PhTh 7210

Contemporary Techniques in Physical Therapy: Vestibular Rehabilitation Component

Background and Objectives

The basis for the class is going to be clinical decision making in the context of complaints of dizziness and imbalance. This course operates on the assumption that vestibular deficits are the source of many problems with balance and falls regardless of the population being treated.

Our goal for the weekend is not to make you specialist providers of vestibular rehabilitation, but rather to provide you with tools that should improve your ability to examine and treat with potential vestibular abnormalities in your practice area. To accomplish this goal, we will utilize a decision-making algorithm that is derived from the Vestibular Rehabilitation Textbook written by Susan Herdman with input from Janene Holmberg, PT, NCS. You will find this clinical decision making algorithm on a subsequent page of the syllabus.

Textbook: Vestibular Rehabilitation 3rd. Edition. Susan J Herdman. FA Davis Publishers, ISBN number: 0-8036-1376-8, 2007

Tasks before class

Before the weekend we would like you to review the decision making algorithm, the attached power point presentations and skim through the text. (Chapters listed below). We expect that a smaller portion of the course will be lecture and more will be laboratory based.

Relevant Readings

  • Chapter 1: Anatomy and Physiology of the Normal Vestibular System Chapter 3: Role of the Vestibular System in Postural Control
  • Chapter 17: Physical Therapy Management of BPV
  • Chapter 19: Physical Therapy Assessment of Vestibular Hypofunction
  • Chapter 20: Interventions for the patient with Vestibular Hypofunction

There are several other chapters that are useful for those working in specialty areas of practice but will not be covered specifically:

  • Neurologic Rehabilitation Practice: Chapters 26
  • Orthopedic Practice: Chapter 29
  • Geriatric Practice: Chapter 23
  • Pediatric Practice: Chapter 22

Completion of this portion of the course (and passing) will be determined by two things

  1. Competency testing of examination and treatment techniques during the weekend. (see the attached competency check off)
  2. Submission of a clinical case report before the end of the semester (see syllabus for the description)

Schedule

TBD

Glossary of Vestibular Terms

Ampulla
Swelling on one end of the semi-circular canal. Houses the sensory structure responsible for transducing angular acceleration.
Common Crus
Connection of the anterior and posterior semicircular canals that empties into the utricle.
Cupula / Christae
Sensory structure that lies within the ampulla of the semicircular canal. Involved in sensing angular acceleration.
Endolymphatic sac
Structure that absorbs endolymph. In Meniere’s disease, endolymph is not absorbed well and one surgical treatment is to permanently insert a tube into the sac to facilitate drainage (endolymphatic shunt).
Ewald’s second law
Depolarization (excitation) of the cupula within the inner ear does not saturate whereas hyperpolarization (inhibition) does saturate.
Fukuda stepping test
Patient marches in place with eyes closed for 50 steps, Rotation of more than 30 degrees or translation of more than 3 feet is considered abnormal (possible vestibulospinal abnormality).
Gain
Slow phase eye velocity/head velocity. Normal value is 1.0. Low gain <1.0, high gain >1.0.
Habituation
Response decline that persists over time induced by a repeated stimulus.
Head shaking nystagmus test
Clinical test in which a patient’s head is oscillated horizontally twenty times in 2Hz. If this elicits significant horizontal nystagmus (>3quick phases), or if it clearly increases spontaneous nystagmus, it is considered positive. Its presence suggests vestibular asymmetry (different gain) between the two horizontal SCC.
Head thrust test
Clinical test in which patient is told to fixate a stationary target while their head is moved short amplitude but very quickly horizontally. If this elicits a corrective saccade at the end of the head movement, it is considered positive. Its presence suggests a decrease in VOR gain.
Labyrinth
Inner ear divided into membranous and bony parts
Linear acceleration
Change in velocity along a straight path (vertical or horizontal) sensed by the otoliths of the inner ear.
Maculae
Sensory structure including hair cells that senses linear movement within utricle and saccule. Otoconia sits on top of the maculae.
Mal de debarquement
Perception of rocking as if on a boat (sea legs) that persists after debarking from prolonged passive transportation (sea cruise, train, plane).
Membranous labyrinth
Structure suspended within bony labyrinth by fluid and supportive connective tissue. Membranous labyrinth contains the membranous portion of the 3 semicircular canals, the utricle and saccule. It is filled with endolymph.
Meniere's disease
Problem in absorption of endolymph into the endolymphatic sac of unknown etiology.
Nystagmus
A non-voluntary rhythmic oscillation of the eyes. It is characterized by fast and slow components beating in the opposite directions. The convention is to name the direction by the fast phase. It can be a normal response to stimuli such as head rotation or visual stimulation or pathologic in response to altered vestibular function.
Oscillopsia
False illusion of movement of environment. Subtypes include head-induced in patients with severe vestibular hypofunction when they move their head, and spontaneous in patients with spontaneous, acquired nystagmus.
Otoconia
Structure in the inner ear. Calcium carbonate crystals in utricle and saccule.
Otoliths
Structures with in the inner ear that sense linear acceleration (utricle and saccule).
Perilymph
Type of fluid in inner ear(high sodium, low potassium similar to extracellular fluid in rest of body).
Saccadic eye movement
Eye movement used to quickly move eye.
Saccule
Otolith structure in the inner ear that detects vertical translation motion of head.
Semicircular canals (anterior or superior: posterior or inferior, horizontal or lateral)
Structure in inner ear. Fluid loops responsible for measuring angular acceleration.
Smooth pursuit eye movement
Eye movement used to track small moving targets.
Utricle
Otolith structure in inner ear that detects horizontal translation and tilt of head.
Velocity storage
Neural circuit in dorsal medulla that stores head velocity neural signal for up to 90 seconds.
Vertigo
Sensation of motion of self or environment (rotation, translation, or tilt.)
Vestibular ocular reflex
Movement of eyes opposite to movement of head. Useful during head movements to stabilize gaze.
VOR cancellation
movement of eyes that suppresses VOR. I\Useful when trying to follow target that is moving synchronously with head.