11/30/2017. My Patient is Dizzy, Now What? An Acute Approach To Vestibular Dysfunction In the Hospital Setting. Kerry Lammers PT, DPT

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1 My Patient is Dizzy, Now What? An Acute Approach To Vestibular Dysfunction In the Hospital Setting Presented by: Kerry Lammers PT, DPT and Gabrielle Steinhorn PT, DPT, NCS APTA CSM Pre-conference course, February 21, 2018, New Orleans, LA 1 Kerry Lammers PT, DPT University of Dayton University of Florida Florida VA, Gait and _Balance Clinic JHH Cardiac Service 2 Gaby Steinhorn PT, DPT, NCS Tulane University University of Florida Marymount University Acute Care Neuro 3 1

2 We Have All Been There Admitted for falls All head imaging and lab work clear No evidence of orthostasis Discharge today 4 Primary Objective Demonstrate how using an evidence based approach for dizzy or unsteady patients can be incorporated into everyday practice in acute care 5 Objectives Describe the basic pathophysiology involved with BPPV and discuss the key screening elements of BPPV to educate referral source. Compare and contrast evidence based clinical balance assessment tools and functional outcome measures most appropriate for the hospital setting. Identify pertinent components of the patient s past medical history and PT examination consistent with BPPV or vestibular dysfunction, which require further clinical assessment. Identify key clinical reasoning and red flag elements for management of vestibular dysfunction in the hospital setting to determine appropriate course of treatment or referral to most appropriate provider. 6 2

3 INTRODUCTION 7 Balance is Important 8 Human Balance Vision Vestibular Proprioception Balance 9 3

4 Why are we talking about vestibular in acute care? Under diagnosis or misdiagnosis Associated with age related decline, diabetes, and education hospital admission, falls, increased medical costs 10 More Common Than We Think VEDA Survey in 3 adults over 40 (asymptomatic) Symptomatic = 8x increased risk for falls Epidemiology Study % fallers presenting to ED reported symptoms of vestibular impairment 11 BPPV BPPV may account for up to 50% of falls in older adults. More than 90% of cases can be easily treated in 1-3 treatment sessions. 12 4

5 The Evidence is Clear Use of Vestibular Clinical Testing 13 BPPV in the Hospital Setting <4% have positional testing 33% had expensive head CT Average 70 months, 8 hospital visits, and >$5000 between symptoms and diagnosis 14 Delay in Diagnosis Increases Medical Costs Poor use of vestibular diagnostic testing Overuse of CT scans Inefficient patient care Readmission Poor utilization of multidisciplinary team 15 5

6 BPPV Case Study 16 Acute PT Practice Is Evolving CPG Vestibular Hypofunction published in 2016 Entry Level Core Competency Guidelines 17 Physical Therapy in the Hospital Multidisciplinary Team PT Consults Falls Unsteady gait Discharge recommendations Adaptive Equipment 18 6

7 Anatomy and Physiology A Review of the Vestibular System 19 Role of Vestibular System in Balance 20 The Vestibular System 21 7

8 The Vestibular System 22 Peripheral Sensory Apparatus: Semi-Circular Canals Semi-Circular Canals =Angular Motion Loop shaped structures filled with fluid and hairlike sensors Push-Pull Relationship 23 Peripheral Sensory Apparatus Semi-Circular Canals Ampulla

9 Endolymph Movement Within The Semi-Circular Canal stb/nrvstbsmcr.htm 25 Peripheral Sensory Apparatus: Inside the Otoliths: Otoconia = crystals which lay across gelatinous membrane Cilia = hair cells imbedded in membrane Kinocillium = Largest of the cilia Otoliths = Linear Motion Saccule = vertical Utricle = horizontal 26 Central Processing System Vestibular Nuclei and Cerebellum Output Projections Extraocular motor neurons Spinal cord motor neurons Contralateral vestibular nucleus Thalamus Cerebral cortex 27 9

10 Definition: Central vs. Peripheral Peripheral Dysfunction Direct damage to the labyrinth, hair cells, or Cranial Nerve VIII Central Dysfunction Lesion located in central pathway Vestibular cortex, thalamus, brainstem, vestibular cerebellum 28 Vestibular Motor Output System Integrated Balance Gaze stability Postural stability Orientation in space Cerebral perfusion Vestibulo-Ocular Reflex (VOR) Vestibulospinal Reflex (VSR) 29 Vestibular Motor Processing System: Vestibulo-Ocular Reflex Primary purpose is to maintain gaze stability during head motion Eye movement will occur in the same plane as the semi-circular canal stimulated Gain is defined as the change in the eye angle divided by the change in the head angle during the head turn Normal=

11 Physiological Nystagmus Slow phase controlled by vestibular system Left Eye Named for fast phase = regulation to reset the eye is always toward the side of increased activity Central vs. Peripheral nystagmus R L 31 Pathologic Nystagmus Central Nystagmus abnormal processes not related to the vestibular organ Gaze Induced Nystagmus Peripheral Nystagmus related to vestibular system Positional Nystagmus Post Rotational Nystagmus (Evoked) Spontaneous Nystagmus 32 Acute Assessment of Nystagmus 33 11

12 Documenting Nystagmus Peripheral Exam Direction Time to onset Duration Symptoms Pure vertical or torsional Example: Patient demonstrates R beating nystagmus with immediate onset lasting 45 seconds. Patient endorses self verbalized dizziness and nausea which resolves after 45 seconds. 34 Assessing Vestibular Dysfunction & the Hospital 35 My Patient is Dizzy, Now What? 36 12

13 Outline Your Approach Past Medical History Chart Review Medications Subjective Objective Assessment Plan Symptoms Prior management Oculomotor Exam, Positional Testing Dynamic Balance Assessment Put all the clues together Differential Diagnosis Considerations for treatment Access to Follow up/referral 37 Subjective Assessment History of falls or *near falls Self-perception of balance Recent head colds/ear infections 38 ***Defining Dizziness*** Temporal Type/Symptoms Onset Auditory Involvement 39 13

14 Temporal Considerations of Vestibular Dysfunction Temporal Dizziness Diagnosis Episodic Seconds Provoked by head movement BPPV VBI Uncomp. stable lab Episodic < 60 seconds Spontaneous Migraine TIA Anxiety Meniere s Episodic min/hours <24 hours Episodic min/hours <24 hours Provoked by head movement Uncomp. stable lab Migraine Spontaneous Labyrinthine disorders 40 Temporal Considerations of Vestibular Dysfunction Temporal Dizziness Diagnosis Episodic min/hours >24 hours Days Days Continuous Spontaneous Migraine Anxiety Cardiovascular Spontaneous and provoked by head movement - Spontaneous and provoked by head movement AND hearing loss Possibly exacerbated by head movement Vestibular neuritis Vascular event Labrynthitis PICA or AICA stroke Central vestibular disorder Anxiety 41 Differential Diagnosis: Cardiac Related Dizziness Cardiac rhythm disturbances Vasovagal response Cardiomyopathy Aortic Stenosis 42 14

15 Differential Diagnosis: Poly Pharmacy Class of Medication Blood Pressure Examples ACE inhibitors lisinopril (Zestril) Beta Blockers - pronanolol or metroprolol Loop Diuretics furosemide (Lasix) Calcium Channel blockers - nifedipine (Procardia) Anti-Depressants Fluoxetine (Prozac) and trazodone (Desyrel) Pain Medications Hydrocodone (other opioid derivatives) Chemotherapy Tamoxiflen (Nolvadex) Sedatives Diphenhydramine (Benadryl, Unisom, Sominex) Temazepam (Restoril) Eszopiclone (Lunesta) Zolpidem (Ambien) 43 Ototoxic Medications Aminoglycoside antibiotics kanamycin, neomycin, amikacin, streptomycin, gentamicin Platinum-based chemotherapy agents Cisplatin Cancer Medications Estrogen Modulators, Tamoxifen (Nolvadex, Soltamox) Loop Diuretics Furosemide (Lasix), ethacrynic acid, bumetanide 44 Subjective Central Findings Sudden onset, 1 or any of 4 D s Diplopia Dysphagia Dysarthria Dysmetria 45 15

16 Subjective Central Findings Vertigo not effected by position Constant Slow onset of imbalance with standing/walking 46 Bedside Objective Exam 47 General Approach Clinical oculomotor exam VOR testing Positional testing 48 16

17 The Hospital 49 Objective Exam (Room Light) Test Technique (+) Finding Conclusion Spontaneous Nystagmus Gaze Holding Nystagmus Assessment of resting/spontaneous nystagmus with patient looking straight ahead Assess for nystagmus using a point target through a range up/down/left/right (+) = nystagmus at rest (+) = nystagmus (very consistent) Abnormal Finding Abnormal Finding 50 Nystagmus 51 17

18 Nystagmus 52 Nystagmus 53 Demo Spontaneous Nystagmus Gaze Holding Nystagmus 54 18

19 Objective Exam Test Technique (+) Finding Conclusion Oculomotor Motility (ROM) VOR Testing - Head Thrust Test (HIT) VOR Testing - Static and Dynamic Visual Acuity inches away from patient s face using tip of pen to assess for conjugate eye movement or double vision at end range 1.) Tilt head at 30 deg angle (horizontal plane) 2.) oscillate back/forth 3.) patient focuses on your nose 4.) keep pattern as random as possible Have patient read from Snellen chart at rest and repeat with 30 flexion at 15 range at approximately 2 Hz (240 per app) (+) = disconjugate eye movement (+) = re-fixation saccades (+) = 3 lines lost Abnormal Finding Diagnostic Test VOR Functional Impairment VOR 55 Head Impulse Test 56 Demo - practice Oculomotor Motility VOR Head Thrust HIT Dynamic Visual Acuity 57 19

20 Objective Exam Tests Independent of the Vestibular System Test Technique (+) Finding Conclusion Vergence Have patient focus on single point - begin 2 feet away from patient s face and move toward bridge of nose (+) = double vision or eye jumps away from center >10 cm from bridge Red Flag, Central Finding Smooth Pursuit Have patient follow point from 30 right to 30 L and back to center at approx. 20 /sec repeat horizontal/vertical (+) = saccadic intrusions (of note, midline jump is ok speed is important and can prevent false positive) Red Flag, Central Finding 58 Objective Exam Tests Independent of the Vestibular System Test Technique (+) Finding Conclusion Saccades VOR Cancellation Have patient look at point object back/forth about 25 from midline move object around your head to assess 1.) speed 2.) accuracy 3.) conjugate movement Grasp patient head tilt forward 30 (horizontal plane) move patients head with your outstretched arms (they focus on your nose) (+) overshoot, disconjugate movement, slow movement (+) = nystagmus/saccadic eye movements Red Flag, Central Finding Red Flag, Central Finding 59 Skew Deviation Left Hypertropia Cover Uncover Test 60 20

21 Tests of Skew 61 Demo Practice Vergence Smooth Pursuit Saccades VOR Cancellation 62 HINTS to Diagnose Stroke Head Impulse Nystagmus Test of Skew 63 21

22 Evidence Based Approach 64 Central Findings Oculomotor tests Smooth pursuit VOR cancellation Saccade testing Vergence Nystagmus Pure vertical nystagmus Direction changing Upper motor signs Cranial nerve dysfunction 65 OBJECTIVE BALANCE MEASURES 66 22

23 Screening Balance in the Hospital Environment 67 Vestibular EDGE Acuity Acute (0-6 weeks) Chronic (>6 weeks) Diagnostic Category BPPV Central vestibular dysfunction Peripheral vestibular dysfunction Other ICF Framework Body Structure & Function, Activity, Participation Rating Scale Acute Care Considerations Available equipment Time Open environment Mobility restrictions/precautions Medical co-morbidities Short length of stay 69 23

24 Static Postural Stability Modified Clinical Test of Sensory Interaction on Balance (mctsib) Mini Balance Evaluation Systems Test 70 Modified Clinical Test of Sensory Interaction on Balance Purpose: To quantify postural control under various sensory conditions. Developed to assess sensory contributions to balance not measure change over time Vestibular EDGE 2- Reasonable to recommend at this time Minimally Clinically Important Difference not established 71 MCTSIB 72 24

25 Mini BEST Purpose: A clinical balance assessment tool that aims to target and identify 6 different balance control systems so that specific rehabilitation approaches can be designed for different balance deficits. Vestibular EDGE 2- Reasonable to recommend at this time Minimally Clinically Important Difference Balance Disorders: 4 points (Godi, et al, 2013) 73 Dynamic Postural Stability Dynamic gait index Timed up and go 10 meter walk test 5x sit to stand 74 Dynamic Gait Index Purpose: Assesses individual s ability to modify balance while walking in the presence of external demands. VEDGE 4 highly recommend Minimal Detectable Change In peripheral vestibular disorders 3.2 points Cut-Off Scores In central and peripheral disorders 19/24 are 2.58x more likely to have reported a fall in the past 6 months. (Whitney et al, 2000) 75 25

26 DGI Video 76 Timed up and Go Timed up and Go Dual Task Purpose: A dual-task dynamic measure for identifying individuals who are at risk of falls. VEDGE 2 reasonable to recommend Cut-Off Scores TUG of >11.1 seconds is sensitive (80%) and specific (56%) in falls prediction. (Whitney et al, 2004) TUG Cognitive Elderly subjects who scored >15 seconds as fallers with an overall correct prediction rate of 87%. (Shumway- Cook et al, 2000) meter walk test Purpose: Assesses walking speed over a short duration. VEDGE 2 reasonable to recommend Can test both comfortable gait speed and fastest possible gait speed to compare

27 5x sit to stand Purpose: A measure of functional lower limb muscle strength. May be useful in quantifying functional change. VEDGE 2 reasonable to recommend Minimally Clinically Important Difference 2.3 seconds in patients with peripheral, central or mixed vestibular dysfunction (Meretta, 2006) Cut-Off Score balance disorders To identify balance dysfunction (Whitney, et al, 2005) Younger (< 60 years): 10 sec Older (> 60 years): 14.2 sec 79 Self Reported measures Activities Specific Balance Scale Dizziness Handicap Index 80 Activities Specific Balance Confidence Scale Purpose: Subjective measure of confidence in performing various ambulatory activities without falling or experiencing a sense of unsteadiness. VEDGE Acute and Chronic 3 Recommend Peripheral, Central, BPPV 2 Reasonable to recommend Cut-Off Score Fallers and non-fallers (Lajoie & Gallagher, 2003) Scores <67% indicates a risk for falling; can accurately classify people who fall 84% of the time 81 27

28 Function/Activity/Participation Activities-Specific Balance and confidence scale 82 Dizziness Handicap Index Purpose: A 25-item self-assessment inventory designed to evaluate the self-perceived handicapping effects imposed by dizziness. VEDGE 4 Highly recommend Minimal Detectable Change (Jacobson & Newman, 1990) peripheral and central vestibular pathology Cut-Off Scores (Whitney et al, 2004) Mild: 0-30 Moderate: Severe: Item Subscale for BPPV Does looking up increase your problem? Because of your problem, do you have difficulty getting into or out of bed? Do quick movements of your head increase your problem? Does turning over in bed increase your problem? Does bending over increase your problem? 84 28

29 Dizziness Handicap Inventory 85 CLINICAL CONSIDERATIONS FOR BPPV IN THE HOSPITAL SETTING 86 What is BPPV? Most common cause of vertigo. (Bharracharyya, 2008) BPPV may account for up to 50% of all vertigo in older adults. (Hain, 2013) Falls associated with vertigo continue to be one of the most common presentations to the hospital. (Fife, 2015) 87 29

30 Anatomical Explanation 88 Objective Exam POSITIONAL VESTIBULAR ASSESSMENT 89 Positional Testing Semi-Circular Canal & Nystagmus Posterior Canal: (+) Upbeating/Ipsi-Torsional Anterior Canal: (+) Downbeating/Ipsi-torsional Horizontal Canal: (+) Horizontal 90 30

31 Cupulolithiasis vs. Canalathiasis 91 Cupulolithiasis vs. Canalathiasis Cupulolithiasis Otoconia adherent to cupula Immediate onset Nystagmus persists Lateral canal apogeotropic nystagmus Canalathiasis Detached otoconia in the SCC Delay in onset Nystagmus Nystagmus fatigues (crescendo-decrescendo) Lateral canal Geotropic nystagmus 92 POSTERIOR CANAL 93 31

32 Positional Testing Posterior Canal: Dix-Hallpike T04788/dix-hallpike.jpeg 94 Positional Testing Posterior Canal: Dix-Hallpike Diagnostic Criteria for BPPV Vertigo AND mixed torsional and vertical nystagmus Paroxysmal nature Fatigability 95 Positional Testing Posterior Canal: Dix-Hallpike Contraindications (Humphriss 2003) Neck surgery Severe rheumatoid arthritis Atlantoaxial and occipitoatlantal instability Aplasia of odontoid process Cervical myelopathy/radiculopathy Vascular dissection syndrome Precautions Respiratory Issues Cardiac pathology Participation 96 32

33 Positive Dix-Hallpike 97 Dix Hallpike Testing s/p TAVR 98 Dix Hallpike - Sideways 99 33

34 Positional Testing Posterior Canal: Side-lying Test 1. Head is turned 45º away from the side being tested 2. Briskly laid on the side being tested Testing the right side 100 Side-lying Test s/p CABG Adaptions Remove bed rails or end of bed Trendelenburg Use of pillow under trunk 2 nd assist for BLE 101 Treatment Test Nystagmus BPPV Dx CRM Maneuver Positive Dix Hallpike or Sidelying test < 60 seconds of nystagmus >60 seconds of nystagmus Canalithiasis Cupulolithiasis Epley Liberatory Maneuver Positive Roll Test Geotropic Nystagmus Ageotropic nystagmus Horizontal Canal Canalithiasis Horizontal Canal Cupulolithiasis BBQ Roll Appiani Modified Semont (Casani)

35 Treatment: Posterior Canalathiasis Epley 103 Treatment Test Nystagmus BPPV Dx CRM Maneuver Positive Dix Hallpike or Sidelying test < 60 seconds of nystagmus >60 seconds of nystagmus Canalithiasis Cupulolithiasis Epley Liberatory Maneuver Positive Roll Test Geotropic Nystagmus Ageotropic nystagmus Horizontal Canal Canalithiasis Horizontal Canal Cupulolithiasis BBQ Roll Appiani Modified Semont (Casani) 104 Posterior Cupololithiasis Liberatory Maneuver

36 Demo and Practice Posterior Canal Dix-Hallpike Test Side-lying Test Epley Liberatory 106 HORIZONTAL CANAL 107 Horizontal Canal: Roll Test Supine with head flexed to 20º Head is quickly rolled to one side and held for a minute. 3. Return to midline and repeat on the other side

37 Positional Testing Horizontal Canal: Roll Test Side of origin and mechanism of BPPV Intensity of nystagmus Stronger on the left side Stronger on the right side Ageotropic nystagmus Right Cupulolithiasis Left Cupulolithiasis Geotropic nystagmus Left Canalithiasis Right Canalithiasis The Canal is in The Ground 109 Horizontal Canal BPPV 110 Treatment Test Nystagmus BPPV Dx CRM Maneuver Positive Dix Hallpike or Sidelying test < 60 seconds of nystagmus >60 seconds of nystagmus Canalithiasis Cupulolithiasis Epley Liberatory Maneuver Positive Roll Test Geotropic Nystagmus Ageotropic nystagmus Horizontal Canal Canalithiasis Horizontal Canal Cupulolithiasis BBQ Roll Appiani Modified Semont (Casani)

38 BBQ Roll 112 Casani 113 Horizontal Canal Demo and Practice Roll Test BBQ Roll Casani

39 Follow up recommendation Follow up in acute care Hospital exercise program Patient education Outpatient vestibular PT Referral to other providers (otolaryngology, neurology, falls and balance clinic) 115 Acute Considerations Minimize bending over Consider HOB elevation Communicate with Nursing about transfers If able to ambulate, may need short term supervision for toileting or other ADLs 116 Summary of Vestibular Exam Diagnostic Findings Eye movements Nystagmus/VOR testing Positional testing Suggestive Findings Outcome measures Dynamic visual acuity Functional Findings Gait measures (DGI, gait speed etc)

40 Common Vestibular Dysfunction in Hospital 118 Differential Diagnosis Vestibular Crisis Vestibular Hypofunction Trauma/Labyrinthine Concussion Vascular Events Acoustic Neuroma Semicircular Canal Dehiscence Vestibular Migraine Dysautonomia 119 Differential Diagnosis: Vestibular Crisis Neuritis or Labyrinthitis Symptoms Acute onset prolonged vertigo Improving over 1-4 days Left with head movement sensitivity Acute change in hearing (labyrinthitis) Postural imbalance Signs (+) Peripheral Signs (-) Central Signs Sensory neural hearing loss (Labyrinthitis) Nausea

41 Differential Diagnosis: Vestibular Crisis Classic Treatment Anti-vertigo meds to control symptoms at onset Gaze stabilization exercises to improve central vestibular compensation Steroids after ~1 week (earlier for labyrinthitis) Prognosis Excellent with compensation Common to have posterior canal BPPV as a sequela 121 Differential Diagnosis: Vestibular Hypofunction Lesion Site Unilateral or Bilateral Labyrinth, CN VIII Symptoms Generalized imbalance, oscillopsia No specific onset of symptoms If bilateral may have more falls at night Signs (+) Head Impulse Test Functional balance tests (MCSTIB) Extent of lesion >> Rotary Chair Test Oscillopsia 122 Differential Diagnosis: Vestibular Hypofunction Classic Treatment Gaze stabilization exercises Adaptation depending on presentation Compensation or substitution exercises for bilateral loss Functional balance and visual scanning activities Vestibular Based Rehab Therapy (VBRT) Prognosis Dependent on patient presentation Generally improved, continued symptoms

42 Differential Diagnosis: Trauma, Labyrinthine Concussion Lesion Labyrinthine to cortical or combination of sites Symptoms Lightheadedness, imbalance, and possible true vertigo of labyrinthine character Dizziness more episodic rather than spontaneous Signs Possible asymmetrical hearing loss Unilateral vestibular hypofunction Maybe mixed central and peripheral signs Postural control can be normal or impaired If all testing is normal then more likely to have direct labyrinthine involvement 124 Differential Diagnosis: Trauma, Labyrinthine Concussion Classic Treatment VBRT and balance training for motion provoked Likely to have post traumatic migraine Prognosis Guarded to good Not unusual for recovery to be prolonged compared to other labyrinthine lesions with similar symptoms 125 Differential Diagnosis: Vascular Events Lesion Site AICA brainstem PICA brainstem SCA cerebellum PCA cerebrum

43 Differential Diagnosis: Vascular Events 4 Ds Diplopia Dysphagia Dysarthria Dysmetria Neurology Consult 127 Differential Diagnosis: Vascular Events Symptoms Episodic vertigo with imbalance and typically other brainstem signs and symptoms Cerebellar and cerebral hemispheric ischemic events loss of coordination and balance Signs AICA/PICA >> could be a mix of central ocular and peripheral hypofunction with postural control abnormalities Cerebellar/cerebral >> ocular motor control, postural control and gait abnormalities 128 Differential Diagnosis: Vascular Events Classic Treatment Neurology Referral! VBRT+ balance and gait therapy Falls prevention Prognosis Dependent on location of lesion

44 Differential Diagnosis: Acoustic Neuroma Lesion Site CN VIII Symptoms Progressive unilateral sensorineural hearing loss Imbalance Ataxia 130 Differential Diagnosis: Acoustic Neuroma Treatment Surgical resection or Cyber-knife Post op rehab addressing unilateral vestibular hypofunction, balance and gait Differential Diagnosis: Semicircular Canal Dehiscence Lesion Site Small defect in the temporal bony wall of the superior canal Symptoms Sound/pressure induced vertigo Auditory disturbances

45 Differential Diagnosis: Semicircular Canal Dehiscence Treatment Surgical plugging Post-op VBRT Compensation Differential Diagnosis Vestibular Migraine Signs and Symptoms dizziness; motion intolerance spontaneous vertigo attacks (often accompanied by nausea and vomiting) diminished eye focus with photosensitivity sound sensitivity and tinnitus balance loss and ataxia cervicalgia (neck pain) with associated muscle spasms in the upper cervical spine musculature confusion with altered cognition spatial disorientation anxiety/panic 134 Differential Diagnosis Vestibular Migraine Treatment Medication Vestibular based rehab Lifestyle modification

46 Differential Diagnosis Dysautonomia An umbrella term describing malfunction of the autonomic nervous system. Primary dysautonomias injury to the nervous system (i.e. Parkinson s) Secondary dysautonomias non-neurologic systemic illnesses of a variety of causes in which injury to the autonomic nervous system (i.e. Drug side effect, DM) ORTHOSTATIC HYPOTENSION 136 Basic treatment for vestibular dysfunction 137 Vestibular Rehabilitation It is delivered to patients according to the nature of their symptoms and not according to their diagnosis

47 Vestibular Rehabilitation When the vestibular system is damaged, it cannot repair itself. Recovery occurs through CNS compensation or adaptation 139 Fundamentals Retraining of the VOR Gaze stability exercises Retraining the VSR Balance exercises Habituation exercise Desensitization of dizziness symptoms Promoting/forced use of vestibular Substitution when adaptation not possible 140 Vestibular Interventions Adaptation Exercises reduced vestibular function Substitution Exercises vestibular loss Habituation Exercises reduced vestibular function

48 Adaptation Exercises The goal is to assist the central nervous system to adapt to a loss in the vestibular system input by improving the gain of the VOR. Exercises use a combination of head movement while fixating on a target to reduce error and restore VOR. 142 Adaptation Exercises VOR x 1 VOR x Adaptation Exercises Progress from VOR x1 to VOR x2 Perform with small head movements Speed of head turns should increase as long as the target is in focus. May provoke symptoms. Work through these. Rest and return back to baseline before next set

49 Adaptation Exercise - Dose APTA Clinical Practice Guidelines (Hall et al, 2016) Acute/Subacute Three times/day minimum (At least 12 minutes/day) Chronic Three times/day minimum (At least 20 minutes/day) 145 Demo and Practice Gaze stability exercises VOR x1 VOR x2 146 Substitution Exercises Goal is to promote alternative strategies and other sensory information. Foster the use of saccadic or pursuit strategies

50 Substitution Exercises Pursuit strategies Imaginary targets Fixating gaze during ambulation On foam, eyes open 148 Substitution Exercises 149 Substitution Visual Dependency

51 Practice/Demo Pursuit strategy Imaginary targets 151 Efficacy of Gaze Stability in Older Adults with Dizziness Hall et. al N = 39 outpatient PT patients Inclusion - 60 years old, balance or mobility deficit, normal vestibular function Exclusion MMSE <24/30, progressive medical issues that affect mobility. Two groups Gaze stability vs placebo eye exercises Both groups had a balance HEP Participants seen weekly for 4 weeks for balance and gait training and progression of HEP. 152 Efficacy of Gaze Stability in Older Adults with Dizziness Hall et. al Results Both groups improved in all outcomes except for VAS disequilibrium between sitting and walking. Fall risk was reduced to a greater extent with treatment group vs control (P =.046) 90% of the treatment group clinically significant improvement in fall risk versus 50% of control (X 2 = 0.008)

52 Habituation Exercises Based on the concept that repeated exposure to a provocative stimulus will result in a reduction of the response to that treatment. Use the Motion Sensitivity Test to prescribe exercises. Up to 4 movements each done 2-3 repetitions 2-3x a day Patient should rest after each movement until symptoms stop 154 Progression Increase duration, # reps Increase speed of movement Alter posture (sitting standing) Alter environment Increase visual conflict Alter the surface 155 General Balance and Gait Intervention Goal is to improve both static and dynamic balance control and overall improvement in gait under a variety of environmental conditions. Static Balance Wide base of support to narrow base of support Eyes open or eyes closed Solid surface or foam surface Perturbations (anticipatory and reactive) Dynamic Balance Incorporate turns, head turns, altered visual input Dual task activities Obstacles

53 Barriers to Vestibular Management in Acute Care Elements of Treatment To Consider in the Hospital Environment Problems, 2 Solutions SMALL GROUP BREAKOUT 158 Clinical Exam Findings Problems Solutions

54 Admission Diagnosis Problems Solutions 160 Participation Problems Solutions 161 Treatment Area Problems Solutions

55 Access to Follow Up Problems Solutions 163 Impact on Discharge Planning Problems Solutions 164 Risk Vs. Benefit

56 Addressing Barriers in Acute Care Managing Patient Access And Referral Source 166 Managing Referrals How are patient s referred to PT? Screening in care coordination rounds Education of the referral source 167 Access Points to Follow Up Outpatient vestibular PT know what s in your area VEDA Academy of Neurologic PT Map of providers APTA find a provider

57 Assisting in Referral 169 Assisting in Referral Search for Vestibular Physical Therapist by zip code, city, or state Can be useful for case manager referral, or patient education 170 Find an NCS

58 Patient Education 172 Create Your Own Patient Handouts can include basic information and recommendations for follow up 173 Developing Staff Competency

59 Building the Culture Establishing Buy-in Identifying A Champion Identifying Barriers Finding Solutions To Those Barriers Education, Education, Education! 175 Review the Evidence 176 Review The Evidence

60 Staff training Vestibular competency Basic anatomy/physiology Subjective exam Objective exam CRM Rehab after surgical interventions Vestibular specialists on staff Provide mentorship Lab trainings 178 Competency Development Patient Handout Student Project Manager Approval Clinical Specialists Learning Materials Skills Check Off 179 Staff Orientation

61 Learning Packet & Quiz Fundamental anatomy and physiology Interpretation of diagnostic testing Brief review of pathophysiology 181 Staff Skills Check Off Review oculomotor exam Perform Positional Tests Demonstrate canalith repositioning maneuvers Discuss progression of basic balance intervention 182 Questions?

62 Differential Diagnosis Temporal Dizziness Auditory Diagnosis Episodic - Seconds HM-HP provoked Normal BPPV uncomp stable lab VBI Episodic - < 60 seconds Spontaneous Normal or mild fluctuations Migraine; TIA Anxiety Meniere s Episodic - min/hrs < 24 HM-HP provoked Normal Uncomp stable lab hrs migraine Episodic - min/hrs < 24 hrs Episodic - min/hrs < 24 hrs Days Days Days typically <7 Continuous Spontaneous Fluctuant + progressive Lab disorders eg Meneires, and autoimmune Spontaneous Normal or mild fluctuant Migraine Anxiety Cardiovascular Spontaneous HM HP Normal Vestibular neuritis provoked 1-3 days Vascular event Spontaneous HM HP Sudden onset at time of Labrynthinitis provoked 1-3 days vertigo onset PICA or AICA stroke Spontaneous or HM HP normal Migraine relatively constant Vascular w/ other neuro symptoms Possibly exacerbated by HM normal Central Vestibular - HP Anxiety Non vestibular eg sensory motor neuropathy Adapted from Vestibular Rehabilitation: A Competency-Based Course, Emory University 2016

63 Vestibular Occulomotor Assessment, (Herdman 2014) Test Technique (+) Finding Conclusion Spontaneous Nystagmus Gaze Holding Nystagmus Occulomotor Motility (ROM) VOR Testing - Head Thrust Test (HIT) VOR Testing - Static and Dynamic Visual Acuity Vergence Smooth Pursuit Saccadic Eye Movement VOR Cancellation Skew Deviation Assessment of resting/spontaneous nystagmus with patient looking straight ahead (+) = nystagmus at rest Abnormal Finding Assess for nystagmus using a point target through a range up/down/left/right (+) = nystagmus (very consistent) Abnormal Finding inches away from patient s face using tip of pen to assess for conjugate eye movement or double vision at end range 1.) Tilt head at 30 deg angle (horizontal plane) 2.) oscillate back/forth 3.) patient focuses on your nose 4.) keep pattern as random as possible Have patient read from Snellen chart at rest and repeat with 30 flexion at 15 range at approximately 2 Hz (240 per app) Have patient focus on single point - begin 2 feet away from patient s face and move toward bridge of nose Have patient follow point from 30 right to 30 L and back to center at approx. 20 /sec repeate horizontal/vertical Have patient look at point object back/forth about 25 from midline move object around your head to assess 1.) speed 2.) accuracy 3.) conjugate movement Grasp patient head tilt forward 30 (horizontal plane) move patients head with your outstretched arms (they focus on your nose) Instruct patient to fix their gaze on a point behind you, repeatedly cover and uncover each eye (+) = disconjugate eye movement Abnormal Finding (+) = re-fixation saccades Diagnostic Test VOR (+) = 3 lines lost Functional Impairment VOR (+) = double vision or eye jumps away from center >10 cm from bridge (+) = saccadic intrusions (of note, midline jump is ok speed is important and can prevent false positive) (+) overshoot, dysconjugate movement, slow movement (+) = nystagmus/saccadic eye movements (+) = affected eye will move up when covered and the opposite will move down Red Flag, Central Finding Red Flag, Central Finding Red Flag, Central Finding Red Flag, Central Finding Red Flag, Central Finding

64 BPPV Pathology Posterior Canalathiasis Posterior Cupulolithiasis Anterior Canalathiasis Anterior Cupulothiasis Horizontal Canalathiasis (Canal in the Ground) Horizontal Cupulolathiasis (Up w/ the Cup) ***Central Positional Test Nystagmus Affected on L Dix Hallpike (+) = same side affected/tested Sidelying Test (+) = lower ear is affected Same Same Same Roll Test Affected side = GREATER sympt/nyst Roll Test **Affected side = LESSER sympt/nyst -occulomotor tests -may presents in DHP -Duration <30s -Direction nyst indicates involved canal (torsion points to ear affected) Persistent > 60 sec -Duration <30 -Direction of nyst indicates involved canal Persistent > 60 sec -Horizontal -Duration <30 -Direction dep on latency -Horizontal -Persistent -No Latency -Persistent -Not affected by position UBN, L Torsion UBN, L Torsion DBN, L Torsion DBN, L Torsion L BN - Geotropic R BN Ageotropic (away from floor) Pure torsional or vertical Affected on R UBN, R Torsion UBN, R Torsion DBN, R Torsion DBN, R Torsion R BN - Geotropic L BN Ageotropic (away from floor) Pure torsional or vertical Treatment Canalith Repositioning Manuever w/ affected side down (continue from testing position) o Hold each position 2x duration of symp/nystag Brandt-Daroff Treatment o Rot head 45 to L then move quickly into R sidelying (nose up) hold till symptom cessation +30 sec (canalathiasis) -> maintain cervical and sit up for symptom cessation +30 sec >> rotate head in opposite and repeat on opp side >> Repeat 5-20x 1-3x/daily until patient has 2 days w/ no vertigo Liberatory Maneuver o Turn head 45 AWAY from affected, lay down on affected side (nose 45 deg up) o Hold each position 2 min w/ very fast transition >> chin tuck upon upright Canalith Repositioning Manuever o Affected side down (continue from testing position) o Hold each position 2x duration of symp/nystag Liberatory Maneuver o Turn head TOWARD affected, lay down on affected side (nose 45 down) o Hold each position 2 min w/ very fast transition >> chin tuck upon upright BBQ Roll o sec hold per position** o Affected ear down >> roll head to middle >> affected ear up >> continue roll till face down prone on elbows >> Appiani o Transition into sidelying w/ affected side UP and hold 2 min >> head quickly to 45 down and hold 2 min >> chin tuck to sitting. Modified Semont Maneuver (Casani) o Patient lays down quickly to AFFECTED side >> rapid rotation to 45 toward floor >> maintain for 2-3 min >> chin tuck to sitting Indicates lesion w/ Flocculus or floor of 4 th ventricle

65 BPPV Treatment Algorithm Test Nystagmus BPPV Dx CRM Positive Dix Hallpike or Sidelying test < 60 seconds of nystagmus >60 seconds of nystagmus Canalithiasis Cupulolithiasis Epley Liberatory Maneuver Positive Roll Test Geotropic Nystagmus Ageotropic nystagmus Horizontal Canal Canalithiasis Horizontal Canal Cupulolithiasis BBQ Roll Appiani Modified Semont (Casani)

66 Instructions for Treating BPPV Canalith Repositioning Maneuver aka Epley Maneuver (Anterior or Posterior Canalithiasis) 1. The patient begins in long sitting 2. Turn the patient s head 45 degrees to the affected ear 3. Quickly lie the patient back, keeping their head turned and their neck in approximately 30 degrees of extension off the bed/mat table. 4. Observe for nystagmus and symptoms holding this position for a minute 5. Turn the patient s head 90 degrees to the other side, without raising it, so the opposite ear faces the floor while maintain the 30 degrees of neck extension. Wait another minute. 6. Keeping the head and neck in a fixed position relative to the body, have the patient roll onto their side so they are now looking at the floor. Wait another minute. 7. Bring the patient slowly up to sitting while maintain the head in 45 degrees of rotation wait 30 seconds before patient returns to a midline neck position. Pictured Above: treating the right side Image source:

67 Liberatory Maneuver (Posterior Canal Cupuolithiasis) 1. Turn the patient s head 45 degrees horizontally toward the unaffected ear. 2. Quickly lay the patient down onto their side of the affected ear with their nose pointed up (maintaining the 45-degree head turn). Hold for 2-3 minutes. 3. Then, quickly bring the patient back through sitting until they are lying on the side of the unaffected ear with their nose pointed towards the ground. Hold for 2-3 minutes. 4. Slowly move back to the seated position. Pictured Above: treating the right side Image source:

68 BBQ Roll (Horizontal Canal Canalithiasis) 1. The patient s head is first pitched forward 30 degrees to bring the plane of the horizontal canals perpendicular to the earth, while in supine. 2. Have the patient lie supine with head turned to the affected side wait 30 seconds 3. Turn the patient s head back to neutral wait 30 seconds 4. Turn the patient s head to the unaffected side wait 30 seconds 5. Have the patient tuck their chin and roll into prone, propping up on elbows but kept looking down at the floor wait 30 seconds 6. Have them roll back onto their affected side wait 30 seconds 7. Slowly return to sitting. Pictured Above treating the left ear Image source:

69 Appiani Maneuver (Horizontal Canal Canalithiasis) 1. The patient is seated with their head in a neutral position 2. Quickly bring the patient down to the unaffected side in a sidelying position. Their head should remain in neutral, facing forward. Hold for 1 minute after their nystagmus ends. 3. The head is quickly turned 45 degrees downward and held there for 2 minutes. 4. The patient is slowly returned to sitting. Pictured Above treating the left ear

70 Modified Semont Maneuver aka Casani Maneuver (Horizontal Cupulolithiasis) 1. The patient keeps their head in neutral and quickly lays onto their affected side. 2. Rapidly rotate their neck 45 degrees towards the floor and hold for 2-3 minutes. 3. Have the patient tuck their chin and return to sitting. Pictured Above: treating the right side Image from Herdman, S. Vestibular Rehabilitation. 3 rd Edition

71 Etiology Symptoms Signs Classic Treatments Prognosis Lesion Site Benign Positional Paroxysmal Vertigo Vestibular Neuritis Labrynthitis Sudden onset (AM) Short duration vertigo (sec) provoked by rolling from supine or saggitial plane Maybe general imbalance with standing/walking May last days-weeks natural history is to resolve spontaneously Vestibular Crisis improving over 1-4 days Left with head movement sensitivity No hearing loss Vestibular crisis event improving over 1-4 days Left with head movement sensitivity *Change in hearing with crisis event (involved side) Vascular Events If in VB supply system w/ AICA and PICA symptoms, can involve episodic vertigo with imbalance and typically other brainstem signs and sympt Cerebellar and cerebral hemispheric ischemic events loss of coordination and balance (+) DHP or Roll Test other clinical tests grossly normal may be found with other disorders of the labrynth Nothing specific Peripheral (+) Central (-) non-specific peripheral No CNS Sensoryneural hearing loss AICA/PICA >> could be a mix of central ocular and peripheral hypofunction with postural control abnormalities Cerebellar/cerebral >> ocular motor control, postural control and gait abnormalities Canalith repositioning maneuvers Surgical intervention very rare Meds to control symptoms at onset VBRT to push compensation Steroids at onset (1 week) Steroids early for hearing loss Suppressive meds for sx control at first VBRT to push compensation Neurology + balance and gait therapy Falls prevention VBRT Excellent for dizziness May have residual imbalance sensations for weeks after successful resolution of vertigo Recurrence is common in first year (50%) Excellent with compensation Common to have posterior canal BPPV as a sequel Excellent for dizziness Hearing loss recovery depends on degree of initial loss (viral vs. bact) Labrynthine Neural vascular causing selected labrynthine damage Labrynthine AICA/PICA central brainstem/ cerebellar and may have a labrynthine component Cerebellar and cerebral hemisphere Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016

72 Meniere s Disease Vestibular Migraine Vestibular Schwannoma AAO-HNS Criteria Spont event > 20 min < 24 hours (IVCD >20 min <12 hrs) Fluctuant hearing with documented loss (prior, during, after spell) Tinnitus and aural fullness No CNS indicators Episodic events of vertigo/dizziness/unsteadin ess Not constant symptoms Minutes to days (72 hours) Diagnostic criteria 5 or more attacks of vestibular symptoms of atleast moderate intensity current or previous history of migraine one of the following in >50% of attacks: photophobia, phonophobia, visual aura not attributable to other disorder Rare to have vestibular symptoms (typically hearing loss) Can appear as brief spell of imbalance or vertigo Sx and lab findings depend on growth site sup vs inferior Nothing specific No CNS Progressive SN hearing loss typically with fluctuations No specific pattern May range from normal to indications for either peripheral or central involvement Maybe mild hypofunction/episo dic smooth pursuit issues Typically unilateral hypofunction HL +/- CNS VEMP (-) in superior div growth, (+) superior VBRT >> if between spells >4 weeks apart Low sodium - Diet changes Suppressive meds Surgery Gent Dietary modification Medications Migraine treatment may be supplemental to VBRT Surgical VBRT pre/post op Excellent control with Gentamicin/surgery Otherwise time typicaly helps Good for reduction or elimination of the dizziness symptoms with control of migraine events Good with VBRT Labrynthine Not known but speculated to involve the labrynth and vestibular nuclei with other areas of the brainstem and midbrain Vestibular portion of CN VIII Labrynth Possible brainstem and cerebellum - contingent on size Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016

73 Bilateral Peripheral Vestibulopathy Depending on etiology usually onset of imbalance & oscillopsia Progressive or stationary Bilateral peripheral hypofunction Extent of lesion by rotational chair VBRT Substitution and balance Improvement but continued symptoms Bilateral labrynthine/ VIIIth n (NF2) Perilymphatic Fistula Arnold Chiari Cranial Cervical junction RW/OW fistula are very controversial o Sudden onset head mov symptoms w/ or w/o fluctuant hrg or prog o After CHI or severe whiplash event o Spont w/ T bone congenital deformities SSC Dehiscensce o Tulio complaints o HL o Autophony o May have antedescent event Episodic to continuous imbalance & light headedness RW/OW o non specific peripheral o possible pressure induced horizontal nystagmus SCD o VNG/ENG normal, o (+) pressure induced movements in plane of canal o LF conductive HL with normal acoustic reflexes but bone better than normal, o abnormally low VEMP threshold, o positive on high resolution CT of T bone Down beat nystagmus in primary gaze, VBRT Bed rest Surgery Loud sound management Neurology/neuros urgery If true OW/RW good SSCD good Guarded Labrynthine Cervical cranial junction Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016

74 Classic Motion Sickness Mal de Debarquement Ramsay Hunt syndrome exacerbated by hyperextension of neck Diplopia on lateral gaze as it advances Increased symptoms w/ passenger in moving vehicle o GI awareness o Light headedness o Yawning o Increased salivation o Nausea o Facial pallor o Cold sweats o Vomiting o Recovers 1 day after motion stops sensation persistent rocking (no vertigo or imbalance) following prolonged sea, train, or air travel >>cont days/months spontaneous resolution typically in months symptoms improve or are absent when in motion very common in most individuals, even seamen for up to 24 hrs after travel sudden onset of otalgia with open vesicles in EAC, pinna and TM loss of hearing with a vestibular crisis event exacerbated w/ lat gaze seen with fixation present and absent Exacerbated by hyperextension and/or ICP All routine tests are typically normal all normal occasional sway ing on postural control testing peripheral vestibular should not suggest central sensorineural HL of neural origin (early in disorder), OAEs normal Be the Driver prophylactic medication desensitization therapy reassurance and possible mildantianxiety meds time Medical antiviral agent and steroids prophylactic control is good good to excellent Good for stabilization usually left with HL and compensated vestibular deficit low midline posterior fossa susceptibility varies widely, not lesion, likely genetically predisposed common w/ migraine unknown CPA VIIth CNVIII Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016

75 can have other CN indications especially bulbar symptoms (the Ds) ABR abnormal w/ I- III interval increase Early MRI can show inflammation of VII/VIII complex Head Trauma (Labrynthine Concussion) Dysautonomia (orthostatic hypotension, hypoglycemia, anemia, hypothyroidism, medication side effects, hyperventilation w/anxiety) Post head trauma Other than BPPV or a development of 2 nd Menieres disease can have labrynthine involvement +Central Lightheadedness, imbalance, and possible true vertigo of lanrynthine character usually episodic not spontaneous Lightheadedness Pre-syncopal Not prevoked by head movement, instead exertion, rising from supine, standing for >20 minutes, hyperventilation, straining, micturition or defacation >>no vertigo or rare at best - 2 nd -5 th dec Possible Assymetrical hearing loss Unilateral vestibular hypofunction Maybe mixed signs for central Postural control can be normal to impaired If all testing is normal then likely to have direct labrynthine involvement typically (-) tilt table likely positive VBRT and balance training for motion provoked Likely to have post traumatic migraine contingent on specific disorder within this general area ranges from volume loading and support hose to SSRI medications Guarded to good, but not unusual for recovery to be prolonged compared to other labrynthine lesions with similar symptoms fair to good Labrynthine to cortical or combination of sites none vestibular typically an autonomic nervous system problem. Wallenberg s Syndrome Sudden onset vertigo, NV, associated with severe Torsional/yaw nystagmus beating Symptom control PICA distribution Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016

76 imbalance and most if not all of the Ds Hoarseness and Hiccups Lateralpulsion being pulled or pushed to one side (ipsilateral to lesion side) ipsilateral w/ fixation can be pure torsional on straight gaze Ocular lateralpulsion Hypoesthesia for pain and temp on trunk contra w/ loss of pain/temp sensation on face ipsilateral Horner s syndrome VBRT for chronic symptoms of head movement sensitivity and imbalance stroke with possible involvement of CN V, IX, IX, - brainstem and cerebellar Cerebellar/Brain stem Degenerative Disease Non-Vestibular (neuropathies, SCI) (Mostly SCA) slowly progressive motor complaints with gait and imbalance and fine motor coordination of UE/LE family history may be predominant for spinocerebellar atrophies slow onset of progressive imbalance or gait complaints postural control abnormal on routine and postural evoked responses (+) pursuit and saccades (+) abnormal tilt suppression testing from rotarychair (+) abnormal visual suppression of VOR (+) saccade intrusions normal occulomotor exam results and no indications of labrynthine involvement postural control likely normal postural evoked responses (surface EMG recordings may reveal abn mostly palliative with falls prevention and maintanence of ambulation if some head movements exacerbate symptoms (CNVIII) >> VBRT may be helpful important to reduce the effects of fear of falls that will reduce the patient s overall activity level poor and progressive guarded to good contingent on etiology many times loss of sensation in lower limbs not reversible and may be progressive cerebellum and brain stem spinal or peripheral sensory and/or motor nerves Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016

77 Wernicke s Encephalopathy mental status change confused not oriented abnormal eye movements w/ fixation gaze evoked nystagmus of central origin gait ataxia onset of symptoms typically associated with a situation of poor nutritional status >> disorder is result of B1 deficiency loss of vibratory sensation at ankle and toe is revealing ocular motor exam suggests central involvement significant unilateral or bilateral hypofunction (likely vestib nucleus involvement not labrynthine) hypotension and hypothermia medication to reverse the deficiency condition VBRT based on chronic symptoms Guarded given permanent daage based on time Central brainstem/ce rebellum and cortical Hereditary (idiopathic Bilateral peripheral hypofunction Multiple Sclerosis slowly progressive imbalance and gait abnormalities in compromised environmental situations with lighting or foot support surfaces several series in the literature patients 2 nd -4 th decade 5-7% will have true vertigo as initial onset symptom others will have lightheadedness and imbalance but may come on suddenly with resolution and repeat classically >> history starting in 1 st -2 nd decades of life of unrelated neurological events (+) Bilateral hypofunction w/ all other findings on ENG/VNG hearing test normal Rotational chair >> bilateral loss and postural control abn noted w/ vision and foot support surface cues are comp (+) Central may include INO, gaze evoked nystagmus, saccadic dysmetria, pursuit abnormalities, pendular nystag VBRT Guarded Vestibular labrynth neurological care/vbrt may be useful in exacerbation for imbalance and in some head movement sensitivity guarded Central Possible CN VIII, unlikely labrynthine Adapted from Vestibular Rehabilitation: A Competency Based Course, Emory University 2016