VESTIBULAR DISORDERS AND REHABILITATIONS

1. ANATOMY
Anatomy of peripheral system:

•Each labyrinth contains five neural structures that detect head acceleration: three
semicircular canals and two otolith organs .
•The three SCCs are orthogonal (placed at right angle ) and they respond to angular
acceleration of head:
1.Horizontal
2.Posterior (inferior)
3.Anterior (superior)
•The horizontal canals with Horizontal (left and right horizontal will work together)
•The posterior (Inf) and contralateral anterior (Sup) SCCs form coplanar pairs. (left
posterior and right anterior work together and vice versa).
•The SCCs are filled with endolymph fluid which moves freely within each canal in
response to the direction of the angular head rotation.
•On movement of head, the endolymph moves and the kinocilia.

Postural balance is activated

Angular movement: semicircular canals
Non-angular movement: saccule and utricle

2. PUSH PULL MECHANISM

The brain detects the direction of head movement by comparing the vestibular inputs
from both the side.In resting state the brain receives equal inputs from both the
SCC.But If you turn your head to LEFT: Brain receives more depolarisation(increased
inputs from vestibular apparatus) from the left side when compared to the right.More
depolarization is coming from LEFT so head is turning LEFT.
Turn LEFT: LEFT SCC excitatory, RIGHT SCC will be inhibitory.

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BUT: Eye ball will go in opposite direction( in the above example eyeball moves to the
right ) in order to maintain gaze on a stationary object

3.VESTIBULO OCULAR REFLEX(VOR)

VOR - conjugate eye movements opposite to that of the head movement

In the above image when head moves to right eyes moves to the left and vice versa

NYSTAGMUS - Involuntary eye movement occuring due to peripheral and central

vestibular leisions.
Nystagmus due to peripheral leisions consists of fast and slow components .
Direction of nystagmus is named based on the direction of fast component .
Nystagmus due to UVH (unilateral vestibular hypofunction ) - Spontaneous or resting
nystagmus is seen

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VESTIBULOSPINAL REFLEX (VSR )
VSR is group of reflexes named according to the timing ( static,dynamic,tonic ) and
sensory input (canal,otolith or both ) and its purpose is to stabilise the body

4. SPONTANEOUS ( RESTING ) NYSTAGMUS

Occurs in the absence of head movement.

In UVH - during rest, there is decreased firing of the vestibular system on one side when
compared to other side (side that is affected has decreased firing>>>less impulses
reach the brain)

Since there is more firing from the normal SCC, the brain perceives it as if the head is
moving to that side. For eg: if there is LEFT UVH --- there is decreased firing of the left
SCC-- decreased impulses reach the brain from left side and there is more impulses
coming from the right side SCC )

In absence of any head movement, brain perceives this difference in potential as that
the head is moving towards the side from which there is increased impulses ( but
actually there is no such head movement )

Therefore in LEFT UVH - brain perceives that head moves to the right and therefore the
eyes start moving to the left.But soon the brain realises there is no head movement
occuring based on the other inputs ( muscle activation, joint receptors) and tries to bring
the eyes back to normal.

This corrective phase of bringing eye back occurs really quick and is called the fast
component.In our example of LEFT UVH - fast component is to the right .As nytagmus
is named according to fast component , in LEFT UVH we see right nystagmus .

BPPV (BENIGN PAROXYSMAL POSITIONAL VERTIGO)

BPPV is one of the most common causes of vertigo (sudden sensation of spinning).
BPPV causes brief episodes of mild to intense dizziness that can be triggered by
specific changes of head position.

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OSCILLOPSIA
Subjective experience of motion of objects in the visual environment that are known to
be stationary.Occurs with head movements in patients with vestibular hypofunction
since vestibular system is not generating an adequate compensatory eye velocity during
head motion.

This deficit in VOR results in motion of images and decline in visual acuity.

5. EXAMINATION
1. HEAD IMPULSE TEST

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2. HEAD SHAKING NYSTAGMUS (HSN) TEST
Useful in diagnosis of unilateral peripheral vestibular defect
In this test patient instructed to close eyes - clinician flexes head to 30 degree and
oscillates horizontally. On stopping oscillation patient open eyes and clinician checks for
nystagmus
Normal subjects - no nystagmus
Persons with UVH - nystagmus is seen

3. POSITIONAL TESTING

Used to identify whether otoconia has been displaced into SCC leading to BPPV
(Benign paroxysmal positional vertigo )

4. DIX HALLPIKE is the most commonly used positional testing

DIX HALLPIKE - FOR ANTERIOR AND POSTERIOR SCC

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5. ROLL TEST - FOR HORIZONTAL SCC

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 6. HYPOFUNCTION
Hypofunction means: not functioning 100%, underperforming so it is not sending
balance signals to your brain correctly.

UNILATERAL VESTIBULAR BILATERAL VESTIBULAR

HYPOFUNCTION (UVH) HYPOFUNCTION (BVH)

Damage to one side Damage to both sides

Sign of nausea, vomiting, vertigo, No sign

nystagmus

Feels off balance severe walking impairment

severe problems with standing balance.

dizziness and visual blurring on rapid No dizziness

head movement

TEST- Head shaking induced nystagmus TEST- Head sustained induced

nystagmus

Exercises Exercises
1. Habituation exercises 1. Habituation exercises will not be
2. Gaze stability 2x2 paradigm beneficial
exercise (moving target) 2. Gaze stability 1x1 paradigm
exercise (stationary target)

7. PATHOLOGY

CENTRAL PATHOLOGY PERIPHERAL PATHOLOGY

Nystagmus is vertical and parallel Nystagmus is horizontal with fast and

slow component

Prolonged recovery Resolves in 1-2 weeks

Last longer than 2 weeks- RED FLAG

Less vertigo episodes more

No hearing loss May have hearing loss

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 - Reappears in dark

Abnormal saccadic eye movements Normal saccadic eye movements

8. BALANCE TESTS

9. CONDITIONS RELATED TO VESTIBULAR SYSTEM

MENIERE'S DISEASE Characterised by low frequency hearing loss and
episodic vertigo, sense of fullness in ear and tinnitus.

Chronic Meniere's disease can result in UVH

Gaze and postural stability exercises advised

Physical therapy beneficial in treating disequilibrium

occuring after vestibular neurectomy

PERILYMPHATIC FISTULA Caused by rupture of membranes separating middle

and inner ear

Rupture causes perilymph leakage into middle ear

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 causing fistula,

Clinical features - vertigo and hearing loss

PT intervention useful in patients who develop

dysequilibrium/ vestibular hypofunction

VESTIBULAR SCHAWANOMA Also known as acoustic neuroma - benign tumours

arising from schwann cell of 8th cranial nerve.

Occurs commonly in internal auditory canal - tinnitus

and hearing loss is seen

Vertigo ,imbalance , facial and even vascular

symptoms can also be seen.

MOTION SICKNESS Sensory inputs of proprioception, vestibular and visual

information do not match the brain stored neural
patterns

As a result of mismatch ---nausea,emesis,diaphoresis

and motion sensitivity is seen

MIGRAINE RELATED Symptoms include vertigo,imbalance,dizziness and

DIZZINESS motion sickness,abnormal nystagmus

DD Between migraine and vestibular pathology - ask

qns related to history and whether symptoms worsen
with changes in barometric pressure, and whether
symptoms changes with intake of certain foods

Vestibular rehab - is helpful in migraine cases but not in

patients with migraine and BVH

MULTIPLE SCLEROSIS Can affect 8th cranial nerve and cause symptoms
related to UVH

MULTI SYSTEM ATROPHY Degenerative disease of the nervous system

Characterised by cerebellar ataxia,autonomic

dysfunction , parkinsons symptoms and corticospinal
dysfunction

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 Causes dizziness and imbalance

CERVICOGENIC DIZZINESS Dizziness or imbalance from pathology affecting

cervical spine or soft tissue .

VBI If suspected, vascular compromise should be ruled out

using special tests

Repeated episodes of vertigo without associated VBI

symptoms usually suggests peripheral vestibular
diagnosis.

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 10. INTERVENTIONS
EPLEYS MANEUVER - ANTERIOR AND POSTERIOR SCC

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CANALAITH REPOSITIONING MANEUVER - HORIZONTAL CANAL

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 GAZE STABILITY EXERCISES
Used to improve VOR and other systems that are used to assist gaze stability with head
motion

HABITUATION EXERCISES

Defined as a reduction in response to a repeatedly performed movement .

Warranted when a patient with UVH has continual complains of dizziness

To prescribe these exercises, first determine the provoking position.

When a position elicits mild to moderate dizziness, patient remains in provoking position
for 30 seconds or until the symptoms subside,whichever comes first .

Patient is also provided with a home exercise program based on the results of the
positional test

Provoking exercises performed - 3 to 5 times each, 2 to 3 times a day

Reference: Susan B. O’Sullivan, Thomas J. Schmitz, George D. Fulk. — 6th ed.

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