Vestibular Dysfunction, Cervicogenic

Dizziness and Sensory Processing

Issues
Susan Martin White, PT

Is the NeoCortex Essentially

Multisensory?
Trends in Cognitive Sciences June 2006
Asif A. Ghazanfar & Charles E. Schroeder
Program in Neuroscience, Department of Psychology, Princeton
University
Cognitive Neurosciences Schizophrenia Program,
Nathan S. Kline Institute for Psychiatric Research

Function of the Vestibular System

Stabilize gaze
Balance
Orientation to movement of self vs.
environment

Role of Vestibular System

Function
Gaze stabilization
Balance

Awareness of
movement
(self/environment)

Sensory Inputs
Vision
Vestibular
Vision
Vestibular
Somatosensory
Vision
Vestibular
Somatosensory
Auditory
Olfactory

Proprioception/Ki
nesthia
Tactile/Pressure

Peripheral System

Effects of Head Rotation on Canals

Otolithic Macula

Peripheral System
Semicircular Canals Angular rotation
Horizontal
Anterior
Posterior

Otoliths Linear motion and Head tilt

Saccule
Utricle

, OTR

Peripheral 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 disease

Benign Paroxysmal Positional Vertigo

Central System
Cerebellum
Brainstem
Cerebral Cortex

Vestibular cortex
Parietal
Temporal
Frontal

Central System

Interaction of Self With 3-D Space

3-D Spatial Interactions

Space

Distance

Sensory Inputs

Function

Peripersonal

0-2m
Central 60

Visual
Somatosensory
Vestibular

Visual graphing
Manipulation

Extrapersonal
(focal)

2m- 6m
Central 20-30

Visual
(Vestibular VOR)

Visual search
Object/face
recognition

Extrapersonal
(action)

2m- 30m
Full 360

Visual
Auditory/Olfactory
(Vestibular)

Navigation
Scene memory
Target orient.

Extrapersonal
(ambient)

Distant
Front 180

Visual
Somatosensory
Vestibular

Spatial orient.
Postural control
Locomotion

Central Lesions
Cerebellum
Brainstem
Cerebral Cortex (Vestibular Cortex)
Parietal
Temporal
Frontal

Areas of central compensation for past peripheral lesions

Common Symptoms
Dizziness, vertigo, light-headedness
Blurred vision, oscillopsia
Disequilibrium/imbalance
Spatial disorientation
Nausea
Sensitivity to environmental stimuli (lights, noise,
crowds, motion, visual complexity)
Hearing loss, tinnitus

Associated 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 organization

Vestibular Function Tests

Test

What it Does

Assesses

ENG

Records eye
movement

Oculomotor
function

Calorics

Test VOR thru

involuntary
responses

Function of SCC &

part of s. vestibular
nerve

Rotary chair

Test VOR thru

involuntary
responses

Function of SCC &

part of s. vestibular
nerve and central
compensation

Test
Posturagraphy

What it Does

Assesses

Tests postural sway

and autonomic
postural responses
under different
visual and
somatosensory
conditions

Interaction of
visual, vestibular
and somatosensory
inputs and motor
output in stance

Vestibular Diagnosis
Different Perspectives
Vestibular Specialists
- ENTs, Vestibular Neurologists
look for site specific lesions generally in peripheral areas or
areas involved in vestibular reflex pathways

Acquired Brain Injury

- TBI Specialists
tend to look at impairments in function that the vestibular
system is involved in, i.e. gaze stability, balance, awareness of
motion of self/environment

Inclusion into VBRT

Vestibular and balance rehab programs are
symptom driven
Development of treatment plans are not specific
to the site of lesion
Clinical therapy exam determines the treatment
plan

Connection 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 agoraphobia

Clinical Diagnosis
Vestibular oculomotor dysfunction
BPPV
Motion sensitivity
Decreased integration of sensory inputs necessary
for balance and awareness of motion in space
Decreased ROM/strength/coordination of motor
outputs necessary for balance reactions
Cervicogenic factors

Cervicogenic Dizziness
Role of cervical reflexes
Role of vestibulocollic reflexes
stabilizes the head
dysfunction may cause cervical ataxia
Possible cause Inaccurate somatosensory inputs
from neck disrupts the normal interaction
between visual/vestibular and somatosensory
inputs

Cervicogenic 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 joints
in cervical area
Provocation of dizziness w/increased cervical pain
Provocation of dizziness w/body on head rotation

Treatment of Cervicogenic Dizziness

Manual therapy
Stretching
Stabilization and Strengthening
Postural Re-education
Vestibular therapy

Treatment of BPPV
Canalithiasis vs. Cupulothiasis
Posterior
Anterior
Horizontal

Treatment
Spontaneous Recovery
Reoccurrence

Vestibular-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 exercises
Repetitions, rates, ROM, complexity of visual
backgrounds, standing/gait

Motion Sensitivity
Mismatch of sensory inputs results in symptoms
provoked by body movement/position
Motion Sensitivity Test
Treatment Habituation Exercises

Balance
Decreased integration of sensory inputs necessary
for motor outputs
Rule out ROM, strength/coordination
Tests BERG, DGI, modified CTSIB, Fukuda
Treatment EO/EC, varied BOS, varied surfaces,
balance strategies, limits of stability,
static/dynamic balance and gait

Integration/Putting It All Together

Combine:
Vestibular ocular movements
Head motion
Balance postures and walking
Varied surfaces
Visual complexity
Cognitive tasks
Auditory inputs
Light

Compensatory Strategies
Earplugs
Glasses
Dynamic foot plates / Foot orthotics
Slowed transitional movements
Rest periods
Relaxation techniques
Pacing / structured schedule

Top 8 Strategies for Vestibular

Multisensory Symptoms
1. Sit to have conversations or think
Dont stand unless you have to
Try not to walk and talk or think at the same time about
something important

2. Sit facing the least stimulating background

Dont sit in middle of a group

3. Use breaks between activities. Plan rest times

daily. Use relaxation techniques.
4. Try to keep focused on one thing at a time

Top 8 Strategies for Vestibular

Multisensory Symptoms
5. Use isometrics to keep head aligned
6. Keep body still. Move slowly
Keep chin tucked
Keep good posture when you can

7. Bend down keeping head up

8. Try to shop when store is not crowded
Stop to scan
Place things on countertop to put them away

Factors Affecting Outcome

Physical co-morbidities especially pain
Peripheral vs. bilateral vs. central
Time from onset
Cognition/behavior/mood/awareness
Symptomatic relapse or slowed recovery due to
fatigue/stress/illness
Reality of clients everyday life

Cornerstones of Treatment
Assessment and reassessment
Treatment based on symptoms
Target cervicogenic issues and BPPV first
Proceed slowly
Compensations make life easier