Vestibular Assessment: Considerations at Both Ends of the Life Spectrum

Transcription

1 Vestibular Assessment: Considerations at Both Ends of the Life Spectrum Julie Honaker, PhD University of Nebraska Lincoln, NE Kristen Janky, PhD Boys Town National Research Hospital Omaha, NE

2 Learner Objectives Participants will be able to: Describe appropriate assessment techniques and modifications to traditional vestibular assessment for both children and the older adult. Describe common disorders specifically effecting children and the older adult. Identify risk factors that increase the risk of falling in the older adult. Identify appropriate candidates to be referred for physical therapy.

3 Disclosure Statement Neither Julie Honaker nor Kristen Janky have financial or nonfinancial relationships relevant to the content of the presentation. It is the policy of the University of Nebraska- Lincoln not to discriminate based upon age, race, ethnicity, color, national origin, gender, sex, pregnancy, disability, sexual orientation, genetic information, veteran s status, marital status, religion or political affiliation.

4 Purpose of the Balance System Perception of Orientation and Movement Control of Eye Movement for Clear Visual Imaging of the World Static and Dynamic Postural Control

5 The Vestibular System Iwasaki et al. (2009)

6 Vestibular Reflexes Vestibulo-ocular Maintain steady vision during head movements Vestibulospinal Maintain posture Vestibulocolic Righting reflex; stabilizes head From Halmagyi & Curthoys, In Herdman Jacobson & Shepard, 2008

7 Vestibular Assessment: Pediatrics

8 Vestibular Development Sensory systems develop at various times in maturation Structurally intact at birth Vestibular-ocular system is intact by 1 year Gaze stabilization is mature by 3 years Visual system (although less mature) is the dominant system for information in postural control for standing prior to 7.5 years Vestibulospinal mature influences emerge at 4-6, but continue to age 15 years Herdman,S. in Vestibular Rehabilitation 3 rd Ed

9 Vestibular Development When vestibular loss occurs congenitally or during early development, it can effect motor development When looked at over time, this delay was found to be progressive (Rine et al., 2000)

10 Vestibular Development Specific problematic activities: Sitting unsupported Standing Walking Navigating in the dark Clumsiness Riding a bike Hopping

11 Vestibular Loss: Children Children with sensorineural hearing loss and bilateral vestibular loss found to have significantly worse visual acuity during head movement (Rine & Braswell, 2003) Visual acuity found to have a relationship with reading acuity Children need larger print size for comfortable reading (Braswell & Rine, 2006a & 2006b)

12 Vestibular Loss: Children Specific problematic activities: Reading (skipping words or letters) Schoolwork Develop gross motor control

13 Vestibular Loss: Children Age of onset: Children with congenital vestibular loss demonstrate greater deficit / delay Abadie et al. (2000) in 17 kids with CHARGE all demonstrated vestibular impairment. Of the kids with bilateral SSC involvement, none learned to walk independently prior to 18 months. Shall (2009) hearing loss since birth demonstrate greater developmental delay (limitation: only VEMP completed)

14 Vestibular Loss: Children Degree of impairment: Otolith involvement: Good prognostic factor in motor development (Abadie et al., 2000) Walking ability has been attributed to be related to otolith function (Wiener Vacher et al., 1996) Those with present VEMP responses tended to perform better on an assessment of gross motor skills (Movement ABC). (Shall, 2009) Children with absent VEMP performed worse on static balance measures (De Kegel, et al., 2012)

15 PEDIATRIC VESTIBULAR TESTING: WHICH POPULATIONS ARE AT RISK?

16 Vestibular Loss: Pediatrics While the incidence is unknown, preliminary data build a strong case for suspecting vestibular dysfunction in these populations Hearing Loss Following cochlear implantation Otitis Media Migraine Other disorders of the labyrinth (30-90 %) (40-60%) (70%) (70%) (rare)

17 Vestibular Loss - Children Vestibular Loss: Pediatrics Hearing Loss Hearing loss occurs in 1-2 of 1000 newborns (Lin et al., 2005) The incidence of vestibular dysfunction estimated between 30 91% (Shinjo et al, 2007; Tribukait et al., 2004; Zhou et al., 2009) Incidence higher (Angeli et al. 2003) As severity of HL increases Postnatally acquired cases (meningitis, CMV, ototoxicity) Some syndromic deafness (Usher s, Waardenburg, Pendred, Alport s) Labyrinthine dysplasia Auditory Neuropathy (some cases)

18 Vestibular Loss: Pediatrics Secondary to Cochlear Implantation General anesthesia and/or temporary disturbance of inner ear fluids (Licameli et al., 2009) 50-70% of individuals demonstrate some degree of vestibular loss before implantation (Jacot et al. 2009; Jin et al., 2006; Ito et al.1998, Buchman et al. 2004) Range in incidence of vestibular dysfunction (40-86%) following implantation depending on type of assessment used (Licameli et al., 2009; Vibert et al., 2001, Krause et al., 2012, Melvin et al., 2009, Jin et al., 2006)

19 Vestibular Loss: Pediatrics Otitis Media: Common cause of balance disorders in children Greater movement disorganization, propensity for falls and accidents (Casselbrandt et al., 2008) Bilateral OME demonstrate delay in motor skills (Cohen et al., 1997) Children demonstrate balance impairment on standardized testing (Rine, 2009) ENG Abnormalities in 71% of OME (Golz et al., 1991) Improved test outcomes after tube insertion Overall suggest OME has a significant effect on development

20 Vestibular Loss: Pediatrics MIGRAINE: Most common cause of dizziness in children Childhood migraine? Migraine equivalent? Characterized by: Motion intolerance Relationship with symptoms and triggers (food, smells, environments, etc.) Family history of migraine Age of onset 2 12 years Treatment: Avoid dietary triggers Prophylactic medications

21 Vestibular Loss: Pediatrics Other disorders of Labyrinth Vestibular Labyrinthitis Meniere s disease MD is rare in pediatrics earliest onset: 9 years (Mizukoshi et al. 2001) Incidence in 1 st two decades 0 to 5.4% Onset is generally in 4 th and 5 th decade Treatment the same as adults

22 Vestibular Loss: Pediatrics Other disorders of Labyrinth BPPV Trauma induced Following CI 60.0% 40.0% 20.0% 0.0% 20s 30s 40s 50s 60s 70s 80s 90s Percentage of Patients within each age group Dx with BPPV From Drs Tusa & Herdman Miami

23 Vestibular Loss: Pediatrics Signs and symptoms associated with vestibular dysfunction (Cronin & Rine, 2010) Dizziness Presence of Nystagmus Difficult with visual acuity Difficulty with spatial relationships Presence of Hearing loss Motion sickness or sensitivity (avoids or craves) Headaches (family history of migraine headaches) Developmental and reflex delays (slow to learn to ride a bike, swim, hop, stair climb, etc) Difficulty with dancing or certain sports

24 Vestibular Testing Referral PURPOSE: to establish that a functional balance deficit exists, isolate the components involved, and provide a basis for referral Hearing Loss Usher, meningitis, Migraine otoxicity, neuropathy, Otitis Media malformations, profound Pre and Post implantation HL, Waardenburg s, rubella, CMV, anoxia Suspect labyrinthine disorder Signs and Symptoms/Parent Concern (Rine, 2007)

25 TESTING CONSIDERATIONS: PEDIATRICS

26 Testing Considerations: Pediatrics - Bilateral weakness - Tubes - Perforation - Malformed canal AUDIOGRAM CASE HISTORY VNG / ENG VEMP CTSIB SCDS BPPV Rotary Chair - CTSIB Abnormal -Major c/o unsteadiness - Known / suggested pathology involving postural control pathways Posturography

27 Testing Considerations: Pediatrics - Bilateral weakness - Tubes - Perforation - Malformed canal AUDIOGRAM CASE HISTORY VNG / ENG VEMP CTSIB SCDS BPPV Rotary Chair - CTSIB Abnormal PT Evaluation: -Major c/o Developmental unsteadiness - Known / suggested milestones pathology involving postural Visual Acuity control pathways Posturography

28 VARIATIONS IN VESTIBULAR ASSESSMENT: PEDIATRICS Case History / Bedside Assessment VNG testing Posturography Rotary Chair VEMP Audiometric Assessment

29 Case History Questions in addition to the character, duration, and associations History of delayed motor development (rolling, sitting, standing, walking) difficulty walking in the dark - generally from parents Frequent Falls/clumsiness Presence of hearing loss, vision loss Motion sickness or sensitivity Headaches Presence of nystagmus Other delays: bike riding, swimming, jumping.

30 Bedside Examination Make it FUN!! BEDSIDE ASSESSMENT Ocular Motors Slow VOR Head Thrust CTSIB DVA

31 Dynamic Visual Acuity (DVA) How clear is vision during head movement? EE EE Rine &Braswell (2003) developed DVA for ages % sensitivity and specificity for identifying bilateral loss (Rine, 2003) Relationship between DVA and reading acuity children need larger print size for comfortable reading (Braswell & Rine, 2006, 2007).

32 Traditional VNG Testing Generally can complete by age 5. Dix Hallpike Ocular Motor Use characters as targets Head Shake Positional Testing Caloric Testing Monothermal if possible

33 Most common assessment < 5 years Does not provide ear specific info SHA test preferred For bilateral loss Testing considerations: Electrodes vs goggles vs neither Maintain communication. Patient seated in parent lap Can use a car seat Infrared camera Rotary Chair

34 Rotary Chair

35 Rotary Chair

36 Rotary Chair

37 Computerized Dynamic Posturography Normative data from 3 years of age Performance increases with age Weight limitations Testing Considerations: Make it into a game Stickers on surround for appeal Halloween or decorated mask for eyes closed conditions May not complete all conditions - attention Bedside / Screening tests May not be heavy enough to compress the foam

38 Vestibular Evoked Myogenic Potential Electromyogram: measuring modulation of muscle activity OCULAR Related to the Vestibuloocular reflex Crossed contralateral response EXCITATORY CERVICAL Related to the Vestibulocollic reflex Ipsilateral response INHIBITORY (release from contraction) of the SCM

39 Vestibular Evoked Myogenic Potential A good alternative to caloric testing which is not generally tolerated in the pediatric population Ear specific information, as opposed to rotary chair, HOWEVER VEMPs assess the inferior VN therefore are not a substitute for caloric testing but an alternative

40 Vestibular Evoked Myogenic Potential VEMPs have been recorded in children as young as 1 month old 1 month 12 months (Sheykholesami, 2005); 24 newborns at 4 weeks (Erbek et al., 2007); 3-11 years (Kelsch et al., 2006) Similar techniques as those used in adults (in terms of equipment settings) SCM contraction: Lie supine and lift up (bilateral contraction) Head Turn Head Turn while lying supine Use of reinforcement to engage head turn Ocular VEMP: Standard chair and a set target to view during testing (VRA)

41 Vestibular Evoked Myogenic Potential ovemp: Utricle and superior vestibular nerve cvemp: Saccule and inferior vestibular nerve

42 Other Standardized Developmental Motor Scales Imaging Studies REINFORCE, REINFORCE, REINFORCE!!

43 Testing Considerations: Pediatric When to refer: Hearing Loss High risk population Signs and Symptoms Developmental Delay Pre and Post cochlear implantation Parent Concern Usher, meningitis, otoxicity, neuropathy, malformations, profound HL, Waardenburg s, rubella, CMV, anoxia Otitis Media / Migraine / Suspect vestibular loss

44 VESTIBULAR FINDINGS: PEDIATRICS

45 Vestibular Findings: Pediatric All can result in unilateral or bilateral vestibular impairment. Cytomegalovirus (CMV) infection Meningitis Cushing et al. (2009) report saccule function to be spared more often than horizontal canal function in children with meningitis. Ototoxicity Usher Syndrome : (Autosomal Recessive) Represent 3-6% of all deaf children - 3 Types based on gene localization: Type I: congenital profound HL, bilateral vestibular loss, progressive loss of vision Type III: Progressive SNHL, Progressive vestibular loss, progressive vision loss beginning in childhood

46 Vestibular Findings: Pediatric Auditory Neuropathy Caloric Evaluations: Abnormal caloric evaluations in 9/14. (Fujikawa & Starr, 2000) Abnormal RC and calorics in 3/3 (Sheykholeslami et al, 2010) VEMP: In 16 ears with AN, normal VEMP in 3, unrepeatable waves in 4 and absent in 9 ears (Sazgar et al., 2010) Normal calorics in 3/3 and ABN VEMP in 2/3 suggesting need to do both (Akdogan et al, 2008) Vestibular dysfunction declined over time in n = 3, (Masuda & Kaga, 2011)

47 Vestibular Loss: Children

48 Vestibular Findings: Pediatric LVAS CLINICAL PRESENTATION: Abnormally low VEMP thresholds (similar to SCD due to similar theory of 3 rd window) Variable hearing loss: profound to mild progressive / sudden Variable vestibular Symptoms: mild imbalance to episodic vertigo Sheykholeslami, et al., 2004; Zhou et al., 2011, Merchant et al., 2007

49 Vestibular Findings: Pediatric Contralateral NON-LVAS LVAS

50 Vestibular Findings: Pediatric SCD NORMAL Rosengren et al., Limited number of pediatric SCD (Zhou et al., 2007, Chen et al., 2009) - Typically, cases present symptomatically at 40.

51 Vestibular Findings: Pediatric Secondary to cochlear implantation 74% (n = 47) of adults report vertigo or imbalance after implantation 35 rec d rehab (Steenerson et al., 2001) Surgical technique may play a factor (Todt et al., 2008) Reductions in VEMP, Rotary Chair, and Calorics (Licameli et al. 2009; Krause et al, 2010; Jin et al., 2006)

52 Vestibular Findings: Pediatric Secondary to cochlear implantation Some notice improved balance function following CI However dev delay also reported. Overall, many children demonstrate vestibular loss prior to implantation, with further risk of vestibular loss as a result of implantation. Jin et al., 2006

53 Vestibular Findings: Pediatric Migraine Test Findings: Normal audiologic findings Mild vestibular findings (i.e. mild caloric paresis, low VEMP amplitude, caloric DP, chair asymmetry) 70% had abnormality in either VEMP or caloric (Chang et al., 2007)

54 Testing Considerations: Pediatric When vestibular loss is diagnosed, then what? Visual System Assessment Vestibular rehabilitation If developmental delays normalize, is PT needed? In a wait list paradigm, Rine et al demonstrated progressive motor development delay was halted, and that performance moved into the normal range

55 Vestibular Rehabilitation Preliminary studies demonstrate that children with vestibular loss improve: Developmental Milestones (Rine et al., 2004) Progressive delay was halted and performance moved into the normal range with therapy (Rine et al., 2004) Critical print size and reading acuity (Braswell & Rine, 2006)

56 Vestibular Rehabilitation Vestibular loss is treated with gaze stabilization exercises - ability to stabilize the visual environment during movement Repeated head and body movements both with and without visual targets Full range of head movement Varying speed, repetitions and sets to build endurance

57 CASE STUDY: PEDIATRIC 3 YEAR OLD MALE

58 Case Study: Pediatric Parental concern for motor development delay Motor development was on time until meningitis at age 13 months After which, walked independently at 23 months Increased clumsiness and falls and struggles when playing in the grass and in sand. Bilateral cochlear implantation at age 2 years and 2 years, 1 month

59 Case Study: Pediatric Running on uneven surfaces is very difficult. No night light in bedroom, recently began having nightmares at night. Not fully engaging with other children And demonstrates limited horseplay with dad

60 Case Study: Pediatric Rotary chair showed severe bilateral vestibular loss Low gain across all frequencies Cervical VEMP showed no responses bilaterally

61 Case Study: Pediatric Recommendation: Vestibular Rehab Normal functional strength and range of motion Standing posture in shoes was normal, demonstrated slight wide base of support depending on surface. The more uneven the surface, the wider the base of support became. Unable to walk on the trampoline Difficulty walking backward and laterally Unable to perform one leg stance

62 Case Study: Pediatric Overall, he showed a scattering of skills in locomotion, stationary, and object manipulation that ranged from 19 to 30 months. He is currently 37 months.

63 Case Study: Pediatric Home Program: Adjusting play environment with varying surface challenges: couch cushions, obstacles, etc. Will work on foam play or coloring on the wall while standing on the floor and then standing on a pillow Will work on play with a bouncy ball, trying to bounce it, trying to bounce it against the wall, watching it, throwing it, and kicking it. Practice, walking backwards, sideways, on tiptoes, and on a short line

64 Vestibular Assessment: Geriatrics

65 Aging Population The U.S. Census Bureau estimates that by 2050, the number of people 65 years and older will rise to 88.5 million (Vincent & Velkoff, 2010) One in three persons over 60 living in community will fall each year, a trend that increases to 50% by the age of 80. (Rubenstein & Josephson, 2002, Blake et al., 1988; O Loughlin et al., 1993) The total direct cost of all fall injuries for older adults is projected to increase to $32.4 billion by (Englander et al., 1996) Effective fall prevention strategies and intervention programs are contingent upon accurate and early identification of falling risk factors. (Sherrington et al., 2008; Gillespie et al., 2009)

66 Aging Population 50% of adults complain of dizziness sometime in their life Dizziness 2 nd most common complaint to medical doctors Prevalence of vestibular impairment affecting U.S. older adults is common - estimated at 32% - 35% (Keber et al., 1988; Lawson et al., 1999; Whitney et al., 2000; Herdman, 2000; Kristinsdottir et al, 2000, 2001; American Geriatrics Society, 2001; Hall et al., 2004; Pothula et al 2004; Murray et al 2005; Jacobson, 2008).

67 Balance and Vestibular Loss: Geriatrics The ability to maintain balance is complex efficient interaction of sensory system input integrity of motor control output Both necessary to coordinate appropriate reflexive muscle response to prevent a fall.

68 Medical Conditions and Risk Factors Associated with Balance Disorders Affective disorders/ psychiatric conditions Depression Fear of Falling Sleep Disorders Substance Abuse Chronic Subj Dizziness/ Health Anxiety Cardiovascular diseases Arrhythmias Congestive heart failure Coronary artery disease Orthostatic hypotension Peripheral arterial disease Infectious and metabolic diseases Diabetes mellitus Hyper-and hypothyroidism Obesity Tertiary syphilis Vitamin B 12 deficiency Sensory Disorders Hearing Impairment Peripheral neuropathy Visual impairment Salzman, 2010

69 Medical Conditions and Risk Factors Associated with Balance Disorders Neurological disorders Cerebellar dysfunction or degeneration Delirium Dementia Multiple sclerosis Myelopathy Normal-pressure hydrocephalus Parkinson disease Stroke Vertebrobasilar insufficiency Vestibular disorders Vestibular Disorders: Vestibular Neuritiis Labyrinthitis BPPV Meniere s Disease Migraine Salzman, 2010

70 Balance and Vestibular Loss: Geriatrics BPPV Trauma induced Age-related 60.0% 40.0% 20.0% 0.0% 20s 30s 40s 50s 60s 70s 80s 90s Percentage of Patients within each age group Dx with BPPV From Drs Tusa & Herdman Miami

71 Balance and Vestibular Loss: Geriatrics Elderly Falls Associated With BPPV 121 older adults years 71 females 50 men Canal involved Posterior (n = 100) Lateral (n = 16) Anterior (n = 4) Number of falls before treatment Number of falls after treatment Wilcoxon test (p-value) < Gananca et al. 2010

72 Medical Conditions and Risk Factors Associated with Balance Disorders Musculoskeletal disorders Cervical spondylosis Lumbar spinal stenosis Muscle weakness or atrophy Osteoarthritis Other Other acute medical illnesses Recent hospitalization Recent Surgery Use of certain medications Salzman, 2010

73 Vestibular and Balance Degeneration Vestibular Changes Hair cell reduction in Maculae and Cristae Primary vestibular neurons reduction Deterioration of the Velocity Storage Mechanism Proprioceptive Reduced VOR gain Changes Decreased Vibratory Sensitivity Reduced numbers of cutaneous and joint mechanoreceptors Visual Changes Diminished Visual Acuity, Depth Perception, & Contrast Sensitivity Motor Function Muscle mass decline Decrease in muscle strength & reaction time (including eye muscles) Barin & Dodson, 2008

74 Vestibular and Balance Degeneration Structural alignment changes Kyphosis: forward rounding of the vertebrae in your thoracic spine. Slide courtesy of Diane Givens, PT Shumway-Cook A., Woollacott M. (2007). Motor Control Translating Theory into Clinical Practice. Chapter 9: figure 9-3, p. 219

75 Vestibular and Balance Degeneration Gait Initiation Steady-State Gait Elble, 1997

76 Vestibular and Balance Degeneration Body sway increases with age. (Manchester et al. 1989, College et al. 1994, Fujita et al. 2005, Abrahamova & Hlavacka 2008.) years optimal age range for quiet stance. (Pyykko et al. 1988)

77 Vestibular and Balance Degeneration Garcia et al. 2012: - Reweighting of the sensory systems throughout lifespan - Visual system improves some (perhaps due to corrective lenses) whereas the other systems tend to decrease over time. Percentage of sensory contribution

78 Vestibular and Balance Degeneration Jeka et al. (2010) Does sensory reweighting occur more slowly in older & fallprone adults than young adults? If yes, then extended period of instability = FALL RISK Results: Compromised ability to reweight visual information with age - Overreliance on visual input Vision more important for ongoing stability of postural control rather than large perturbations

79 Vestibular and Balance Degeneration Efficient integration of sensory inputs in the brain might be compromised due to age-related decline in gray & white matter. (Van Impe et al. 2012; Baezner et al )

80 Vestibular and Balance Degeneration Baezner et al Aim: To analyze the strength of association of gait & balance disturbances with the degree of ARWMC Mild Moderate Severe Total Sample Patients, n(%) 284 (44.4) 197 (30.8) 158 (24.7) 639 (100) SPPB score 10% Single leg stance time < 15 seconds, % Walking speed < 1.2 m/second, % ARWMC Severity Group Results: Clear association of age-related white matter changes and severity of gait/balance performance exercise may reduce risk of limitations in mobility

81 TESTING CONSIDERATIONS: GERIATRICS

82 Testing Considerations: Geriatrics - Bilateral weakness - Tubes - Perforation AUDIOGRAM CASE HISTORY VNG / ENG VEMP CTSIB - Malformed canal History of Falls, Fear of Falling, or Imbalance? Conductive hearing loss not of middle ear origin Rotary Chair Risk of Falling Assessment - CTSIB Abnormal -Major c/o unsteadiness - Known / suggested pathology involving postural control pathways VEMP Posturography

83 Testing Considerations: Geriatrics Definition of a fall: unintentional event that results in a person s coming to rest on the ground or on another lower level

84 Mortality Consequences of Falls Among those age 65 and older, falls are the leading cause of injury death In 2007, over 18,000 older adults died from unintentional fall injuries in the U.S. Englander, Hodson, Terregrossa, 1996

85 Consequences of Falls Morbidity Fractures Soft tissue injuries Head trauma Joint dislocations Activity Restriction Loss of Confidence Englander, Hodson, Terregrossa, 1996

86 Common Intrinsic Fall Risk Factors 1. History of Falls 2. Age > 80 years 3. Cognitive Impairment 4. Depression 5. Muscle Weakness 6. Gait deficit 7. Balance (Vestibular) deficit 8. Visual deficit 9. Assistive device use 10. Arthritis 11. Impaired Activities of Daily Living Relative Risk Ratio (RRR) American Geriatrics Society (2001)

87 Common Extrinsic Fall Risk Factors Poor lighting Unsafe stairways Irregular floor surfaces Loose rugs Footwear

88 Fall Risk in the Audiology Clinic Aim: To examine the fall history and risk factors of older adults seen in an audiology hearing clinic Participants: 88 older adults (range 60 to 96 years) Q2: Have you ever fallen? Q2a: How many falls in the past 12 months? Q3: Did you have an injury from the fall? Criter & Honaker

89 Testing Considerations: Geriatrics Intrinsic Factors Assessment of Falling Risk Factors Extrinsic Factors Fall Injury Loss of Independence Activity Restriction Loss of Confidence

90 Testing Considerations: Geriatrics Purpose of Risk of Falling Assessment 1. Identify patients at greatest risk for falling via risk of falling assessment tests Clinic uses empirical approach to determine number of risk factors Purpose is to quantify number of risk factors demonstrated by the patient 2. Keep older adults independent Lord et al, 2001; Jacobson & McCaslin, 2008

91 P Testing Considerations: Geriatrics Survey of Audiologists Best Practice for Assessing Risk of Falling Major themes: 1) Risk of falling is within our scope of practice - Only for vestibular audiologists? - Referral to PT 2) Time & Reimbursement barriers to performing the assessment Patterson & Honaker

92 VARIATIONS IN VESTIBULAR ASSESSMENT: GERIATRICS Audiometric Assessment Case History / Bedside Assessment Self-Assessment Measures Posturography Gait Assessment Vestibular Assessment: VNG/ENG, VEMP, Rotary Chair, DVA/GST

93 Audiometric Assessment Fall Risk is correlated with hearing loss (Grue et al, 2009; Viljanen et al, 2009; Hawkins et al, 2011; Lin and Ferrucci, 2012; Stevens et al, 2012) Approximately 45% of adults (9.5 million) ages 60 to 69 years experience bilateral hearing loss, with the percentage of hearing loss increasing with age (Lin et al, 2011) At least one of three older adults who fall report some degree of hearing difficulty (Stevens et al, 2012) Approximately two out of three older adults who fall and sustain hip fractures have a hearing impairment (Grue et al, 2009)

94 Directed Case History Questions to ask the Patient History of previous falls Medications Gait Problems or Weakness Dizziness/Vertigo Loss of Consciousness Environmental problems Co-Morbid conditions (illnesses) Balance concerns and limitations in activities of daily living Questions to ask the Family History of previous falls Explanation of falling event/what lead to the fall? Fall related injuries Changes in balance/problems with gait, weakness Reports of dizziness/vertigo Balance Concerns and limitations in activities of daily living

95 Evaluation for Impaired Cognitive Function & Depression How can we screen cognitive function? Mini-Mental State Examination (MMSE) Screens overall mental status 23 points is considered abnormal suggests additional testing is necessary does not indicate dementia. 87% sensitivy/82% specificity How can we screen for depression? Geriatric Depression Scale (GDS) Standardized screening measure 30 yes/no questions 11 points indication of depression 84% sensitivity/95% Specificity Yesavage et al., 1983; Liu, Topper, Reeves, Gryfe, & Maki, 1995; Nygaard, 1998; Folstein, Folstein, & McHugh, 1975

96 Evaluation for Fear of Falling Why should we screen for Fear of Falling? FoF is a risk factor for future falls! How can we screen Fear of Falling? Activities Specific Balance Confidence (ABC)Scale 16 item scale activities (rate confidence 0% to 100%) Average score of 16 items (Maximum score =100) 80 points highly functioning, physically active adult Myers, Fletcher, Myers, & Sherk, 1998; Honaker, 2007

97 Evaluation of Impaired Static and Dynamic Balance Function/Postural Control How can we evaluate the balance system? Computerized Dynamic Posturography

98 Computerized Dynamic Posturography Increased sway with age observed on SOT of CDP. Adults > 60 yrs less stable; however, greater in those with vestibular symptoms (not necessarily vestibular disorders) (Pedalini et al. 2009) Methods: 3

99

100 Functional Reach Test Estimates anterior limits of stability Instructions: Yard stick attached to the wall at shoulder height Patient positioned close to wall, feet shoulder distance apart, arms extended (90 ), fist with one hand Interpretation: 6 inches, significant risk for falls, 6-10 inches, moderate risk for falls (Duncan et al, 1992)

101 Evaluation of Impaired Gait How can we evaluate impairments with gait? Document patient s movement strategy, presence of gait deviations Evaluation of gait speed 20 distance, markers at start and finish calculate distance/time, Walk While Talk Test Walk 20 distance, turn around and return Cognitive task simple & complex WWT simple: > 20 s at risk for falls WWT complex: > 33 s at risk for falls

102 Dynamic Gait Index (DGI) Assesses the ability to modify balance associated with walking under varying external demands Instructions: Strict use of instructions and scoring guidelines 8 gait tasks, score of 0-3, total score of 24 points Interpretation: Score of 19/24 or less indicate falling risk Shumway-Cook et al., (1997)

103 Functional Gait Assessment (FGA) Modification of DGI Strict use of instructions and scoring guidelines 10 item gait assessment: walk at different speeds, with head turns, with eyes closed, in tandem, over obstacles, backwards, and stair climbing 0-30; 4-level ordinal scale; best score 30/30 Interpretation: Score of 22/30 or less indicate falling risk Wrisley and Kumar, 2010

104 Timed Up & Go (TUG) Specific instruction and time criteria used Materials/Instructions 3 meter path with room to turn (marked with visible line), stopwatch, chair with arms placed against wall Stand up, walk as quickly and safely as you can, cross tape, turn around, walk back to the chair and sit down Interpretation: 13.5 sec correlates with fall risk in older adults *Can add cognitive/manual task to TUG Shumway-Cook, 2000

105 Evaluation of Impaired Vestibular Function Fall risk is also highly associated with vestibular and balance dysfunction. Herdman et al (2000) found that community dwelling adults age 65 to 74 years old with bilateral vestibular hypofunction had a greater risk for falls compared to those with unilateral vestibular hypofunction and the general population. Individuals with peripheral vestibular dysfunction have been shown to have decreased balance confidence (Legters et al, 2005). A survey by Gananca et al in Brazil (2006) of adults age 65 years and older revealed that there is a high association between chronic vestibular problems and recurrent falls.

106 Evaluation of Impaired Vestibular Function How can we evaluate the vestibular system? Direct vestibular office exam Dizziness Handicap Inventory (DHI) ENG/VNG Rotational Chair VEMPs Unilateral centrifugation Dynamic Visual Acuity Gaze Stabilization Testing

107 VNG/ENG & Rotary Chair Abnormal Vestibular results common in elderly patients referred for falling risk (Agrawal et al. 2012; Jacobson et al. 2008) Jacobson et al. 2008: 73% of sample had evidence of vestibular system impairments + Moderate self-report dizziness handicap (DHI = 44.25)

108 DVA, Cervical & Ocular VEMPs Agrawal et al. 2012: characterized semicircular canal and otolith dysfunction that occurred with aging Results: Increased logmar scores with age (all canals) cvemp peak-to-peak amplitude decline N1 ovemp amplitude decline with age

109 Gaze Stabilization Test

110 Gaze Stabilization Test DGI + AUC 1.0 GST Honaker et al. in press

111 Home Risk Assessment How can we evaluate extrinsic factors? Home Safety Checklist for Detection of Fall Hazards 65 yes/no questions Do you have light switches near every doorway? U.S. National Safety Council, 1982

112 Reporting Risk of Falling Results Report for referring physician should include the following: General impression of overall falling risk Description of subtests indicating risk of falling Description of appropriate interventions to decrease falling risk Reassessment of meds Referral to ophthalmology, physical therapy, etc Jacobson and McCaslin, 2008

113 Indications for Vestibular Balance Retraining Therapy (Older Adult): Etiologies Vestibular Neuritis Vestibular Labyrinthitis Meniere s Disease Chronic Subj Dizziness/Health Anxiety Superior Canal Dehiscence Migraine BPPV Bilateral Vestibular Hypofunction Central Lesions Head Trauma Gait Abnormalities Physical Therapy Referral Symptoms Uncompensated Complaint of falls Chronic Imbalance Head motion provoked symptoms History of Falls Possible Falling Risk Fear of Falling/Lack of Balance Confidence When vestibular dysfunction is diagnosed

114 Vestibular Rehabilitation Goals Aims To decrease vertigo intensity or symptoms To improve gaze stabilization and endurance to movement To improve postural stability on multiple surfaces and visual situations To improve overall function in multiple environments Effective treatment for older adults with and without dizziness attributed to vestibular pathology (Jung et al. 2009)

115 Vestibular Rehabilitation Aims Hall et al. (2010) -Significant reduction in fall risk with addition of gaze stability (GS) exercises

116 Geriatric Case Study 70 year old female Assessment of Falling Risk Factors: History of falls: no recent history of falls; however near fall in 2003 Gradual decline in balance > 2 years; reported fear of falling Positive for migraine, Hx of depression remainder of Hx negative

117 Cognitive function screening: 24/30 points on Mini-Mental State Exam Fear of falling: 39/100 points on ABC scale Hx fear of falling Depression: 70 year old female Assessment Hospital Anxiety and Depression Scale (HADS): borderline clinically significant anxiety and depression scores (Anxiety = 8 & Depression = 8) Fall risk may exist Fall risk may exist

118 Cognitive function screening: 24/30 points on Mini-Mental State Exam Fear of falling: 39/100 points on ABC scale Hx fear of falling Depression: 70 year old female Assessment Fall risk may exist Hospital Anxiety and Depression Scale (HADS): borderline clinically significant anxiety and depression scores (Anxiety = 8 & Depression = 8) Fall risk may exist

119 Vestibular function: DHI score 32/ year old female Assessment Increased phase lead at 0.01 Hz (rotary chair) 35% Caloric Left RVR (no spontaneous/positional nystagmus) Normal Cervical VEMPs Abnormal Dynamic Visual Acuity abnormal decrease in visual acuity ability following horizontal head movements Fall risk may exist

120 70 year old female Assessment Computerized Dynamic Posturography: Equilibrium Composite score of 53 SOT vestibular dysfunction pattern (fall reactions on conditions 5 & 6) Abnormal leftward weight symmetry during Motor control testing Fall risk may exist

121 Gait: 70 year old female Assessment Timed Up and Go : sec (normal = 13.5 sec or less) Dynamic Gait Index: 11/24 points (normal = points) Reduced gait speed observed (preferred and maximal) Functional Reach: Averaged 5 inches ( normal = > 10 inches) Fall risk may exist

122 Recommendations: 70 year old female Assessment Appropriate candidate for VBRT emphasis on fall prevention Consider consult to behavioral management for evaluation of depression and anxiety secondary to history and high score on HADS. Consider consult to Neurology for assistance with headache control

123 70 year old female Vestibular Rehabilitation Important considerations 35% caloric weakness DGI 11/24, TUG 23 sec, reduced Functional Reach Fear of Falling Abn Posturography Abn DVA

124 70 year old female Home Program Ambulation with horizontal and vertical head movement with surface and lighting challenges Gradually taking larger and faster steps backward Heel and toe standing on level and uneven surface Use of gym ball with progression of challenge VOR x 1 adaptation exercises for motion intolerance

125 Conclusion - Pediatrics Primary purpose of the vestibular balance center is to maintain steady vision during head movement Vestibular dysfunction in children results in: Gross motor development delays Abnormal dynamic visual acuity

126 Conclusion - Pediatrics If vestibular loss is suspected, vestibular testing can be completed Signs and Symptoms Hearing Loss Migraine Otitis Media Pre and Post implantation Suspect labyrinthine disorder

127 Conclusion Pediatric Vestibular testing should include assessments of both otolith and semicircular canal function, due to differential damage If vestibular loss is diagnosed, appropriate therapy should be initiated Vestibular rehabilitation can improve both developmental milestone delay and visual acuity/gaze stability

128 Conclusion - Geriatrics Primary purpose of the vestibular & balance center is to maintain balance, steady vision during head movement & prevent falls Vestibular (otolith & semicircular canal), postural control & gait dysfunction common It is important that audiologists are aware of the increased risk of falls among their patients and address this issue.

129 Conclusion Geriatric Fear of Falling common in older adults this can lead to future falls & health concerns Multi-disciplinary approach to assessment and management best practice Vestibular rehabilitation can improve balance, gaze stability and reduce falling risk

130 Conclusion Geriatric Intrinsic Factors Extrinsic Factors Fall Audiologist s Role 1. Identify patients who are at risk for falling 2. Recommendations 3. Educational information for patients, family members and clinicians as needed

131 References Abrahamova, D., Hlavacka, F. (2008) Age-related changes of human balance during quiet stance. Physiol Res; 57: Agrawal et al Decline in Semicircular canal and Otolith function with age. Otology & Neurotology: 33: American Geriatrics Society (2001) Guideline for the Preventionof Falls in Older Persons, JAGS, 49, Anthony JC, LeResche L, Niaz U, Von Korff MR, Folstein MF. (1982) Limits of the 'Mini- Mental State' as a screening test for dementia and delirium among hospital patients. Psychol. Med, 12: Baezner et al Association of gait and balance disorders with age-related white matter changes The LADIS study. Neurology; 70: Braswell J, Rine RM. Preliminary evidence of improved gaze stability following exercise in two children with vestibular hypofunction. Int J Pediatr Otorhinolaryngol 2006;70: Braswell J, Rine RM. Evidence that vestibular hypofunction affects reading acuity in children. Int J Pediatr Otorhinolaryngol 2006;70: Cronin, GW, Rine, RM (2010). Pediatric vestibular disorders: Recognition, evaluation, and treatment. VEDA.

132 References Duncan P W, Studenski S, Chandler J, & Prescott B. (1992). Functional reach: Predictive validity in a sample of elderly male veterans. Journal of Gerontology 47,M93-8. Elble RJ (1997). Changes in gait with normal aging. In. Masdeu, JC, Sudarsky L, & Wolfson, L (Eds). Gait disorders of aging: falls and therapeutic strategies, (p ). Lippincott- Raven Publishers. Englander F, Hodson TJ, Terregrossa RA.(1996) Economic dimensions of slip and fall injuries. Journal of Forensic Science, 41(5), Folstein MF, Folstein SE, & McHugh PR. (1975). Mini-Mental State : A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Fuller G F. (2000) Falls in the Elderly. American Family Physician, 61(8), Furman JM, Cass SP, & Whitney SL. (2010) Orthostatic Hypotension, In. Vestibular disorders: a case study approach to diagnosis and treatment (3 rd Ed), (p ). Oxford University Press. Gananca et al. (2010) Elderly falls associated with benign paroxysmal positional veritigo. Braz J Otorhinolaryngology; 76(1): Garcia et al Influence of age and gender in the sensory analysis of balance control. Eur Arch Otorhinolaryngology; 269:

133 References Herdman SJ (2007). Vestibular Rehabilitation 2 nd Ed. F.A. Davis Co., Philadelphia. Hausdorff JM, Rios DA, Edelber HK. (2001) Gait variability and fall risk in community living older adults: a 1 year prospective study. Archives of Physical Medicine and Rehabilitation, 82(8), Honaker, J.A. (2007). A team approach risk of falling assessment and remediation program for community- dwelling older adults with balance disorders and a fear of falling. Dissertations Abstracts International, B67, (12), 170 pages. Jacobson et al Significant vestibular system impairment is common in a cohort of elderly patients referred for assessment of falls risk. J Am Acad of Audiology; 19: Jacobson, GP & McCaslin, DL. (2008) Assessment of Falls Risk in the Elderly. Balance Function Assessment and Management. Ed. Jacobson, GP & Shepard, NT. Plural Publishing: SanDiego. Pp Jeka et al (2010) The dynamics of visual reweighting in healthy and Fall-prone older adults. Journal of Motor Behavior; 42(4): Jin Y, Nakamura M, Shinjo Y et al. Vestibular-evoked myogenic potentials in cochlear implant children. Acta Otolaryngol 2006;126: Kellogg International Work Group on the Prevention of Falls by the Elderly. (1987)The prevention of falls in later life. Dan Med Bull, 34(4), Krause E, Louza JP, Wechtenbruch J et al. Influence of cochlear implantation on peripheral vestibular receptor function. Otolaryngol Head Neck Surg 2010;142: Liu BA, Topper AK, Reeves RA, Gryfe C, & Maki BE (1995). Falls among older people: Relationship to medication use and orthostatic hypotension. Journal of the American Geriatric Society, 43, Licameli G, Zhou G, Kenna MA. Disturbance of vestibular function attributable to cochlear implantation in children. Laryngoscope 2009;119:

134 References Lord SR, Sherrington C, & Menz HB. (2001). Falls in older people: Risk factors and strategies for prevention. New York: Cambridge University Press. Melvin TA, Della Santina CC, Carey JP et al. The effects of cochlear implantation on vestibular function. Otol Neurotol 2009;30: Myers AM, Fletcher PC, Myers AH, & Sherk W. (1998). Discriminative and evaluative properties of activities-specific balance confidence (ABC) scaled. Journal of Gerontology,53A (4), M287-M294. Nygaard HA (1998). Falls and psychotropic drug consumption in long-term care residents: is there an obvious association? Gerontology, 44, O Reilly, RC, Grindle, C, Zwicky, EF, Morlet, T (2011). Development of the vestibular system and balance function: Differential diagnosis in the pediatric population. Otolaryngol Clin N Amer, 44 (2): O Reilly, RC, Morlet, T, Nicholas, BD, Josephson, G, Horlbeck, D, Lundy, L, Mercado, A (2010). Prevalence of vestibular and balance disorders in children. Otol Neurotol, 31: Pedalini et al Sensory organization test in elderly patients with and without vestibular dysfunction. Acta Oto-Laryngologica; 129: Rine, RM (2009). Growing evidence for balance and vestibular problems in children. Audiological Med, 1-5. Rine RM, Braswell J, Fisher D et al. Improvement of motor development and postural control following intervention in children with sensorineural hearing loss and vestibular impairment. Int J Pediatr Otorhinolaryngol 2004;68:

135 References Rine RM, Braswell J. A clinical test of dynamic visual acuity for children. Int J Pediatr Otorhinolaryngol 2003;67: Rine RM, Cornwall G, Gan K et al. Evidence of progressive delay of motor development in children with sensorineural hearing loss and concurrent vestibular dysfunction. Percept Mot Skills 2000;90: Salzman, B. (2010). Gait and balance disorders in older adults. American Family Physician, 82(1), Shumway-Cook A, Brauer S, & Woollacott M. (2000). Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical Therapy, 80, Shinjo Y, Jin Y, Kaga K. Assessment of vestibular function of infants and children with congenital and acquired deafness using the ice-water caloric test, rotational chair test and vestibular-evoked myogenic potential recording. Acta Otolaryngol 2007;127: Tribukait A, Brantberg K, Bergenius J. Function of semicircular canals, utricles and saccules in deaf children. Acta Otolaryngol 2004;124: U.S. National Safety Council (1982). Home Checklist: For detection of Hazards, Itasca, IL. Valente, LM (2011). Assessment techniques for vestibular evaluation in pediatric patients. Otolaryngol Clin N Amer, 44 (2), Valente LM, Goebel JA, Sinks B. Pediatric vestibular evaluation: two children with sensorineural hearing loss. J Am Acad Audiol 2012;23: Van Impe et al White matter fractional anisotropy predicts balance performance in older adults. Neurobiology of Aging; 33:

136 References Vibert D, Hausler R, Kompis M et al. Vestibular function in patients with cochlear implantation. Acta Otolaryngol Suppl 2001;545: Yesavage, JA, Brink TL, Rose TL et al. (1983) Development and Validation of a Geriatric Depression Screening Scale: A Preliminary Report. Journal of Psychiatric Research, 17, Zhou G, Kenna MA, Stevens K et al. Assessment of saccular function in children with sensorineural hearing loss. Arch Otolaryngol Head Neck Surg 2009;135:40-44.

137 Questions? Thank-you

138 Julie Honaker University of Nebraska Lincoln cehs.unl.edu/dizzinesslab Kristen Janky Boys Town National Research Hospital