Vestibular

Vestibular Dysfunction, Cervicogenic Dizziness and Sensory Processing IssuesSusan Martin White, PTIs the NeoCortex Essentially Multisensory?Trends in Cognitive Sciences June 2006Asif A. Ghazanfar & Charles E. SchroederProgram in Neuroscience, Department of Psychology, Princeton UniversityCognitive Neurosciences Schizophrenia Program,Nathan S. Kline Institute for Psychiatric ResearchFunction of the Vestibular SystemStabilize gazeBalanceOrientation to movement of self vs. environmentRole of Vestibular SystemFunction Sensory InputsGaze stabilization VisionVestibularBalance VisionVestibularSomatosensoryAwareness of movement(self/environment)Vision VestibularSomatosensoryAuditoryOlfactory Proprioception/Kinesthia Tactile/PressurePeripheral SystemEffects of Head Rotation on CanalsOtolithic MaculaSemicircular Canals Angular rotation Horizontal Anterior PosteriorOtoliths Linear motion and Head tilt Saccule Utricle , OTR Peripheral SystemPeripheral Lesions Neuronitis viral Labyrinthitis - viral/bacterial Acoustic neuromas BPPV (benign paroxysmal positional vertigo) Perilymphatic fistulas Labyrinthian concussion Temporal bone fractures which pass through vestibule of inner ear (causing damage to peripheral structures) Pharmacological toxicity Menieres diseaseBenign Paroxysmal Positional VertigoCentral SystemCerebellumBrainstemCerebral Cortex Vestibular cortex Parietal Temporal FrontalCentral SystemInteraction of Self With 3-D Space3-D Spatial InteractionsSpace Distance Sensory Inputs FunctionPeripersonal 0-2mCentral 60Visual SomatosensoryVestibularVisual graphingManipulationExtrapersonal (focal)2m- 6mCentral 20-30 Visual(Vestibular VOR)Visual searchObject/facerecognitionExtrapersonal (action)2m- 30mFull 360VisualAuditory/Olfactory(Vestibular)NavigationScene memoryTarget orient.Extrapersonal (ambient)DistantFront 180Visual SomatosensoryVestibularSpatial orient.Postural controlLocomotionCentral Lesions Cerebellum Brainstem Cerebral Cortex (Vestibular Cortex) Parietal Temporal Frontal Areas of central compensation for past peripheral lesionsCommon SymptomsDizziness, vertigo, light-headednessBlurred vision, oscillopsiaDisequilibrium/imbalanceSpatial disorientationNauseaSensitivity to environmental stimuli(lights, noise, crowds, motion, visual complexity)Hearing loss, tinnitusAssociated Symptoms Irritability associated w/increased visual/sensory stimuli Fatigue Shut down behavior or sleepiness associated with increased visual/sensory stimuli or cognitive tasks Decreased socialization Decreased ability to complete activities of daily living or work Decreased memory, attention, and organizationVestibular Function TestsTest What it Does AssessesENG Records eye movementOculomotorfunctionCalorics Test VOR thru involuntaryresponsesFunction of SCC & part of s. vestibular nerveRotary chair Test VOR thru involuntaryresponsesFunction of SCC & part of s. vestibular nerve and central compensationTest What it Does AssessesPosturagraphy Tests postural swayand autonomic postural responses under different visual and somatosensory conditionsInteraction of visual, vestibular and somatosensoryinputs and motor output in stanceVestibular DiagnosisDifferent PerspectivesVestibular Specialists - ENTs, Vestibular Neurologistslook for site specific lesions generally in peripheral areas or areas involved in vestibular reflex pathwaysAcquired Brain Injury- TBI Specialiststend to look at impairments in function that the vestibular system is involved in, i.e. gaze stability,balance, awareness of motion of self/environmentInclusion into VBRTVestibular and balance rehab programs are symptom drivenDevelopment of treatment plans are not specific to the site of lesionClinical therapy exam determines the treatment planConnection Between Agoraphobia/Panic and Vestibular Dysfunction Dizziness most common symptom in panic disorder in 50-80% of patients Research shows connections between agoraphobia and vestibular/spatial dysfunction Vestibular Therapy effective in persons diagnosed with vestibular dysfunction and agoraphobiaClinical DiagnosisVestibular oculomotor dysfunctionBPPVMotion sensitivityDecreased integration of sensory inputs necessary for balance and awareness of motion in spaceDecreased ROM/strength/coordination of motor outputs necessary for balance reactionsCervicogenic factorsCervicogenic DizzinessRole of cervical reflexesRole of vestibulocollic reflexes stabilizes the head dysfunction may cause cervical ataxiaPossible cause Inaccurate somatosensory inputs from neck disrupts the normal interaction between visual/vestibular and somatosensory inputsCervicogenic Symptoms Neck and cervicogenic headache pain which occurred w/onset of dizziness Weakness of intrinsic neck and upper back muscles that stabilize the neck Forward head posture Change in dizziness symptoms provoked w/mobilization testing to myofascia and/or jointsin cervical area Provocation of dizziness w/increased cervical pain Provocation of dizziness w/body on head rotationTreatment of Cervicogenic DizzinessManual therapyStretchingStabilization and StrengtheningPostural Re-educationVestibular therapyTreatment of BPPVCanalithiasis vs. CupulothiasisPosteriorAnteriorHorizontalTreatmentSpontaneous RecoveryReoccurrenceVestibular-Oculomotor Dysfunction Eye-head incoordination Evaluation includes: visual system ocular motor tests VOR head thrust, DVA VOR cancellation tests Treatment (adaptation) Saccades, pursuits Gaze stability exercises VOR cancellation exercisesRepetitions, rates, ROM, complexity of visual backgrounds, standing/gaitMotion SensitivityMismatch of sensory inputs results in symptoms provoked by body movement/positionMotion Sensitivity TestTreatment Habituation ExercisesBalanceDecreased integration of sensory inputs necessary for motor outputsRule out ROM, strength/coordinationTests BERG, DGI, modified CTSIB, FukudaTreatment EO/EC, varied BOS, varied surfaces, balance strategies, limits of stability, static/dynamic balance and gaitIntegration/Putting It All TogetherCombine: Vestibular ocular movements Head motion Balance postures and walking Varied surfaces Visual complexity Cognitive tasks Auditory inputs LightCompensatory Strategies Earplugs Glasses Dynamic foot plates / Foot orthotics Slowed transitional movements Rest periods Relaxation techniques Pacing / structured scheduleTop 8 Strategies for Vestibular Multisensory Symptoms1.Sit to have conversations or think Dont stand unless you have toTry not to walk and talk or think at the same time about something important2.Sit facing the least stimulating background Dont sit in middle of a group3.Use breaks between activities.Plan rest times daily.Use relaxation techniques.4.Try to keep focused on one thing at a timeTop 8 Strategies for Vestibular Multisensory Symptoms5.Use isometrics to keep head aligned6.Keep body still.Move slowlyKeep chin tuckedKeep good posture when you can7. Bend down keeping head up8. Try to shop when store is not crowdedStop to scanPlace things on countertop to put them awayFactors Affecting OutcomePhysical co-morbidities especially painPeripheral vs. bilateral vs. centralTime from onsetCognition/behavior/mood/awarenessSymptomatic relapse or slowed recovery due to fatigue/stress/illnessReality of clients everyday lifeCornerstones of TreatmentAssessment and reassessmentTreatment based on symptomsTarget cervicogenic issues and BPPV firstProceed slowlyCompensations make life easier