L4 Vestibular Treatment Flashcards
What is the goal of vestibular rehab?
optimize patient recovery by addressing gaze stability, motion sensitivity, and postural stability deficits through customized therapeutic exercise and patient eduction
Potential impacts of vestibular impairment on function
- unsteadiness and balance impairments that worsen with dimly lit surroundings or uneven surfaces
- Dizziness exacerbated by riding in a vehicle, positional changes, visually busy environments
- Patinets may limit head and neck movements to help decrease exacerbation of S/S, leading to secondary impairments
Otolith demineralization
of otoconia in saccule and utricle is decreased
earliest change seen
Hair cell degeneration and loss
occur after age 50
hair cell density has more of a decrease in the saccule and cristae ampullaris
Over the age of 55,
impaired vestibular dysfunction can be seen in the decline in VOR function
Vestibular adaptation
recovery mechanism of the VOR
allows the vestibular system to make long-term improvements in how it responds to input to capitalize on remaining capabilities
goal is to rebalance the baseline firing rate within the peripheral vestibular system
Substitution exercises
use of other strategieis to replace the lost function, not classified as a true mechanism of recovery
increased reliance on visual and somatosensory inputs
Habitutaion exercises
provoking position or stimulus is repeated until the person no longer has symptoms
relies on the principle that repeated exposure decreases the brain’s pathological response to the stimulus
Canalith repositioning maneuvers
series of positions designed to remove the dislodged otoconia from the SC to treat BBPV
Comprehensive Treatment Activities
- Vestibular Adaptation
- Substitution exercises
- Habituation exercises
- Canalith repositioning maneuvers
- Balance exercise
- Aerobic exercise
Stable unilateral deficit
very good candidates for vestibular rehab using adaptation techniques
Stable bilateral deficit
treatment with habituation or substitution
Unstable unilateral or bilateral deficit
not good candidates for vestibular rehab
medicine, lifestyle changes, rest
Central vestibular deficit
treatment uses substitution and habituation
VOR gain
the ratio used to describe the relationship of eye movement to head movement
Retinal slip
occurs when VOR gain is impaired
movement of the visual image on the retina during head movement that causes the image to become blurry or jump
Adaptation Exercises Goal
create a retinal slip and utilize that error signal to modify the gain of teh VOR
incorporates visual stimuli with head movement
Gradual increasing retinal slip
more effective than producing larger errors
repeated exposure to retinal slip during gaze stabilization activities allows for vestibular adaptation
Adaptation Exercises may cause the patient to
experience their symptoms
important to establish a baseline of what S/S your patient has
treatment should be titrated so as to not increase your patients S/S more than 3 points above their baseline
Residual symptoms should not last more than 10 min
How to progress and regress Adaptation exercises
position changes: sitting/standing
incorporate movement
change background
vary speed of head movement
vary ROM
Goal of habituation exercises
reduce response to stimuli
will not change the VOR gain
Creating habituation intervention
-appropriate for pts with CNS dysfunction, BVH, unilateral vestibular hypofunction
-make sure to perform a subjective exam to know what actions make their S/S worse, then use that to create an exercise
-choose up to four movements that cause the patient to have S/S during testing, the pt is to perform those throughout the day
-it will take about 4 weeks for S/S to decrease
Goal of substitution exercises
promote the use of alternative strategies to substitute for impaired vestibular function
help the pt maintain gaze stability
Benign Paroxysmal Positional Vertigo
-mechanical problem of inner ear caused by dislodged otoconia from the utricle making their way into the semicircular canals
-about 20-30% of patients that are seen for vertigo have BPPV
Canalithiasis
otoconia are free floating in the canal
most common type of BPPV
S/S will be short lived
S/S will cease once debris settles in most dependent portion of canal
Cupulolithiasis
otoconia adhere to the cupula of the crista ampullaris
vertigo doesn’t go away for a few minutes
cupula becomes relatively heavy in endolymph and will persist as long as the individual is in the provoking position
BPPV presentation
vertigo lasting 30s to 2 minutes after positional change
normal vestibular and oculomotor exam
Causes of BPPV
-usually idiopathic
-most common after head trauma, illness, ischemia of anterior vestibular artery
common in older adult population due to degenerative changes of inner ear
Horizontal Canal Canalithiasis Treatment
lemper roll/BBQ roll
gufoni maneuver for geotropic nystagmus
Horizontal cupulothiasis treatment
gufoni maneuver for apogeotropic nystagmus
rapid head shaking
Canalithiasis treatment (A/P canals)
modified epley
Cupulolithiasis A/P canals treatment
semont
Smooth pursuit results
CNS = saccadic intrusions
PNS = normal
BPPV = normal
Saccades results
CNS = dysmetria/overshoots
PNS = normal
BPPV = normal
Gaze holding nystagmus results
CNS = direction changing
PNS = increased beating away from lesion or normal
BPPV = normal
VOR Test results
CNS = normal
PNS = lose gaze fixation
BPPV = normal
Head Thrust Test Results
CNS = normal
PNS = catch up saccade in side of movement
BPPV = normal
Head Shake Test results
CNS = normal
PNS = nystagmus to opposite side of lesion
BPPV = normal
VOR Cancel Test
CNS = eyes not following thumbs, saccadic intrusions
PNS = normal
BPPV = normal
