Vestibular Rehabilitation Therapy: What Every Audiologist Should Know

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1 Vestibular Rehabilitation Therapy: What Every Audiologist Should Know Diron Cassidy, PT, DPT, GCS Vortex Physical Therapy and Balance San Jose, California

2 What is Vestibular Rehabilitation Therapy (VRT)? It s not simply treating BPPV (benign paroxysmal positional vertigo) Although vertigo is one of the most common complaints at intake It isn t always just about BPPV 80% resolve spontaneously Once BPPV is resolved, we then assess for additional balance or vestibular issues Definition: Vestibular rehabilitation is an exercise-based program, designed by a specialized physical therapist, to improve balance and reduce dizziness-related problems. 13 Requires an in-depth knowledge of how the three balance systems interact to produce appropriate balance reactions Somato-sensory, vision, and vestibular 14

3 Somato-sensory Somato-sensory provides information about the different kinds of stimuli a person can detect from the skin, muscles, and joints. 14 For Balance: The use of proper postural alignment and awareness to identify where the body is in space

4 Vision Visual input helps create appropriate balance reactions through visual stability. 14 Cervical-Ocular Reflex (COR) Stabilization of the eye within the eye socket to maintain a stable visual environment during motion. Maintains 1:1 ratio of head motion to eye motion The COR consists of eye movements driven by neck proprioceptors. When movement is less than 2 hz. Saccades or object finding for visual fixation The eyes are physiologically incapable of not having a target to focus on Eyes are always targeting for visual stability Optokinetic stimuli Eyes following movement through an environment crowds trains passing by driving in a car

5 Vestibular The vestibular system provides sensory information identifying rotational motion (canals), gravity (otiliths), and linear acceleration & deceleration of the head (otiliths). 14 This controls three significant reflexes of our balance system Vestibular-Ocular Reflex (VOR) Vestibular-Cervical reflexes (VCR) Vestibular-Spinal Reflex (VSR)

6 Vestibular (Cont.) Vestibular Ocular Reflex (VOR) 16 Stabilization of the eye within the eye socket to maintain a stable visual environment during motion. Maintains 1:1 ratio of head motion to eye motion The VOR consists of eye movements driven by the vestibular system When movement is >2 hz. One of the fastest reflexes in the body Vestibular-Cervical reflexes Vestibular-Collic Reflex (VCR) 15 Stabilize the head on top of the body The neural pathways mediating this reflex are uncertain. Vestibular-Spinal Reflex (VSR) 15 Stabilize the trunk under the body implies motor output to skeletal muscles below the neck

7 Goals of Vestibular Rehabilitation Reduce vertigo and dizziness Determine if there is any vestibular pathology Improve patient s balance

8 Reduce vertigo and dizziness At evaluation, assess for BPPV and treat APTA recommends everyone over 65 be screened for BPPV Once resolved, assess for residual dizziness and motion sensitivity AKA motion-induced dizziness/vertigo Why do patients have residual symptoms? How I explain these symptoms to my patients With BPPV, the vestibular system is out of alignment. Upon repositioning, the push pull mechanism of the vestibular system has been restored, but the central processing of this information is inaccurate because the brain has been trying to compensate for the BPPV. Now that the BPPV is no longer there, the brain needs to re-calibrate. We can quantify the amount of motion sensitivity or how dizzy a patient is by using an assessment called the Motion Sensitivity Quotient (MSQ)

9 How do we treat vestibular issues? Habituation Repeated motion to re-orient the brain and body to the same movements over and over; re-calibrating the system. Uses simple every day motions broken down to their most basic core movements. Rolling back and forth in bed Sitting up from side lying position and back to side lying position Leaning over to pick something off the ground and returning to upright Turning head back and forth Looking up and down Turning around

10 Determine if any vestibular pathology exists Physiological deficit Head Thrust test horizontal 10 right anterior, left posterior (RALP) left anterior, right posterior (LARP) Head Shake test (fixation blocked) Functional deficit Dynamic Visual Acuity (DVA)

11 When a vestibular deficit exists? Main issue: VOR deficits Inability to hold visual target stable on retina when head is in motion Other reflex deficits VCR VSR Inability to hold head steady relative to gravity Inability to maintain trunk stability and postural alignment

12 How do we treat this? VOR re-training Gaze stabilization: x1 viewing: vision is fixed on a target and the head is rotated up to 45 degrees on either side of mid-line maintaining visual contact with the target, at all times. x2 viewing: vision is fixed on a target and the head is rotated up to 20 degrees on either side of mid-line maintaining visual contact on a target held at arms length moving in the opposite direction of the head motion (out of phase). These can be done in sitting (not recommended unless severely impaired), or standing on solid or soft surface, while walking, in complex visual environments.

Improve balance Assess for postural instability and gait/safety Postural stability: Sensory Organization Testing (SOT) Testing equipment options: Foam & Dome, Smart Balance Master, Bertec

13 Improve balance Assess for postural instability and gait/safety Postural stability: Sensory Organization Testing (SOT) Testing equipment options: Foam & Dome, Smart Balance Master, Bertec Modified Clinical Test of Sensory Integration on Balance (mctsib) Gait, balance assessments, and fall risk assessments: Berg TUG Dynamic gait index Functional gait index BEST test/ Mini-best

14 How do we treat this? Somatosensory reweighting 3 Reorganization of the hierarchy of sensory input Vision is typically dominant but visual dominance with poor vestibular input causes visual instability and inability to tolerate visual motion Increase reliance of somato-sensory input and reduce visual reliance Training for postural alignment and maintaining good postural alignment during movement Good posture is KEY Patient must have good core strength Critical for dizziness symptom management during vestibular therapy exercises

Balance Exercises Static postural stability Solid & soft surfaces, eyes open and closed Head turns and nods on solid surface, eyes open then closed Head turns and nods on soft surface, eyes open then

15 Balance Exercises Static postural stability Solid & soft surfaces, eyes open and closed Head turns and nods on solid surface, eyes open then closed Head turns and nods on soft surface, eyes open then closed Dynamic postural stability Gait training Lateral weight shifting, lunging, single leg stance, & tandem stance Solid & soft surface Balance strategy retraining Ankle vs hip vs step reactions Specific to Physical Therapy Practice Act PTs are the only providers who can perform gait training Speed, step length, heel strike, etc. Path management with visual scanning, head motions Fall prevention and fall recovery Tips to reduce falls: changed to home environments, assistive devices How to get off the floor once a fall has occurred

Walking though grocery store Virtual Reality/VR goggles Roller coaster, swing Complex

16 Advanced visual vestibular exercises Optokinetic 9 Complex background during VOR retraining (gaze stabilization) YouTube videos Simple: moving stripes Complex: Driving, Walking though grocery store Virtual Reality/VR goggles Roller coaster, swing Complex environment de-sensitization Exposure therapy Performing high level balance act in these complex environments

17 Advancement with Clinical Practice Guidelines The APTA recently published Clinical Practice Guideline for the treatment of unilateral and bilateral vestibular loss. It outlines effective treatment options people with Peripheral Vestibular Hypofunction (unilateral or bilateral). It also highlighted the removal of outdated, ineffective exercises including saccadic or smooth-pursuit exercises in isolation (ie: without head movement) as specific exercises for gaze stability. 17 These smooth pursuit and saccadic eye motions are the first exercises listed in the Cawthorne-Cooksey protocol.

18 Retiring Cawthorne-Cooksey Exercises Cawthorne-Cooksey is a set of 15 exercises developed in 1940 s 3 Still being prescribed by medical providers today Typically given as a handout with no instruction on performance Patient told to do these exercises at home Handouts are typically written instructions with limited or no visual examples. Infrequent or no follow-up provided. Without follow-up, who knows what the patient is actually doing. All vestibular activities will make the patient feel dizzy, unbalance, & nauseous At beginning of therapy, a patient s baseline level of dizziness will typically increase the for several days. For this reason, patients usually give-up before symptoms start to resolve.

19 Benefits of Physical Therapy Individual, personalized treatment plan 2,3,5,11 Comprehensive evaluation Define the problem with quality assessment tools Justify the exercise prescription Document Functional deficits Activity limitations Progress towards rehabilitation goals

20 Individual, supervised, personalized treatment plan Establish a Home Exercise Program (HEP) Supervised 8 Starts off conservative Plenty of patient education Limited symptom provocation during initial stages Symptoms will typically get worse before they get better Progressive Gradual increase in exercise difficulty with each visit Modification of the HEP is based on the patient s response to the changes from the previous week. Tailored Specific needs of the patient; different exercises for different reasons.

21 Common mistakes of an inexperienced vestibular therapist Not having a mentor Need someone to ask for advice and recommendations Thinking vestibular therapy = treating BPPV Not knowing how to address residual dizziness and imbalance following successful treatment of BPPV Unable to treat more than just posterior canal BPPV Starting patients on balance exercises above their capabilities Not building a patients confidence in the beginning by starting at a level too high. Balance act should be challenging, but not unattainable. Poor instruction on habituation activities Must allow for symptoms provoked by motion resolve before moving again. Poor instruction on gaze stabilization Speed of head motion, head movement quality, and duration of the act is critical to patient progress.

22 Common mistakes of an inexperienced vestibular therapist (cont.) Lack of understanding of how dizziness and anxiety are closely related Anxiety is not simply a psychological problem It is caused or exacerbated by Fear of falling Apprehension of movement Relationship between severe anxiety (panic attacks and agoraphobia) and vestibular issues 6,12 On vestibular testing, abnormal responses were more prevalent in panic disorder patients compared to healthy controls.

23 Who Should be Referred for Vestibular Rehabilitation Therapy (VRT)? Anyone who walks in to your office who complains of dizziness, imbalance, or fear of falling. They DO NOT need to have a history of falling. They DO NOT need to have a vestibular diagnosis. They DO NOT need have to have testing, such as a VNG, ECoG or VEMP. Less than 1/3 of our patients have any kind of vestibular testing Of those who do have a VNG, only about half remember what the test was or what the results indicated. Doctors rarely send the information with the referral. A doctor s referral is not required to initiate a referral and start care; California has had Direct Access to physical therapy services since 2014.

24 Finding a Qualified Vestibular Therapist Step 1: Ask your Professional Peers Talk to other audiologists, doctors and healthcare providers in your area Do they have a referral to a vestibular therapist who has produced good results? Step 2: Search the Internet Google search vestibular therapy or vestibular therapist and your location Several organizations have a searchable provider database Vestibular Disorders Association (VEDA) APTA Vestibular special interest group Note: there is no vetting process for the people listed on these pages; people can sign up, pay dues and create a listing

25 Finding a Qualified Vestibular Therapist (cont.) Step 3: Do your homework Once you find a local vestibular therapist, check them out online Does their website have a page dedicated to vestibular therapy services? Does their bio provide information regarding their vestibular training/experience? Read online reviews; do any specifically refer to treating dizziness or vertigo? Call or stop by their office to inquire about their vestibular practice Ask about their caseload. What percent are vestibular patients? Where do their referrals come from? How long are their vestibular therapy sessions? Do they see patients 1:1? min How often do they treat BPPV? Qualified vestibular therapists will be more than eager to tell you about what they do.

Vestibular Therapy Training Physical Therapy Doctoral (DPT) programs Basic vestibular training and treatment of BPPV is now part of the curriculum in a number of DPT programs.

26 Vestibular Therapy Training Physical Therapy Doctoral (DPT) programs Basic vestibular training and treatment of BPPV is now part of the curriculum in a number of DPT programs. However, it is still very limited in scope. This really dependent on the individual faculty of a specific institution Post-graduate continuing education course work Many con-ed courses, some good, some not so good. Clinical competency coursed hosted by APTA Courses held at Emory University, University of Southern California (USC), and Duke University Vestibular faculty members come from all over the country Five courses are included in the vestibular competency program including: 1) Basic competency, 2) Advance competency, 3) Cervicogenic competency, 4) Pediatric competency, and 5) Diagnostic testing competency

27 The Typical Vestibular Patient We Treat Medicare (65+) Non-Medicare (20-64) Post-concussion

28 Some Historical Background Treatment for vestibular issues has been available since the 1940s with Cawthorne-Cooksey In the 1980s, vestibular rehabilitation took a leap forward with the advent of two new therapy protocols: Brandt-Daroff exercises were developed to treat benign paroxysmal positional vertigo (BPPV) Dr. Epley developed the Epley Maneuver, still the most recognized treatment for BPPV and most associated with vestibular rehabilitation Many advancements in vestibular rehabilitation therapy have taken place in the last years Research has helped the medical community better identify the causes of vestibular dysfunction, balance issues and evidence-based treatment options This expanded medical knowledge about vestibular disorders has improved awareness However, there is still much more to learn

29 REFERENCES 1. Black FO, Angel CR, Pesznecker SC, Gianna C. Outcome analysis of individualized vestibular rehabilitation protocols. Am J Otol. 2000;21: Brown KE, Whitney SL, Wrisley DM, Furman JM. Physical therapy outcomes for persons with bilateral vestibular loss. Laryngoscope. 2001;111: Cawthorne, T. Vestibular Injuries. 1943; Haran, FJ, Keshner, EA. Sensory reweighting as a method of balance Training for labyrinthine loss. J Neurol Phys Ther. 2008;32(4): Herdman SJ, Schubert MC, Das VE, Tusa RJ. Recovery of dynamic visual acuity in unilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg. 2003;129: Jacob RG, Møller MB, Turner SM, Wall C 3rd. Otoneurological examination in panic disorder and agoraphobia with panic attacks: a pilot study. Am J Psychiatry Jun;142(6): Lim DJ (1984). The development and structure of otoconia. In: I Friedman, J Ballantyne (eds). Ultrastructural Atlas of the Inner Ear. London: Butterworth, pp Pavlou M, Bronstein AM, Davies RA. Randomized trial of supervised versus unsupervised optokinetic exercise in persons with peripheral vestibular disorders. Neurorehabil Neural Repair.2013;27(3): Pavlou M, Kanegaonkar RG, Swapp D, Bamiou DE, Slater M, Luxon LM. The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study. J Vestib Res. 2012;22(5-6): Schubert MC, Tusa RJ, Herdman SJ, Grine LE. Optimizing the sensitivity of the head thrust test for identifying vestibular hypofunction. Phys Ther. 2004;84: Szturm T, Ireland DJ, Lessing-Turner M. Comparison of different exercise programs in the rehabilitation of patients with chronic peripheral vestibular dysfunction. J Vestib Res. 1994;4: Tecer A 1, Tükel R, Erdamar B, Sunay T. Audiovestibular functioning in patients with panic disorder. J Psychosom Res Aug;57(2):

30 REFERENCES (con t)

Paediatric Balance Assessment

BAA regional meeting 11 th March 2016 Paediatric Balance Assessment Samantha Lear, Lead Clinical Scientist, Hearing Services, SCH overview The balance system Vestibular disorders referrals Vestibular assessment