evidence-based practice in vestibular rehabilitation
DESCRIPTION
Presented at the Indiana Occupational Therapy Association Fall Conference, October 26, 2013, at IUPUI. This presentation gives occupational therapists a few tools to recognize, begin treatment, and refer patients with vestibular dysfunction, for earlier identification and return to productive living.TRANSCRIPT
Evidence Based Practice in Evidence Based Practice in Vestibular Rehabilitation: An Vestibular Rehabilitation: An Occupation-based PerspectiveOccupation-based Perspective
Brenda S. Howard MHS OTRBalance Point IndianapolisAnd University of Indianapolis, DHS ProgramOctober 26, 2013
How is Vestibular Rehabilitation How is Vestibular Rehabilitation Occupation-Based?Occupation-Based?
• Vestibular function underlies all human activity
• Vestibular impairment impacts all occupations
• Occupational Therapy Perspective• Remediate vestibular function• Compensate for safety• Environmental modification
How is Vestibular Rehabilitation How is Vestibular Rehabilitation Evidence-Based?Evidence-Based?
• Evaluation based in neurology & evidence
• Treatment tools based in evidence• Foundation of evidence allows for
creativity in practice• See reference list
Learning ObjectivesLearning Objectives Gain knowledge of vestibular rehab and
evidence Identify vertigo, central vs. peripheral Three tools for evidence-based
assessment and treatment When to refer Spark interest in further education
What do patients complain of when What do patients complain of when they have a vestibular impairment?they have a vestibular impairment?
Vertigo a sense of movement where there is no
movement; an illusion of movement
What do patients complain of when What do patients complain of when they have a vestibular impairment?they have a vestibular impairment?
Dizziness a combination of vertigo, lightheadedness, and
imbalance
What do patients complain of when What do patients complain of when they have a vestibular impairment?they have a vestibular impairment?
Vision Hearing Nausea
What do patients complain of when What do patients complain of when they have a vestibular impairment?they have a vestibular impairment?
Cognition Balance, Coordination Emotions
Central ConnectionsCentral Connections
• Vestibulo-ocular reflex• Vestibulo-spinal reflex• Vestibulo-collic reflex• Autonomic connections• Limbic connections
What can go wrong? Peripheral What can go wrong? Peripheral causes of vertigocauses of vertigo
Unilateral Vestibular Hypofunction
◦ Peripheral Vestibular Asymmetry ◦ Labyrinthitis◦ Vestibular Neuronitis◦ Vestibular Infarct◦ Vestibular Schwannoma/Acoustic
Neuroma(Herdman, 2007; Herdman & Clendaniel, 2007)
Peripheral Vertigo History and Peripheral Vertigo History and SymptomsSymptoms
Sudden onset (illness, trauma, or unknown)
Constant dizziness, provoked by motion (especially head and body turns)
(Herdman, 2007; Herdman & Clendaniel, 2007)
Peripheral Vertigo History and Peripheral Vertigo History and SymptomsSymptoms
Discomfort with watching movement or patterns
Mild-Moderate Imbalance
(Herdman, 2007; Herdman & Clendaniel, 2007)
Peripheral Vertigo History and Peripheral Vertigo History and SymptomsSymptoms
Horizontal unidirectional gaze-evoked nystagmus
http://www.youtube.com/watch?v=YntJiBCz3pA
(Herdman, 2007; Herdman & Clendaniel, 2007)
Bilateral Vestibular Hypofunction Bilateral Vestibular Hypofunction
Not dizzy Off balance No balance in the dark Oscillopsia (“things bounce visually”)
Bilateral Vestibular Hypofunction Bilateral Vestibular Hypofunction
Dynamic Visual Acuity loss of greater than 6 lines
Immediate fall Romberg eyes closed on compliant surface
Causes: Chemotherapy, ototoxic antibiotics, autoimmune
BPPV (Benign Paroxysmal BPPV (Benign Paroxysmal Positional Vertigo)Positional Vertigo) Etiology:
Otoliths in semicircular canal Cupula deflects more than usual
(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)
BPPVBPPV Posterior canal: 95% of cases
(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)
BPPV SymptomsBPPV Symptoms Dizziness with position changes Lying flat, rolling over, sit up, stand up, bend
over, look up “Top Shelf or “Dentist Office” vertigo Strong spinning for less than one minute May have “leftover” symptoms for hours
Seniors may describe symptoms differently; rocking, tilting, passing out
(Herdman, 2007; Herdman & Clendaniel, 2007); Helminski et al, 2010; Epley, 1992, 1995)
BPPV is Designated by:BPPV is Designated by:Canal
◦Right or left◦Anterior (Superior)◦Posterior ◦Horizontal
Otolith Position◦Canalithiasis◦Cupulolithiasis
BPPVBPPVDiagnosed with Dix Hallpike maneuver
BPPV Nystagmus:BPPV Nystagmus:
http://www.youtube.com/watch?v=gyvSmTlGu2k
BPPV – Canalith RepositioningBPPV – Canalith RepositioningEpley Maneuver for Posterior Canal BPPV
canalithiasis
What can go wrong? Central What can go wrong? Central Causes of VertigoCauses of Vertigo
• Migraine Associated Vertigo (MAV), Vestibular Migraine
• Post-Concussive Disorder• CVA (cerebellar, pontine)
(Herdman, 2007; Herdman & Clendaniel, 2007)
Vestibular MigraineVestibular Migraine
• May or may not have headache• May have vertigo without migraine• Headache may be low grade but
persistent• A history of migraines (or persistent
headaches)
(Herdman, 2007; Herdman & Clendaniel, 2007)
Vestibular MigraineVestibular Migraine
• Symptoms similar to a unilateral vestibular loss but with no objective findings on VNG
• Motion, light, and sound sensitive
(Herdman, 2007; Herdman & Clendaniel, 2007)
Vestibular MigraineVestibular Migraine
• May be episodic • Or may “wax and wane”• Typically responds better to balance
and gentle habituation exercises
(Herdman, 2007; Herdman & Clendaniel, 2007)
Post Concussive DisorderPost Concussive DisorderCentral AND Peripheral
Concussion Labyrinth trauma BPPV
Cognition Headache – post-concussive migrainesImbalanceMotion sensitive, visually sensitive
(Herdman, 2007; Herdman & Clendaniel, 2007)
CVA – Cerebellar, PontineCVA – Cerebellar, Pontine◦ Diplopia, dysmetria, dysarthria◦ “Constant hum” of vertigo◦ Pursuits/Saccades◦ Subjective visual vertical◦ Direction-changing nystagmus
http://www.youtube.com/watch?v=jeYe-SMMW9k
(Herdman, 2007; Herdman & Clendaniel, 2007)
Diagnostic TestsDiagnostic Tests Medical Tests: MRI, CT, cardiac Audiology Tests:
Audiogram VNG/ENG Rotary Chair Positional Testing including Dix Hallpike VEMP Computerized Dynamic Posturography (CDP)
Vestibular Therapy EvaluationVestibular Therapy EvaluationHistory
Detailed description of symptoms Past Medical History, Medications Occupational Profile – the “so what” Questionnaires
◦Dizziness Handicap Inventory (Jacobson, et al., 1990)
◦ABC Scale (Whitney, et al, 1999)
Oculomotor ExamOculomotor ExamPursuitsSaccadesGaze Evoked NystagmusSlow Head RotationEye-Head to PeripheryDynamic Visual Acuity (DVA) – using
logMAR chart (Herdman et al., 2003)
Gaze-Evoked NystagmusGaze-Evoked Nystagmushttp://www.youtube.com/watch?
v=mghGeKkNBzQ
Dynamic Visual Acuity and x1Dynamic Visual Acuity and x1http://www.youtube.com/watch?v=8eWKMO7RNak
Practice!Practice!Dynamic Visual AcuityVestibular Adaptation Exercises – x1 Gaze
Stabilization
◦What are some ways you can grade this exercise?
◦How can you add a functional component?
BPPV Evaluation and TreatmentBPPV Evaluation and TreatmentDix Hallpike and Canalith Repositioning
(Epley) ManeuverDix Hallpike:
http://www.youtube.com/watch?v=7pDOaFKrTbU
Epley: http://www.youtube.com/watch?v=ZqokxZRbJfw
PRACTICE!PRACTICE!
Dix Hallpike and Canalith Repositioning Maneuver
American Academy of Neurology American Academy of Neurology BPPV Assessment and Treatment BPPV Assessment and Treatment (full video)(full video)http://www.youtube.com/watch?v=hq-
IQWSrAtM
HabituationHabituationTest: Motion Sensitivity Quotient (Test)
(Shepherd & Telian, 1995; Akin & Davenport, 2003)
Habituation Exercises◦Otolith ◦Semicircular Canals◦Functional Movement: Progressive Sequences◦Brandt Daroff: NOT a habituation exercise(Whitney & Sparto, 2011; Clendaniel, 2010; Cohen, et al., 2006;
Cohen, et al., 1995; Cronin, 2013)
Habituation, continuedHabituation, continuedExercises:
◦Head horizontal, vertical◦Forward bend in straight plane, diagonal◦Wall rolling, ball-to-wall◦Add a functional task!
Vestibular Habituation Vs. Vestibular Habituation Vs. Adaptation – when to use?Adaptation – when to use?
Use adaptation for impaired VOR (DVA)Use habituation for motion sensitivity
You can use both, but be cautious to not overload the vestibular system
BalanceBalancemCTSIB (Modified Clinical Test of
Sensory Integration and Balance) (Shumway-Cook & Horak, 1986; Cohen, et al., 1993)
Dynamic balance◦Dynamic Gait Index (DGI) (Whitney, et al., 2000)
◦Functional Gait Assessment (FGA) (Wrisley, et al., 2010)
BalanceBalanceDemonstration and Practice!
◦Come up with one adaptation of this test that could be used for treatment
◦Come up with one functional activity to be used for balance treatment
Evidence-Based Treatment Evidence-Based Treatment Techniques - summaryTechniques - summary
Canalith Repositioning (Epley) Maneuver Vestibular Adaptation Exercise (x1) Habituation Exercises Static and Dynamic Balance Exercises
Evidence-Based Treatment Evidence-Based Treatment Techniques - summaryTechniques - summary
Compensatory techniques, sensory calming techniques (relaxation, deep breathing, visual targeting)
Functional activities, of course! - always link treatment to the patient's occupation-based goals
Patient Education ResourcesPatient Education Resources
Vestibular Disorders Association◦www.vestibular.org
Dr. Timothy Hain MD – “The Dizzy Doctor”◦http://www.dizziness-and-balance.com/
index.html
◦http://dizzy-doctor.com/index.phpVestibular Seminars
◦http://www.vestibularseminars.com/home.html
Case Study ExamplesCase Study Examples
What is one thing you would like to test?
If positive, what treatment would you select?
What referrals might you make?
A Word about Fall PreventionA Word about Fall Prevention
Multiple factors:◦Cognitive◦Environmental◦Strength, Endurance, Balance◦Peripheral Neuropathy◦Orthopedic Deficits◦Neurologic Deficits◦Vertigo◦Behavioral
All must be addressed!(AGS/BGS, 2010)
A Word about Non-Vestibular A Word about Non-Vestibular Causes of VertigoCauses of Vertigo
CardiacVertebrobasilar insufficiencyOrthostatic hypotensionLow blood pressureLow blood sugar
(Herdman, 2007; Herdman & Clendaniel, 2007)
A Word about Non-Vestibular A Word about Non-Vestibular Causes of VertigoCauses of Vertigo
Autoimmune disordersOther central disorders (MS, PD)Psychogenic – anxiety, depressionMedicationsCervicogenic(Herdman, 2007; Herdman & Clendaniel, 2007)
A Word About PrecautionsA Word About PrecautionsNeck ROM, painBack painFall RiskCirculatory issues
◦Vertebrobasilar Artery CompressionAutonomic reactionsNausea, vomitingSeizuresCoexisting diagnoses
When to ReferWhen to Refer
Refer to MD, ENT, Neurologist for diagnosis
Refer to audiologist for VNG, audiogram for suspected ear pathology
Refer to vestibular rehabilitation specialist if patient does not respond to treatment in 2-3 weeks OR if you are unsure what to do based on what you know
A Word about LogisticsA Word about LogisticsAOTA Position Paper (Cohen, et al., 2006)Indiana License (IPLA, 2011)Billing CPT codes:
◦Initial: 97003◦Timed treatment codes: 97112 (neuromuscular
re-education), 97110 (therapeutic exercise), 97530 (therapeutic activity).
Recommended CoursesRecommended Courses
Education Resources: Richard Clendaniel DPT, Gaye Cronin OTR
Jeff Walters DPT - http://www.vestibularseminars.com/
Sue Whitney PTJanet Helminski PT, Dr. Timothy Hain MDAPTA/Emory University Certificate Course
(Susan Herdman PT)Dr. Richard Gans PhD
http://dizzy.com/education_without_boundaries.htm
(See Cohen, et al., 2011 for educational guidelines)
SummarySummary
Evidence-basedOccupation-based
Post-testCourse Evaluation
THANK-YOU FOR ATTENDING!THANK-YOU FOR ATTENDING!
http://www.youtube.com/watch?v=rbwmfEXu75s
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Clendaniel, R. (2010). The effects of habituation and gaze stability exercises in the treatment of unilateral vestibular hypofunction: a preliminary results [sic] [Abstract]. Journal of Neurologic Physical Therapy, 34(2), 111-116.
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