Vestibular and Balance Flashcards
Balance is a skill that emerges from what 3 systems
Vestibular Visual Somatosensory
T/F Balance can improve with practice
True
Needs for balance control
Musculoskeletal components Internal representations Adaptive mechanisms Anticipatory mechanisms Sensory strategies Individual sensory systems Neuromuscular synergies
Berg Balance score for non-fall risk
> 45/56
Dynamic Gait Index
Assesses ability to modify balance while walking in the presence of external demands
Function of Vestibular system
Maintain equilibrium and balance
Signs and symptoms of vestibular impairment
Nystagmus Tinnitus Vertigo – room spins around pt. or pt. feels like they are spinning Hearing loss Loss of balance and possible falls Broad-based stance (to accommodate for imbalance) Sweating, nausea, and vomiting (due to ANS involvement)
Peripheral Vestibular System: Functions
- Stabilization of visual images on the fovea of the retina during head movement to allow clear vision 2. Maintain postural stability especially during movement of the head 3. Provide information used for spatial orientation
Peripheral vestibular system: Apparatus in inner ear
Semicircular canals (SCC) Utricle Saccule CN VIII: Vestibulocochlear nerve
Central vestibular system: Vestibular reflexes controlled by processes in ___________.
Brainstem
Central Vestibular System connections
Connections between the vestibular nuclei, reticular formation, thalamus and cerebellum
Central Vestibular System: Role of thalamus and cortex
arousal and conscious awareness of the head and body in space
Electro-oculography (ENG): Recording eye movements
– indirect method of using electrical fields changes to estimate the position of the eyes as a function of time - Use remote electrodes lateral and above and below the eye gives a representation of yaw and pitch eye movements, but not torsional
Video-oculography (VNG):
- Recording of eye movements – direct method of estimating the position of the eyes as a function of time 2. In a typical 2D system the video signals that show the complete eye movement
Caloric Irrigation Test
Cold/Hot water or air into ear to create nystagmus. Good to have response - vestibular system is working
Purpose of rotational chair test
determine whether or not dizziness may be due to a disorder of inner ear or brain, and particularly to determine whether or not both inner ears are impaired at the same time
3 Parts to rotational chair test
Chair test
Optokinetic test
Fixation Test
T/F: Persons with inner ear disease becomes LESS dizzy than a normal person during the chair test
True
Chair test
measures dizziness (well jumping of the eyes really – called nystagmus) while being turned slowly in a motorized chair
Optokinetic Test
measures dizziness caused by viewing of moving stripes
Test for bilateral vestibular loss and central conditions
Optokinetic Test
Does patient with bilateral vestibular loss ever experience dizziness?
No
Pt. has bilateral vestibular loss and closes their eyes, what will happen?
Fall backwards
Fixation Test
measures nystagmus while the person is being rotated, while they are looking at a dot of light that is rotating with them —. Fixation suppression is impaired by central nervous system conditions and improved by bilateral vestibular loss
Why perform ENG test and rotary chair test
Adds accuracy –ENG tests by themselves may be falsely positive or falsely negative. They can be falsely positive when wax blocks one ear canal.
T/F: Rotary chair test IS affected by mechanical block in the ear
False
Situation where ENG is false negative
Damage to each ear
Bony Labyrinth
3 semicircular canals, the cochlea and the vestibule. It is filled with perilymphatic fluid (similar to cerebral spinal fluid)
Membranous Labyrinth
is suspended within the bony section and contains membranous portions of the canals and utricle and saccule. It is filled with endolymphatic fluid (similar to intracellular fluid)
Motion Sensors in the ear
Ampulla and otolith organ
Ampulla
contain the cupula (hair cells) which convert displacement into neuro firing thru bending of hair cells to detect linear/angular motion
Otolith Organ
(Utricle and Saccule): contain calcium carbonate crystals called otoconia. Shift in these crystals set off neuro firing detecting gravity and acceleration
Rotation of head movements (GAIN) should be….
1:1 Abnormal gain can cause symptoms of blurry vision or vertigo
Head movements are detected by….
cupula and transmitted via Vestibular Nerve to the Brain. Which then controls eye movement to stabilize the gaze
Main vascular supplier to both central and peripheral vestibular system
Vertebral-basilar artery
Most commonly missed stroke
Cerebellar Stroke
VOR (Vestibular Ocular Reflex)
generates eye movements, which enables clear vision while head is in motion. Quick movement to see kids screaming
VSR (Vestibular Spinal Reflex)
generates compensatory body movement in order to maintain head and postural stability, thereby preventing falls
VCR (Vestibular Collic Reflex)
stabilizes the head in space
Function of vestibular system: VOR
stabilize vision when head moves
Function of vestibular system: Vestibular spinal reflex (VSR)
balance control
Visual requirements
Visual Acuity Position of image: Gaze Shifting Holding image steady: Gaze holding
Visual Acuity depends on
- Position of image on fovea 2. Ability to hold image steady
Shaking head up and down is called pitch and sensed by
anterior and posterior canals (ANGULAR VOR)
Shaking head side to side horizontally is called yaw and is sensed by..
Horizontal canals (ANGULAR VOR)
Angular VOR - sensory organs
Semi-Circular Canals: Horizontal Anterior Posterior
Linear or Translational VOR - sensory organs
Otoliths Saccule Utricle
Ocular Tilt Reflex - Sensory organs
Otolith Utricle
Migraines are peripheral or central?
Central
Motor output - Linear or translational VOR
Eyes move opposite to linear movement of the head. Linear movement up and down (riding in elevator) is sensed by the saccule. Linear movement horizontally (riding on a train on a straight track) is sensed by the utricle
Motor Output - Ocular Tilt reflex
Eyes and head move opposite to the tilt of the head. Tilt left causes elevation of the left eye, depression of the right eye, torsion of both eyes to the right and the tilt of the head on the body to the right.
3 Cervical reflexes
- The Cervicoocular Reflex (COR) 2. The Cervicocollic Reflex (CCR) 3. Cervicospinal Reflex (CSR)
The Cervicoocular Reflex (COR)
Weak reflex Does not play direct role in gaze stability May help VOR to compensate Proprioceptors and somatosensory receptors -C1-C2 dorsal nerve roots
The Cervicocollic Reflex (CCR)
Provides head stability Contraction of stretched muscles to align head
Cervicospinal Reflex (CSR)
-acts in conjuction with the VSR -provides postural stability through limb activation
Common Diseases of Dizziness and Imbalance - Peripheral
Vestibular Neuritis/labryinthitis Acoustic Neuroma Meniere’s Disease BPPV Toxicity
Common Diseases of Dizziness and Imbalance - Central
Disequilibrium of Aging CVA Migraine Head Trauma (TBI/Concussion)
Vestibular Neuritis
Key Features: Vestibular crisis (vertigo, imbalance, nausea) improving over 1-4 days, absence of associated auditory symptoms, left with head movement sensitivity Gradual and complete recovery is expected
Vestibular Neuritis Prognosis
Excellent with compensation, vestibular and balance rehab
Age commonly affected by vestibular neuritis
30-60
Maddox Rod testing - when line is to the left of the light
Exotropia Maddox rod used to detect troupe
Maddox Rod testing - when line is to the right of the light
Esotropia
Cover uncover test is used for
Tropia
Cover - cross cover test is used for
Phoria
Viral Endolymphatic Labryinthitis
Acute vestibular crisis lasting 1-4 days with a history and recovery similar to vestibular neuritis Key feature is a sudden hearing loss accompanied with vertigo. Hearing loss within a few hours before or after the onset of vertigo Hearing loss may recover or persist. If no vertigo reported suspect bilateral loss
Prognosis of viral endolymphatic labryinthitis
excellent for dizziness with compensation and vestibular balance rehab, need immediate steroid tx for hearing loss
Acoustic Neuroma
3rd most common intracranial tumor Nerve sheath benign tumors arise from Schwann cells lining the axons of the cochleovestibular n. Causes progressive unilateral hearing loss or tinnitus without vestibular symptoms. Balance issues (if present) tend to be mild and intermittent Rarely cause acute vestibular crises but may produce syndromes that mimic other vestibular diagnoses.
3 Therapeutic options for Acoustic Neuroma
watchful waiting, radio surgery, and surgical resection
Meniere’s Disease
A disorder of the inner ear function resulting in devastating hearing loss and vestibular symptoms. Unknown cause.
Key Features of Meniere’s Disease
Recurrent, spontaneous intense rotational vertigo persisting from 30 minutes to 24 hours, postural imbalance, nystagmus, nausea, vomiting, hearing loss, tinnitus and aural fullness.
Benign Paroxysmal Positional Vertigo
Most common cause of vertigo. Key features include brief episodes of vertigo when head is moved in certain positions. Symptoms are triggered by lying down, rolling over in bed, bending over, and looking up.
What is the most common single known cause of bilateral vestibulopathy?
Gentamicin toxicity, which is confirmed by rotary chair test. Symptoms include imbalance and visual symptoms. Visual symptoms include oscillopsia.
Vertebrobasilar Vascular Insufficiency
Blockages of one or more arteries (either posterior inferior cerebellar a., vertebral a., anterior inferior cerebellar a., basilar a., and/or superior cerebellar a.) Symptoms include episodic vertigo with imbalance with other brainstem signs and symptoms, loss of coordination, ocular motor control deficits as well as postural control, gait and speech abnormalities.
Treatment of Vertebrobasilar Vascular Insufficiency
Neurology, balance, gait therapy, and fall prevention, habituation if symptoms present
What are people with migraines more likely to suffer from?
Severe motion sickness, Meniere’s Disease, or BPPV
Migraine without Aura
Consists of periodic headaches that are usually throbbing and one sided, worse with activity, and associated with nausea and increased sensitivity to light and noise. Vertigo can occur before, during or separately from the episodes of migraine headache
Migraine with Aura
Associated with short lived symptoms (noises, flashes of light, tingling, numbness, vertigo and others) known as the aura. Symptoms usually precede the headache and usually last 5-20 mins
Basilar Migraine
Symptoms include vertigo, tinnitus, decreased hearing and ataxia (loss of coordination)
Triggers of migraines
Stress, anxiety, hypoglycemia, fluctuating estrogen, certain foods, smoking and other factors
Concussion Signs and Symptoms
Physical: headache, balance problems, light/noise sensitivity, blurred vision, dizziness, fatigue, nausea Cognitive: mentally foggy, difficulty concentrating, confusion Emotional: irritability, sadness, nervousness, anxiety Sleep: drowsy, altered sleep patterns Duration of Symptoms is highly variable and may last from several minutes to months or even longer in some cases
Ocular Motor Findings after Concussion
Pursuits: “Saccadic” pursuits or “Saccadic Intrusions” Symptomatic w/ pursuit movements Saccades: Hypometric Saccades Slowed Saccades Symptomatic with saccades eye movements
Meniere’s Disease Key features
A disorder of the inner ear function resulting in devastating hearing loss and vestibular symptoms Key Features: recurrent, spontaneous spells intense rotational vertigo lasting several hours, postural imbalance, nystagmus, nausea, vomiting, hearing loss, tinnitus and aural fullness. Vertigo will persist anywhere from 30 mins to 24 hours.
Meniere’s Disease Cause
Cause of disease is unknown. Hereditary factors may play a role. Usual onset in the 4th and 6th decades of life, equally between the sexes
How many days until ambulatory with Meniere’s Disease
3 Days.. Symptoms gradually abate, usually ambulatory within 3 days. Some sensation of unsteadiness will persist but then normal balance returns between spells
Saccadic Pathway
Front cortex–Frontal eye field (FEF) Dorsal lateral prefrontal cortex Superior Colliculus (SC) Brainstem Posterior parietal cortex (PPC)
Pursuit Pathways
(overlap with saccadic movement) FEF PPC Cerebral structures Medial temporal and medial superior temporal cortex
Vergence System
Moves the eyes in opposite direction to align foveas on the same object in space. Responsible for near to far bilateral disconjugate eye movements. Stimulus for a vergence response: double vision or different positions of image on the retina, which creates a “fusional vergence movement”
Convergence
Ability of eyes to turn inward to focus on a near target. Response = Visual signal from occipital cortex to vergence premotor neurons in midbrain reticular formation to midbrain CN III to TRIAD Triad: (1) convergence leads to: (2) accomodation leads to: (3) miosis of the pupil
Vergence Testing
Patient fixates on target brought in along the mid-sagittal plane toward the nose • Near Point of Convergence: when target becomes double • Normal NPC
Vergence Dysfunction Symptoms
Asthenopia when reading, frontal headaches, intermittent or constant double vision, squints (closes one eye), letters will appear to float or move around the page, lack of symptoms but findings persist (suppression, avoidance, or occlusion)
Conjugate Movements
EOM movement, Saccades, and Pursuits
Disconjugate Movements
Convergence and Divergence
Tropia
Overt deviation of the eye. Exo - outward (laterally) Eso - inward (medially) Hyper - upward Hypo - downward
Phoria
Ocular deviation occurs when dissociation occurs
Misalignment Symptoms
Severe = diplopia, head tilt (vertical misalignment), noticeable eye turn Subtle = difficulty maintaining focus, cosmetically normal, ocular soreness, headaches, mental dullness
Orthostatic Hypotension or Intolerance
Symptoms of dizziness: Faintness or lightheadedness which appear only in standing, and which are caused by low blood pressure, Only rarely is spinning vertigo caused by orthostatsis, Chest pain, Sweating/nausea
Ramsay Hunt Syndrome
Herpetic infection of the VII and VIII CN. Sudden onset of pain with open sores, loss of hearing with a vestibular crisis event, facial mm weakness. Treatment: medical antiviral with steroids Prognosis: usually left with hearing loss and needs vestibular balance rehab
Arnold Chiari
Episodic to continuous imbalance and lightheadedness exacerbated by hyperextension of neck, double vision on lateral gaze. Down beating nystagmus in primary gaze usually exacerbated with lateral gaze. Treatment: neurology/neurosurgery Prognosis: post surgery gait and balance therapy
Multiple Sclerosis
5-7% will have true vertigo as initial onset symptom. Others will have lightheadedness or imbalance. Shows central signs of saccades and pursuit abnormalities, nystagmus. Treatment: neurological care/vestibular rehab may be useful in exacerbations for imbalance and habituation to motion sensitivity
Peripheral Disorders
Vestibular neuritis, labryinthitis, acoustic neuroma, toxicity, BPPV, and Meniere’s disease
Central Disorders
Disequilibrium of aging, CVA, Migraine, and head trauma
Questionnaires (examining vestibular system)
Dizziness Handicap Inventory (DHI), Activities of Balance Confidence Scale (ABC), Visual Vertigo Analog Scale, Situational Vertigo Questionnaire
What is the most important part of the evaluation?
History
Symptoms of Dizziness
Vertigo, imbalance (general or actual ataxia with possible falls), lightheadedness, or a combination of these.
Objective Tests/Measures of the Vestibular System
Cervical ROM/cervical instability, gross strength and mobility, ocular motor system, special tests, and balance assessment
Joint Position Error Test (JPE)
Patient is seated 3 feet away from a target and uses a laser pointer strapped to the patient’s head and patient will close eyes and look either right/left/up/down and then back to the center to measure joint position error. Error > 4.5 degrees are likely significant for head and neck position sense/proprioception.
5 Red Flags during the Vertebral Artery Test
Diaphoresis, dysphagia, dysarthria, drop attacks, and diplopia
CN Screening 1-6
- Olfactory: smell 2. Optic: vision (chart, peripheral) 3. Oculomotor: eye movement (dilation of pupils, follow target) 4. Trochlear: eye movement down 5. Trigeminal: facial sensation/chewing 6. Abducens: eye movement laterally
CN Screening 7-12
- Facial: expression and taste 8. Vestibulocochlear: hearing and balance 9. Glossopharyngeal: swallowing and speech 10. Vagus: swallowing and speech 11. Accessory: muscle control, shoulder shrug 12. Hypoglossal: tongue movement
Eye movements are controlled by…
Saccadic, smooth pursuit, vestibulo-ocular, vergence
Spontaneous Nystagmus
Holding pt’s head still while looking straight ahead, observe for nystagmus
Fixed Gaze Nystagmus
pt’s head still, have pt look 30 degrees left, right, up and down from center and hold gaze. Observe for nystagmus
Oculomotor ROM
18-24” from pt, eyes should move smoothly and together
Convergence
pt focus on finger until diplopia or blurry vision; should be 5-8cm from brow
Positive Test for Saccades
Overshoots
Cover-Uncover Test
Tests for tropia if there is movement
Cover-Cross Cover Test
Tests for phoria or measures magnitude of phoria or tropia
Maddox Rod
Always test the right eye! .5” or less is normal deviation of the line
VOR Cancellation
Tilt pt’s head down 30 d; have pt hold thumbs in front of them. PT move head/hands in same direction. + saccadic eye movement
VOR
Tilt pt’s head down 30 d, move head side to side while they look at your nose
Head Thrust Test
+ test indicates vestibular hypo function on ipsilateral side
Head Shaking Nystagmus
+ nystagmus suggesting unilateral vestibular hypofunction
Visual Acuity
2 line difference is normal; 3+ is abnormal
Tragal Pressure
+ nystagmus or increased dizziness
PT Goals, Outcomes,
Safety: sensory substitution, compensatory strategies, AD
Exercises to promote vestibular adaptation
Habituation training, gaze stability exercises, postural stability exercises, emphasize functional mobility skills, relaxation training
PT Treatment Principles
Adaptation, Substitution, Habituation
Goals of Compensation
Normal gaze stability and postural control Reprogram eye movements and postural responses Movement/exposure to stimuli that challenge system Error signal to brain so it can reset
VORx1
side-to-side eyes on stationary target
VORx2
side-to-side eyes on moving target
BPPV stands for?
Benign paroxysmal postitional Vertigo
BPPV symptoms
Starts suddenly describe vertigo with tilting of head, looking up and down, rolling over in bed nausea and vomiting NO HEARING LOSS OR TINNITUS
How is BPPV diagnosed?
Head CT scan MRI Dix-Hallpike (Hallpike-Dix) along with patient history
Dix-Hallpike Test looks for?
Anterior and posterior canal issues
Roll Test for?
Horizontal Canal
Treating BPPV
medications Canalith Repositioning Procedure Surgery
What to consider before thinking BPPV?
Cervical ROM Vertebral Artery Compression Functional Status Standardized test and measures (Dizziness Handicap Inventory) Medical interventions (Vestibular suppressant medications)
Precautions for testing BPPV
cervical spine instability prolapsed intervertebral disc cervical myelopathy Arnold Chiari malformation Vascular dissection syndromes Previous cervical spinal surgery Carotid sinus syncope Aplasia of odontoid process
Canalithiasis
Debris floating freely in the endolymph in the long arm of the semi circular canal
Cupulolithiasis
Debris, probably fragments of otoconia from the utricle, adhere to the cupula
Canalithiasis Theory
Otoliths become dislodged from the utricle & enter the Posterior SCC (most dependent of the 3 SCCs)
Canalithiasis Symptoms
nystagmus under 60 seconds
Cupulolithiasis Symptoms
nystagmus over 60 seconds
Treating Canalithiasis
Canalith repositioning maneuver/procedure (Epley) 84-90% remission rate Sleep upright for one night
Children with canalithiasis
Extremely rare with youngest at 5 years old. Age is a determining factor
Right Posterior Canal nystagmus
Cupulolithiasis – Persistent UBN & R Torsion Canalithiasis – Transient UBN & R Torsion
Left Posterior Canal nystagmus
Cupulolithiasis – Persistent UBN & L Torsion Canalithiasis – Transient UBN & L Torsion
Horizontal ageotrophic is which?
Cupulothiasis
Horizontal geotropic is which?
Canalithiasis
Right Anterior canal nystagmus
Persistent DBN & R Torsion
Left anterior canal nystagmus
Persistent DBN & L Torsion
Cupulolithiasis
No latency Weak nystagmus (about 5 deg/sec), directed about the axis of the canal being stimulated. Cupulolithiasis might occur in any canal – horizontal, anterior or vertical, each of which might have it’s own pattern of positional nystagmus. For the lateral SCC, the nystagmus is ageotropic, meaning that it beats upward with respect to the head position.
Assessment and treatment of BPPV
Dix-Hallpike (Posterior/Anterior Canal) Roll Test (Horizontal Canal) Maneuvers for repositioning
What are the Dix-Hallpike Test steps?
Patient sits on table Clinician turns patient’s head horizontally 45 degrees and quickly moves patient down to supine position with neck extended 30 degrees beyond horizontal. Check for symptoms (Vertigo & Nystagmus) Return patient to sitting & test other side Positive for BPPV on side that produces symptoms
What are the Roll Test steps?
Patient’s head is placed in 20 degrees of cervical flexion on a wedge Head is turned 90 degrees to the L – check for nystagmus & vertigo Turn head gently to neutral starting position Test is repeated to other side & PT again checks for nystagmus & vertigo
Treatment options for BPPV in physical therapy
CRP (Ant/Post Canalithiasis) Semont or Liberatory Maneuver (Ant/Post Cupuloithiasis) Epley * only if use vibration to mastoid area Barbeque roll (Horizontal Canalithiasis) Semont maneuver as modified by Casani (HC Cupuloithiasis) Appiani (HC Canalithiasis) Brandt Daroff Habituation Exercises- use as last resort
Epley’s maneuver or Canalith repositioning procedure
Treatment of choice Patient is positioned in a series of steps so as to slowly remove the otoconia particles from the posterior SCC back into the utricle Takes about 5 minutes One week after CRP procedure, repeat the Dix-Hallpike test IF the patient does experience vertigo and nystagmus, the CRP test is repeated and can add vibrator placed on the skull to better dislodge the otoconia (true Epley)
Canal Repositioning procedure
1) Turn head to 45 degrees to involved side 2) Patient then reclines to supine with 20-30 degrees cervical extension 3) Hold for 30-60 seconds 4) Turn head 90 degrees away from affected ear 5) Patient then rolls onto shoulder toward the head 6) Patient’s head sould be 45 degrees to floor facing shoulder 7) Patient then sits up with examiner holding patient for a minute
Semont Liberatory Maneuver
Position 1. Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear. Position 2. While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex. Position 3. Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.
Casani treatment
Patient is taken into sidelying toward the Involved side Maintain neutral cervical rotation – hold 1 min. Cervical spine is then rotated downward – hold for 1 min after end of nystagmus. Patient returns to sitting.
Appiani treatment
Patient is taken into sidelying toward the uninvolved side Maintain neutral cervical rotation – hold 1 min. Cervical spine is then rotated downward – hold for 1 min after end of nystagmus. Patient returns to sitting.
Barbecue Roll treatment
Begin patient in supine position Patient rolls towards unaffected ear. Patient continues to roll “barbecue” style. Patient continues to roll until reaching the starting position. Rolls are 90 degree increments and the procedure is repeated 2-3 times until the patient is symptom free.
Brandt-Daroff Exercisises: HEP
Start in an upright, seated position. Move into the lying position on one side with your nose pointed up at about a 45-degree angle. Remain in this position for about 30 seconds (or until the vertigo subsides, whichever is longer), then move back to the seated position. Repeat on the other side.
Adaptation
Error signal sent to brain; brain tries to reduce it. Vestibular system is frequency specific and have to advance head frequencies and head positions
Adaptation Exercises
VOR x1 and x2 Exercises. Progress: duration, velocity, busy backgrounds, position, target distance.
Substitution
Use other strategies to replace lost/impaired function. Eye tracking, oculomotor exercises and saccades.
Substitution Protocols
Strengthen weakened system to return to function by challenging remaining ones. Progress from easy/static EO/EC to difficult/dynamic EO/EC
Substitution Exercises
Eye and head movements between 2 targets Remembered target practice
Habituation
Systematically provoke symptoms to produce reduction in those symptoms.
Pick 2 or 3 of the worst provoking maneuvers as basis of tx. pt performs up to 5 reps, once or twice daily.
Habituation Training
Repetition of movements and positions that provoke dizziness and vertigo
Postural Stability Exercises
Static or Dynamic balance exercises:
Bending forward, turning, walking, walking & turning, walking with head turns.
Emphasize functional mobility skills: community activities, activities with spatial and timing constraints.
Vestibular Recovery Rates
UVL: 6-8 wks
BPPV: Remission in 1/few tx
BVL: 6 months - 2 years
CNS Lesion: 6 months - 2 years
Vestibular Exercise Program Objectives
Diminish dizziness and vertigo
Enhance gaze stabilization
Enchance postural stability in static/dynamic situations
Enhance overall functional activity
Patient Education
Vestibular Program Components
Gaze stabilization to retrain VOR
Balance retraining to retrain VSR
Conditioning exercises to increase fitness level
Habituation or canal repositioning maneuvers as indicated
PT Interventions
Outpatient: 1-2 times/week (4-6 weeks)
HEP: 5 min, 3x/day
Walking program (health and fitness)
Compliance is essential for success
Convergence Exercises
Pencip Push Ups
Brock String
Arrow Chart/Dot Chart
Accommodative Exercises
Heart Chart
Cervical Proprioceptive Exercises
Head laser with targets
Combine with saccades
Eyes closed awareness
