VESTIBULAR

REHABILITATION
DR.RAMESH NATRAYAN
ASSOCIATE PROFESSOR
CUSPC
THREE COMMON VESTIBULAR DIAGNOSIS –
MOSTLY 80%

LABYRIN
BPPV
THITIS

MINIERE’S
DIESEASE
Histor
Is it
episodic

Duration

y of the
spell
True
vertigo
Number
of times it
occurs

Triggering
events
Episodic Vertigo
True vertigo is
associated with
 Associated
with
Episodic positional ?BPPV
movement
s
Diving incident/ loud pop

Episodic vertigo

Associated hearing loss

Baro trauma/perilymphatic
fistula
 Superior
canal
Exposure dehiscence
Leads to
to loud /low
frequency
vertigo
noise
conductive
hearing loss
THE MOST COMMON DISORDER
WITH EPISODIC VERTIGO IS
MENIERE’S DISEASE.
Vertiginous
Hearing loss episode

Meniere’s
disease
Aural
fullness Tinitus

True Meniere’s consists of four

separate symptoms
 Examination
of the Vestibular
 FUNCTIONAL BALANCE

Vestibular

Visual

Proprioceptive

Abnormalities in any one of these can result

in the
 EXAMINATION OF THREE
SYSTEMS

OTOLARYNGOLOGI
C OTOLOGIC

NEUROLOGIC NEUROTOLOGIC

12
Neurologic Examination
 Occulomotor nerve
Examination

Saccadic eye movements

 saccadic
abnormalities
assessment

Slow saccads –
Velocity
brainstem lesion

Inaccurate or dysmetric
Accuracy
– cerebellar

Initiation late –
Initiation time parkinson’s and
hungtinton
 Ocular flutter and opsoclonus are
rapid saccadic to-and-fro movements
of the eye without a normal
intersaccadic interval in the horizontal
plane and multidirectional movement,
respectively.

The causes of ocular flutter and

opsoclonus include structural lesions
of the pons or cerebellum, viral
encephalitis, paraneoplastic
Pursuit eye movements
Gaze evoked Nystagmus
 Jerk nystagmus has a slow
component due to vestibular input
signals and a fast component that
resets the eye back to the center of
the orbit.

Although the direction of the

slow component is more clinically
useful, nystagmus is described in
the direction of the fast component
Misalignment of the visual axes,
such as with strabismus, may
produce complaints similar to
those of a vestibular disorder.

Misalignment of the visual axis is

not an abnormality of the
vestibular system
Skew deviation has been reported mostly
commonly in association with brainstem or
cerebellar lesions, and also can be due to
imbalances along peripheral or central pathways
 Romberg test

Romberg testing evaluates the

patient’s use of visual, vestibular, and
proprioceptive cues to maintain
balance.
Romberg test
Romberg test
 GAIT ASSESSMENT
PATH
BASE OF SWAY
SUPPORT

OVERALL
AMBULATIO ASSESSMEN
N WITH T
HEAD
TURNS

26
Base of
Path Ambulation Gait
suppor with head
t
sway turns quality

Drift in the Step length

Normal – 4 Walk on 12 direction
inches inch path they are
looking Stride
length

Sway Signs of
Wider BOS Patient may foot scuffing
indicate
- Bilateral avoid
unilateral
vestibular turning
vestibular
loss their head Posture
loss
Otologic Examination
The pneumatic otoscope should
be used to confirm normal tympanic
membrane mobility and to elicit
signs or symptoms of vestibular
sensitivity to pressure.
Pressure-induced eye symptoms,
such as nystagmus, may point
toward a perilymph fistula or
superior semicircular canal
dehiscence.
Weber test
Neurotologic
Examination
 Nystagmus with Post head
eyes open in shaking
dark

Bedside VOR Dynamic

test visual acuity

Dix
hallpike Romberg
test test

NEUROTOLOGIC EXAMINATION
Dix-Hallpikes Test
This test is performed by rotating
the patient’s head 30° to 45° to
the testing side followed by a
rapid placement into a supine
position
The characteristic nystagmus with
BPPV has a short latency followed
by an upbeat and torsional
nystagmus that generally lasts less
than 1 minute.
Post Head Shaking test
Rapid horizontal head
movements for 30 seconds
followed by an abrupt stop. It
can help detect unilateral
vestibular weakness.

Not reliable for central

vestibular abnormalities.
Vibration Induced
Nystagmus
 Vibration stimulates the
labyrinths bilaterally, with the
asymmetry in those with unilateral
vestibular damage resulting in
nystagmus with the slow phase
directed toward the side of the
lesion.

Vibratory stimulation is a reliable

and easily administered bedside test
 Head Thrust or
Head Impulse test
The head thrust or head impulse
test is used to determine whether
the VOR is adequate to maintain
gaze stabilization during brisk head
movements

Unilateral vestibular loss will have a

refixation saccade to the target
Dynamic illegible E test
After visual acuity has been
established, the patient rotates the
head 60° in both directions at a
frequency of 1 to 2 Hz.

Normal - decrease in around 1 line.

Unilateral weakness - decrease in 3 to

4 Lines

bilateral weakness - decrease of 5 to 6

 Computerized Testing of the
Vestibular Patient

No single Battery of test

diagnostic test needed for
for dizziness diagnosis
Diagnosis not
Computerized evident from
testing is not history or bedside
indicated for all testing
dizzy patients

46
 Computerized Testing of the
Vestibular Patient

SITE OF
ABNORMAL PATHOLOGY

PERIPHERAL CENTRAL

UNILATERAL BILATERAL
 COMPUTERIZED
VESTIBULAR TEST

VESTIBULAR
HSCC PSCC ASCC OTOLITHS
NERVE
 Posturography

Videonystagmograph Rotational chair test

y(VNG) (RCT)

Bithermal caloric Vestibular evoked

test(BCT) potential (VEMP)

Sinusoidal Video head

hormonic impulse test
acceleration
COMPUTERIZED VESTIBULAR
49
TEST
Videonystagmography(V
NG)
The VOR functions to create compensatory eye
movements that are equal to, but opposite to,
head
movement, to maintain a steady visual image.
 VNG fall into three
categories
03 Positional
Testing
Occulomot 01
or Testing
BCT
02

51
Benign Paroxysmal
Positional
In 1952, Dix and Hallpike described the
characteristic
ipsidirectional torsional nystagmus provoked
by the head maneuver they developed to
identify
BPPV.4
Approximately 94% of BPPV cases involve the
posterior
semicircular canal.6 Lateral (horizontal)
semicircular
canal (LSC) involvement is the next most
common