Vestibular Rehabilitation

by Herdman, Susan J.

• ISBN13: 9780803646247
• ISBN10: 0803646240
• Edition: 1st
• Copyright: 1994-01-01
• Publisher: DAVIS F A COMPANY

Summary

Aimed at physical therapists and students of rehabilitation, this series exposes the reader to today's most challenging concepts in rehabilitation in a problem-solving format. The emphasis is on clinical decision making. The intent of the series is to promote a clear grasp of concepts in clinical practice through an analytical perspective that will complement the academic or workshop presentations in the field of rehabilitation therapy.

Table of Contents

Fundamentals	p. 1
Anatomy and Physiology of the Normal Vestibular System	p. 3
Purpose of the Vestibular System	p. 3
The Peripheral Sensory Apparatus	p. 5
Bony Labyrinth	p. 5
Membranous Labyrinth	p. 6
Hair Cells	p. 6
Vascular Supply	p. 7
Physiology of the Periphery	p. 8
Semicircular Canals	p. 8
Otoliths	p. 10
The Vestibular Nerve	p. 12
Central Processing of Vestibular Input	p. 13
Vestibular Nucleus	p. 13
Vascular Supply	p. 13
Cerebellum	p. 14
Neural Integrator	p. 15
Motor Output of the Vestibular System Neurons	p. 16
Output for the Vestibulo-Ocular Reflex	p. 16
Output for the Vestibulospinal Reflex	p. 16
Vestibular Reflexes	p. 17
The Vestibulo-Ocular Reflex	p. 18
The Vestibulospinal Reflex	p. 18
The Vestibulocollic Reflex	p. 18
Cervical Reflexes	p. 19
The Cervico-Ocular Reflex	p. 19
The Cervicospinal Reflex	p. 19
The Cervicocollic Reflex	p. 19
Visual Reflexes	p. 19
Somatosensory Reflexes	p. 20
Higher-Level Problems in Vestibular Processing	p. 20
Velocity Storage	p. 20
Compensation for Overload	p. 21
Sensor Ambiguity	p. 21
Motion Sickness	p. 22
Repair	p. 22
Summary	p. 23
Role of the Vestibular System in Postural Control	p. 25
Sensing and Perceiving Position and Motion	p. 26
Orienting the Body to Vertical	p. 29
Postural Alignment	p. 29
Selecting Sensory Information	p. 32
Controlling Center of Body Mass	p. 36
Role in Static Positions	p. 37
Role in Automatic Postural Responses	p. 39
Stabilizing the Head	p. 45
Summary	p. 46
Postural Abnormalities in Vestibular Disorders	p. 52
Examining the Vestibulospinal System	p. 53
Advantages and Limitations of Clinical Tests	p. 53
Dynamic Posturography	p. 54
Tests of Quiet Stance	p. 57
Stabilometry	p. 58
Tiltboards	p. 58
Stepping Tests	p. 58
Postural Reactions in Peripheral Vestibular Disorders	p. 59
Deficient Labyrinthine Inputs	p. 59
Indicators of Vestibulospinal Deficiency	p. 60
Indications of Vestibulospinal Distortion	p. 63
Postural Reactions in Central Vestibular Lesions	p. 63
Postural Dysfunction with Pathology of Other Sensory-Motor Centers	p. 64
Mechanisms for Recovery of Postural Stability	p. 66
Sensory Substitution	p. 66
Compensatory Processes	p. 69
Summary	p. 71
Vestibular Adaptation	p. 77
Recalibration, Substitution, and Alternative Strategies	p. 77
Loss of Unilateral Labyrinthine Function	p. 78
Loss of Bilateral Labyrinthine Function	p. 82
Studies of Vestibulo-Ocular Reflex Adaptation in Normal Subjects	p. 84
Imagination and Effort of Spatial Localization in Vestibular Adaptation	p. 85
Context Specificity	p. 86
Neurophysiologic Substrate of Vestibulo-Ocular Reflex Adaptation	p. 87
Summary	p. 87
Vestibular System Disorders	p. 91
Benign Paroxysmal Positional Vertigo	p. 91
Vestibular Neuritis	p. 93
Meniere's Disease and Endolymphatic Hydrops	p. 94
Perilymphatic Fistula	p. 97
Vestibular Paroxysmia (Disabling Positional Vertigo)	p. 98
Bilateral Vestibular Disorders	p. 99
Summary	p. 101
Medical Assessment	p. 103
Quantitative Vestibular Function Tests and the Clinical Examination	p. 105
Clinical Evaluation of Vestibular Patients	p. 106
Dizziness and Vertigo	p. 106
Nystagmus	p. 108
Recording Pathological Nystagmus	p. 112
Characteristics of Different Types of Pathological Nystagmus	p. 115
Quantitative Vestibular Ocular Tests	p. 128
Tests of Visual-Ocular Control	p. 130
Saccadic Eye Movements	p. 131
Smooth Pursuit	p. 134
Optokinetic Nystagmus	p. 135
Test of Vestibulo-Ocular Reflex Function	p. 139
Tests of Visual Vestibular Interaction	p. 159
Subjective Vestibular Tests	p. 165
Clinical Changes in Vestibular Function with Time after Unilateral Vestibular Loss	p. 172
Consequences of Unilateral Vestibular Loss in Humans	p. 172
Static Sensory Components	p. 173
Dynamic Sensory Components	p. 173
Static Motor Components	p. 178
Dynamic Motor Components	p. 181
Summary of Changes in Vestibular Function with Time after Lesions	p. 184
Factors Influencing the Restoration of Static and Dynamic Equilibrium	p. 184
Visual Inputs	p. 185
Vestibular Inputs	p. 185
Proprioceptive Inputs	p. 185
Medications	p. 185
Lesions	p. 186
Chronic Vestibular Insufficiency Following Unilateral Vestibular Loss	p. 186
Neural Activity in the Vestibular Nuclei during Vestibular Compensation	p. 187
Normal Medial Vestibular Nucleus Activity	p. 188
Ipsilesional Medial Vestibular Nucleus Activity	p. 188
Contralesional Medial Vestibular Nucleus Activity	p. 188
Normal Lateral Vestibular Nucleus Activity	p. 190
Ipsilesional Lateral Vestibular Nucleus Activity	p. 190
Contralesional Lateral Vestibular Nucleus Activity	p. 190
Summary	p. 191
Otolith Function Tests	p. 195
Otolith Structure	p. 196
Normal Otolith Function	p. 198
Primary Otolithic Afferents	p. 198
Central Projections	p. 199
Function of Otolithic Input	p. 199
The Subjective Visual Horizontal (or Vertical): A Test of Utricular Function	p. 200
Physiological Background	p. 200
Central Vestibular Lesions and Settings of the Subjective Visual Vertical	p. 202
Vestibular-Evoked Myogenic Potentials: A Test of Saccular Function	p. 204
Physiological Background	p. 204
Method	p. 206
Clinical Applications	p. 206
Case Study	p. 208
Summary	p. 213
Audiological Assessment and Management	p. 215
Audiological Assessment	p. 215
Measurement of Behavioral Hearing Threshold	p. 215
Types of Hearing Loss	p. 217
Speech Audiometry	p. 218
Acoustic Immittance Measurements	p. 219
Auditory Brainstem Response Testing	p. 220
Otoacoustic Emission	p. 225
Management of Hearing Impairment	p. 225
Hearing Aids	p. 226
Aural Rehabilitation	p. 227
Cochlear Implants	p. 228
Auditory Training	p. 230
Summary	p. 231
Medical Management	p. 235
Pharmacological and Optical Methods of Treating Vestibular Disorders and Nystagmus	p. 237
Vertigo	p. 239
Pathophysiology	p. 239
Neuropharmacology of Vertigo and Nystagmus	p. 239
Treatment	p. 240
Oscillopsia	p. 242
Pathogenesis	p. 242
Treatment	p. 244
Nystagmus and Its Visual Consequences	p. 244
Pathogenesis	p. 244
Treatments	p. 244
Summary	p. 248
Surgical Management of Vestibular Disorders	p. 251
Acoustic Neuromas (Vestibular Schwannoma)	p. 251
Middle Cranial Fossa	p. 252
Translabyrinthine Approach	p. 253
Suboccipital Craniectomy	p. 254
Meniere's Disease	p. 256
Post-Traumatic Vertigo	p. 259
Benign Paroxysmal Positional Vertigo	p. 259
Perilymph Fistula	p. 260
Vascular Loops	p. 261
Summary	p. 262
Assessment and Management of Central Vestibular Disorders	p. 264
Clinical Classification of Central Vestibular Disorders	p. 265
Vestibular Disorders in (Frontal) Roll Plane	p. 269
Etiology	p. 274
Natural Course and Management	p. 275
Thalamic and Cortical Astasia Associated with Subjective Visual Vertical Tilts	p. 276
Torsional Nystagmus	p. 277
Vestibular Disorders in (Sagittal) Pitch Plane	p. 278
Upbeat Nystagmus (Vestibular Upbeat Syndrome)	p. 281
Vestibular Disorders in (Horizontal) Yaw Plane	p. 284
Vestibular Cortex: Locations, Functions, and Disorders	p. 285
The Parietoinsular Vestibular Cortex	p. 286
Multimodal Sensorimotor Vestibular Cortex Function and Dysfunction	p. 286
Spatial Hemineglect, a Cortical Vestibular Syndrome?	p. 287
Paroxysmal Room-Tilt Illusion	p. 288
Vestibular Epilepsy	p. 288
Paroxysmal Central Vertigo	p. 289
Summary	p. 292
Diagnosis and Management of Neuro-Otological Disorders Due to Migraine	p. 298
Incidence	p. 298
Classification and Criteria for Diagnosis	p. 299
Migraine without Aura	p. 300
Migraine with Aura	p. 300
Childhood Periodic Syndromes	p. 301
Migrainous Infarction	p. 301
Neuro-Otological Syndromes	p. 301
Disorders Due to Migraine	p. 302
Disorders Associated with Migraine	p. 303
Pathophysiology	p. 304
Neurochemical Mechanism	p. 304
Genetics	p. 304
Management	p. 305
Reduction of Risk Factors	p. 305
Medications	p. 308
Case Examples	p. 310
Summary	p. 313
Patient Information	p. 313
Psychological Problems and the Dizzy Patient	p. 316
Prevalence	p. 316
Psychological Problems in Patients with Dizziness	p. 316
Dizziness in Patients with Psychological Disorders	p. 317
Disability	p. 318
Psychological Disorders	p. 318
Anxiety	p. 318
Somatoform Disorders	p. 319
Factitious Disorders	p. 319
Malingering	p. 320
Phobic Postural Vertigo	p. 320
Mal de Debarquement Syndrome	p. 320
Assessment	p. 320
History	p. 320
Examinations for Psychogenic Stance and Gait Disorders	p. 323
Management	p. 324
Longitudinal Studies	p. 325
Case Studies	p. 325
Summary	p. 328
Rehabilitation Assessment and Management	p. 331
Physical Therapy Assessment of Vestibular Hypofunction	p. 333
Functional Deficits	p. 333
Vestibulo-Ocular Dysfunction	p. 334
Motion-Induced Disequilibrium	p. 334
Postural Instability	p. 335
Physical Deconditioning	p. 335
Physical Therapy Evaluation	p. 336
History	p. 336
Clinical Examination	p. 339
Balance Assessment	p. 346
Gait Evaluation	p. 353
Transition from Assessment to Treatment	p. 359
Summary	p. 360
Disability in Vestibular Disorders	p. 373
Taxonomies of Disablement	p. 374
World Health Organization System	p. 374
National Institutes of Health Taxonomy	p. 376
Functional Limitations and Disability in Activities of Daily Living	p. 377
Assessments	p. 377
Self-Care Tasks	p. 378
Instrumental Tasks	p. 379
Mobility Skills	p. 379
Psychosocial Consequences	p. 380
Diagnosis-Specific Problems	p. 381
Effects of Vestibular Rehabilitation	p. 384
Summary	p. 384
Treatment of Vestibular Hypofunction	p. 387
Mechanisms of Recovery	p. 387
Cellular Recovery	p. 387
Spontaneous Recovery	p. 388
Vestibular Adaptation	p. 388
Substitution	p. 389
Habituation	p. 391
Evidence that Exercise Facilitates Recovery	p. 392
Predictors of Outcome	p. 393
Goals of Treatment	p. 394
Is Recovery Maintained after the Exercises Are Stopped?	p. 394
Treatment Approaches	p. 394
Adaptation	p. 394
Substitution	p. 397
Cawthorne-Cooksey Exercises	p. 397
Habituation Exercises	p. 399
Expectations for Recovery	p. 400
Treatment	p. 401
General Considerations	p. 401
Problem-Oriented Approach	p. 402
Problem: Visual Blurring and Dizziness When Performing Tasks that Require Visual Tracking or Head Stabilization	p. 403
Problem: Exacerbation of Symptoms	p. 405
Problem: Static and Dynamic Postural Instability	p. 405
Progression of Balance and Gait Exercises	p. 409
Problem: Physical Deconditioning	p. 409
Problem: Return to Driving	p. 411
Summary	p. 411
Case Studies	p. 411
Assessment and Treatment of Complete Vestibular Loss	p. 424
Primary Complaints	p. 424
Balance	p. 424
Oscillopsia	p. 425
Sense of Disequilibrium or Dizziness	p. 425
Physical Deconditioning	p. 425
Assessment	p. 426
History	p. 427
Subjective Complaints	p. 428
Vestibular Function	p. 428
Visual System	p. 428
Somatosensory System	p. 429
Balance and Gait	p. 429
Mechanisms of Recovery	p. 431
Gaze Stability	p. 432
Postural Stability	p. 433
Compensatory Strategies	p. 433
Evidence that Exercise Facilitates Recovery	p. 434
Treatment	p. 434
Progression of Exercises	p. 438
Guidelines to Treatment and Prognosis	p. 438
Summary	p. 440
Case Studies	p. 440
Assessment and Treatment of Patients with Benign Paroxysmal Positional Vertigo	p. 451
Characteristics and History	p. 451
Mechanism	p. 452
Canal Involvement	p. 454
Diagnosis	p. 454
Treatment	p. 459
Canalith Repositioning Treatment: Posterior and Anterior Canal Canalithiasis	p. 459
Canalith Repositioning Treatment: Horizontal Canal Canalithiasis	p. 462
Liberatory Maneuver: Posterior Canal	p. 463
Brandt-Daroff Habituation Exercises: Posterior Canal Cupulolithiasis	p. 465
Treatment Guidelines	p. 466
Postural Disturbances	p. 468
Management	p. 469
Conclusion	p. 470
Case Studies	p. 471
Vestibular Rehabilitation of the Patient with Traumatic Brain Injury	p. 476
Vestibular Pathology	p. 477
Concussion	p. 477
Fractures	p. 477
Intracranial Pressure and Hemorrhagic Lesions	p. 478
Central Vestibular Lesions	p. 478
Vestibular Rehabilitation	p. 478
Vertigo	p. 479
Eye-Head Coordination	p. 480
Postural Control Underlying Stability	p. 481
Time Course for Recovery	p. 488
Case Study	p. 489
Summary	p. 490
Cervical Vertigo	p. 494
Posterior Cervical Sympathetic Syndrome	p. 494
Vertebrobasilar Insufficiency	p. 495
Altered Proprioceptive Signals	p. 495
Anatomy and Physiology	p. 496
Findings Following Cervical Spine Lesions	p. 497
Examination and Treatment	p. 502
Conclusion	p. 505
Case Study	p. 505
Management of the Elderly Person with Vestibular Dysfunction	p. 510
Vestibular Function	p. 510
Semicircular Canal Function	p. 511
Utricular and Saccular Function	p. 511
Vestibular Function Tests	p. 512
Visual Deficits	p. 512
Somatosensory Changes	p. 515
Musculoskeletal Deficits	p. 516
Postural Hypotension	p. 516
Cerebellar Atrophy	p. 516
Fear of Falling	p. 516
Attention	p. 517
Depression	p. 517
Risk of Falling in Older Adults with Vestibular Disorders	p. 517
Questionnaires for Balance Assessment	p. 522
Dizziness Assessment	p. 525
Typical Balance Tests	p. 525
Home Assessment	p. 526
Length of Treatment	p. 526
What To Do Once the Risk Factor Has Been Identified	p. 526
Case Studies	p. 527
Summary	p. 531
Treatment of Patients with Nonvestibular Dizziness and Disequilibrium	p. 534
Patient Identification	p. 535
Ruling Out a Vestibular Problem	p. 535
Nonvestibular Dizziness	p. 535
Treatment Program for Patients with Nonvestibular Dizziness	p. 536
Outcome Measures	p. 537
Diagnostic Categories and Results	p. 538
Mal de Debarquement	p. 538
Migraine	p. 540
Disequilibrium Associated with Aging	p. 540
All Test Findings Normal	p. 541
Primary Anxiety and Panic	p. 541
Central Nervous System Lesions	p. 542
Summary	p. 543
Evaluation and Treatment of Vestibular and Postural Control Deficits in Children	p. 545
Incidence of Vestibular Deficits in Children	p. 546
Development of Postural and Oculomotor Control as They Relate to Vestibular System Function	p. 549
Evaluation	p. 551
Treatment	p. 558
Peripheral Disorders	p. 558
Central Vestibular and Postural Control Deficits	p. 558
Case Studies	p. 559
Summary	p. 562
Physical Therapy Diagnosis for Vestibular Disorders	p. 566
History	p. 566
Clinical Examination	p. 567
Diagnostic Flowchart	p. 567
Identification of Modifiers	p. 569
Summary	p. 570
Index	p. 573
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