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ENT
Vestibular Rehabilitation
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
7 sections · 121 slides
Overview
- Scope of vestibular rehabilitation
- Evidence for vestibular rehabilitation
Physiologic basis for vestibular rehabilitation
- Site of peripheral vestibular loss
- Vestibular compensation
- Four stages of vestibular compensation
- Unilateral vestibular deafferentation
- Characteristic clinical symptoms associated with unilateral vestibular deafferentation (uVD), including the typical pattern of sudden onset vertigo, early spontaneous episodes, and progression to head-motion– provoked symptoms during central compensation
- Static compensation: the initial asymmetry
- Primary afferent firing rate after acute right-sided loss
- Cerebellar clamping
- Restoring the resting rate at the vestibular nuclei
- Time course of static compensation
- Requirements and endpoint of static compensation
- Dynamic compensation
- Drivers and determinants of dynamic compensation
- Mechanisms facilitating dynamic compensation
- Vestibular adaptation
- Retinal slip and oscillopsia
- Context dependence of adaptation
- Vestibular habituation
- Habituation in PPPD and in fluctuating lesions
- Sensory substitution
- Maladaptive sensory substitution
Factors influencing vestibular compensation
- Site of lesion and compensation efficiency
- Test before destructive procedures
- Activity level after vestibular injury
- Psychological comorbidity and recovery
- Vestibular suppressant medication
- Guideline position on suppressant withdrawal
- Decompensation and relapse
- Core requirements for successful compensation
Evaluating the state of vestibular compensation
- History of the dizzy patient
- Predisposing factors to document
- Irritative versus stable lesions
- Purposes of vestibular function testing
- Limits of the vestibular test battery
- Tests informing the compensation picture
- Videonystagmography and the caloric test
- Weaknesses of the caloric test
- Rotational chair testing
- Video head impulse test technique
- Overt and covert saccades
- How covert saccades reduce retinal slip
- Implication for the rehabilitation target
- Vestibular evoked myogenic potentials
- Otolith organs and their orientation in the head
- Cervical and ocular VEMP pathways
- Otolith dysfunction and rehabilitation outcome
- Computerised dynamic posturography
- Six sensory conditions of the sensory organization test
- Timing limitations of posturography
- Dynamic visual acuity testing
- Dynamic visual acuity and fall prediction
- Gaze stabilization test
- Role of testing in planning therapy
Choosing appropriate candidates for therapy
- BPPV as the first-line indication
- Evolution of BPPV pathophysiology and treatment
- Left posterior canal BPPV and its ocular connections
- Left horizontal canal canalithiasis and its ocular connections
- Left superior canal BPPV and its ocular connections
- Canalith repositioning manoeuvre
- Liberatory and Brandt-Daroff approaches
- Candidacy in peripheral vestibular hypofunction
- Medication policy in candidates for therapy
- Rehabilitation around ablative vestibular procedures
- Expected course after a destructive procedure
- Goals of the acute post-ablative program
- Preoperative education before ablation
- Meniere disease and vestibular rehabilitation
- Rehabilitation alongside medical treatment of Meniere disease
- Rehabilitation after chemical and surgical ablation in Meniere disease
- Traumatic brain injury and concussion
- Assessment and therapy in head-injured patients
- Persistent postural-perceptual dizziness
- Vestibular rehabilitation as a therapeutic trial
- Decompensation after a definitive procedure
- Patients for whom rehabilitation is inappropriate
- Tests do not select candidates for therapy
Functional and self-report outcome measures
- Consequences of uncompensated hypofunction
- Validated physical performance measures
- Commonly used functional balance and gait outcome measures in patients with vestibular and balance dysfunction, including descriptions of each assessment and clinically relevant scoring thresholds associated with fall risk
- Commonly used functional balance and gait outcome measures in patients with vestibular and balance dysfunction, including descriptions of each assessment and clinically relevant scoring thresholds associated with fall risk (continued)
- Rationale for self-report outcome measures
- Dizziness Handicap Inventory
- Dizziness Handicap Inventory score bands
- Activities-specific Balance Confidence scale
Core vestibular rehabilitation exercises
- Building a personalised exercise program
- Common vestibular disorders and functional impairments with corresponding core vestibular rehabilitation strategies, including repositioning maneuvers, gaze stabilization exercises, balance training, and habituation exercises
- Basis of gaze stabilization exercises
- Gaze stabilization exercise with a handheld target
- VORx1 and VORx2 paradigms
- Substitution exercises and progression
- Optokinetic stimulation
- Habituation exercises in practice
- Dosing and counselling for habituation
- Limits of habituation
- Postural control exercises
- Sensory reweighting and balance progression
- Gait exercises
- Progression of gait challenges
- Conditioning and maintenance activities
- Choosing a maintenance activity
- Summary of vestibular rehabilitation
- References
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- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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