Vestibular Rehabilitation Notes

        Vestibular Rehabilitation

HISTORY

·       Cawthorne and Cooksey – First clinicians to offer exercises for dizziness and vertigo.

·       Harold Schuknecht – Cupulolithiasis theory.

·       John Epley – Canalithiasis theory – Revolutionized treatment for BPPV.

DIFFERENTIAL DIAGNOSIS FOR DIZZY PATIENT

·       LIGHT HEADEDNESS – Feeling that fainting is about to occur .(Causes – Hypotension, Hypoglycaemia, or anxiety)

·      DISEQUILIBRIUM – Sensation of being off balance. (Causes – nonvestibular problems – decreased somatosensation or weakness in the lower extremeties)

·      VERTIGO – Illusion of movement. (Causes- pathology within the vestibular periphery or along the vestibular pathways)

·      OSCILLOPSIA– Experience that objects in the visual environment that are known to be stationary are in motion.(Cause – Vestibular hypofunction)

DIAGNOSTIC TECHNIQUES

·       Careful history

·       Clinical examination – Assessment of eye movements, posture and gait

·       HEAD IMPULSE TEST – Assess semicircular canal function.

·       HEAD SHAKING INDUCED NYSTAGMUS – Diagnosis of  people with asymmetry of peripheral vestibular input to central vestibular regions.

·       POSTIONAL TESTING – To identify whether otoconia have been displaced into the SCC BPPV. The Dix – Hallpike test commonly used to verify displaced otoconia.

·       DYNAMIC VISUAL ACUITY – Measurement of visual acquity during self – generated horizontal motion of the head.

·       POSTURE & BALANCE TESTING – Determination of a patient’s functional status. Testing includes static balance, weight shifting, automatic postural responses and ambulation.

PHYSICAL THERAPY INTERVENTION

Vestibular Rehabilitation refers to interventions such as repositioning techniques, vestibular adaptation exercises, habituation excercices, and general exercise to improve muscle force, gait or balance.

·       BENIGN PAROXYSMAL POSITIONAL VERTIGO – Nystagmus is generated when SCC with displaced otoconia are placed into gravity – dependent positions, as in the Dix-Hallpike test.

TREATMENT	DIAGNOSIS
Canalith Repositioning Maneuver (CRM)	BPPV due to Canalithiasis
Liberatory Maneuver	BPPV due to Cupulolithiasis
Brandt-Daroff Exercises	Persistent BPPV unresolved with CRM/Liberatory Residual vertigo without nystagmus Maybe useful for the patient who cannot tolerate CRM.

·       UNILATERAL VESTIBULAR HYPOFUNCTION – Recovery time upon initiating vestibular rehabilitation averages 6 to 8 weeks.

ü  Primary focus – gaze and gait stability exercises.

ü The two primary paradigms of  vestibular adaptation are X1 (times 1) and X2 execises (times 2).

ü X1 – Patient is asked to move the head horizontally (and vertically if appropriate) as quickly as possible while maintaining focus on a stable target.

ü X2 – Patient to move the head and target in opposite directions.

·       BILATERAL VESTIBULAR HYPOFUNCTION – Designed to address the primary complaints of gaze instability during head motion, disequilibrium, and gait ataxia.

ü Other recommended activities – execises in a pool and Tai Chi.

ü Habituation exercises do not work for the patient with a bilateral vestibular loss.

·       CENTRAL VESTIBULAR LESION – Time to recovery will be 6 months or more and may be incomplete.

ü Though vestibular rehabilitation offers promise for treating persons with Traumatic brain injury, it may not always be the treatment of choice due to its irritative nature.

·       NON VESTIBULAR DIZZINESS – Vestibular rehabilitation techniques  similar to those patients with true vestibular pathology.

·       CONCLUSION 
         The vestibular system requires movement to recover from most lesions.