? 8. Does performing ambitious activities like sports, dancing, household chores such Physical as sweeping or putting dishes away increase your problem? 9. Because of your problem are you afraid to leave your home, without having Emotional someone to accompany you? Emotional 10. Because of your problem, have you been embarrassed in front of others? Physical 11. Do quick movements of your head increase your problem? Functional 12. Because of your problem, do you avoid heights? Physical 13. Does turning over in bed increase your problem? 14. Because of your problem, is it difficult for you to do strenuous housework or yard Functional work? Emotional 15. Because of your problem, are you afraid people may think you are intoxicated? Functional 16. Because of your problem, is it difficult for you to go for a walk by yourself? Physical 17. Does walking down a sidewalk increase your problem? Emotional 18. Because of your problem, is it difficult for you to concentrate? 19. Because of your problem, is it difficult for you to walk around your house in the Functional dark? Emotional 20. Because of your problem, do you feel handicapped? Emotional 21. Because of your problem, are you afraid to stay home alone? Emotional 22. Has your problem placed strain on you relationships with family and friends? Emotional 23. Because of your problem, are you depressed? Functional 24. Does your problem interfere with your job or household responsibilities? Physical 25. Does bending over increase your problem? FOR OFFICE USE ONLY: Initial Visit Follow-up Visit Functional (36) Emotional (36) Physical (28) Scoring: Yes = 4; Sometimes = 2; No = 0 Jacobson and Newman 1990.

137 Vertigo Score Card Developed by Savundra 1993 Position Changing Stimuli Do You Get Dizzy.. No Yes 1. Bending down to pick up something from the floor? 2. Looking up? 3. On first laying in bed? 4. Upon turning left or right? 5. When walking in the dark? Subtotal No = 1 Yes = 0 Visual Stimuli Do You Get Dizzy.. No Yes 1. Walking between shelves in a store? 2. Sitting in a moving vehicle? 3. Ironing striped material? 4. Walking up or down stairs? 5. Walking up an escalator? Subtotal Total