Back To Chiropractic CE Seminars Neurology: The Dizzy Patient ~ Advanced ~ 6 Hours

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By: Larry E. Masula, D.C., DACNB, FAVRB, FAFICC Dipolmate American Chiropractic Neurology Board, Fellow American Vestibular Rehabilitation Board, Fellow Academy of Forensic and Industrial Chiropractic Consultants [email protected]

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 3 Larry E. Masula, DC, DACNB, FABVR, FAFICC

 Carrick Institute for Advanced Neurological Studies: Frederick C. Carrick, PhD, Cambridge University.  Diplomate American Chiropractic Neurology Board  Fellow American Board of Vestibular Rehabilitation  Fellow Academy of Forensic and Industrial Chiropractic Consultants

 Evaluation and Management of Dizziness and Balance Disorders, Neil T. Shepard , PhD, director of the Dizziness and Balance Disorders Program at the Mayo Clinic, Rochester, Minnesota, and professor of audiology in the Mayo Clinical School of Medicine. Joel A. Goebel, M.D., FACS. Director, Dizziness and Balance Center Washington University School of Medicine, St. Louis, MO

 American Institute of Continuing Medical Education, Certified in 101 Vestibular Rehabilitation, 201 Ocular Motor Testing, 202 Gaze, Headshake and Positional Testing. Richard E. Gans, PhD., Executive Director American Institute of Balance

Larry E. Masula, D.C, DACNB.FABVR, FAFICC 2/1/2020 4 Objectives

▪ General overview of the clinical anatomy and physiology of the vestibular system and posterior fossa (cavity) will be discussed with emphasis on diagnostics and chiropractic management.

Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 5 Recommended Reading ▪ Clinical Neurophysiology of the Vestibular System, Edition 2, Robert W. Baloh, Vicente Honrubia. Chapters 1-3 ▪ Principles of Neural Science, 4th Edition, Eric R. Kandel, James H. Schwartz, Thomas M. Jessel, McGraw-Hill. Chapter 42: The Cerebellum ▪ Technique of the Neurological Examination, 4th Edition, DeMeyer, W. McGraw-Hill. Chapter 8: Examination of Cerebellar Dysfunction ▪ Neurological Differential Diagnosis, 2nd Edition, John Patten, Springer 1996. Chapter 12: The Extrapyramidal System and the Cerebellum ▪ The Neurology of Eye Movements, 3rd edition, Leigh & Zee ▪ The Brain That Changes Itself, Norman Doidge, M.D. ▪ Vestibular Rehabilitation, 4th Edition, Susan J. Herdman, Richard A. Clendaniel

Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 6 IRISIS 1889

Larry E. Masula, D.C, DACNB, FABVR FAFICC 7 Almond Blossoms 1890

Larry E. Masula, D.C, DACNB, FABVR FAFICC 2/1/2020 8 At Eternity’s Gate 1890

Larry E. Masula, D.C, DACNB, FABVR, FAFICC 2/1/2020 9 The Church at Auvers 1890

Larry E. Masula, D.C, DACNB, FABVR, FAFICC 2/1/2020 10 Prisoners Exercising 1890

Larry E. Masula, D.C, DACNB, FABVR, FAFICC 2/1/2020 11 Can You Find a Common Theme Among These 5 Paintings

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 12 Can You Find a Common Theme Among These 5 Paintings ▪ 1. Yes, they have been painted by the same artist ▪ 2. Yes, they are all roughly painted within one year ▪ 3. Yes, the artist may well have had a disturbance of spatial orientation (vertigo). Why? Much of the paintings are leaning to the left. ▪ 4. If so, on which side is the artist’s problem? ▪ 5. What are the possible causes?

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 13 Answer: The left vestibular system was most likely affected and may have failed.

Explanation: Due to the length of time, based on the painting dates, (over a year) it was no longer an acute problem. We will discuss the various problems which affect our sense of spatial awareness. We will also discuss why in this case; the left vestibular apparatus was no longer being inhibited by the right and why the left vestibular system appeared overly active.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 14 Who is the Artist?

Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 15 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 16 On the Verge of Insanity

Vincent cut off his left ear on December 23, 1888 after being upset with a fellow painter. It was the first of several serious breakdowns that plagued him until his tragic suicide a year and a half later. We don’t know precisely what his illness was, but it had a huge impact on his life.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 17 January 28, 1889 Van Gogh’s - Letter to his brother Theo from Arles, France

“I well knew that one could break one’s arms and legs before, and that then afterwards that could get better but I didn’t know that one could break one’s brain and that afterwards that got better too.”

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 18 Because ▪ Patient Care and Safety are Preeminent ▪ Develop Improved Diagnostic Skills ▪ There is a Great Need for Skilled Practioners ▪ (9.47%) 31 million Americans experience Lower back pain at any given time. www.acatoday.org/backpain ▪ (21.1%) 69 million US adults aged 40 years and older had vestibular dysfunction. Disorders of Balance and Vestibular Function in US Adults. Data From the National Health and Nutrition Examination Survey, 2001-2004

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 19 WHAT IS DIZZINESS AND VERTIGO?

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 20 Historical Background

Prosper Meniere (1861) – first to recognize the association of vertigo with hearing loss and to localize the symptoms to the inner ear. Robert Barany (1906) ▪ First clinical description of BPPV in 1921. ▪ Introduced Caloric testing – most widely used test of the vestibulo-ocular reflex (VOR) ▪ Nobel Prize for mechanism of caloric stimulation

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 21 Vertigo and Dizziness are considered:

▪ Either an unpleasant Disturbance of Spatial Orientation

▪ The Illusory perception of body movement (spinning, wobbling, or tilting) and/or of the surroundings

Larry E. Masula, D.C, DACNB, FABVR, FAFICC 2/1/2020 22 Dizziness / Vertigo

▪ Dizziness refers to various abnormal sensations relating to perception of the body’s relationship to space. ▪ Dizziness – may represent a variety of symptoms which may include spinning, or movement of the environment, light-headedness, or presyncope, or imbalance while walking

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 23 Centers for Disease Control and Prevention

▪ Falls Are Serious and Costly ▪ One out of five falls causes a serious injury such as broken bones or a head injury.1,2 ▪ Each year, 2.5 million older people are treated in emergency departments (visits) for fall injuries.3 ▪ Over 700,000 patients a year (1/3) are hospitalized because of a fall injury, most often because of a head injury or hip fracture.3 ▪ Each year at least 250,000 older people are hospitalized for hip fractures.5 More than 95% of hip fractures are caused by falling,6 usually by falling sideways.7 ▪ Falls are the most common cause of traumatic brain injuries (TBI).8 ▪ Adjusted for inflation, the direct medical costs for fall injuries are $34 billion annually.9Hospital costs account for two-thirds of the total.

Larry E. Masula, D.CDACNB, FABVR, FAFICC . 06/15/2019 24 The Burden Dizziness and Vertigo Impose on the Community Dizziness is the third most common major medical symptom reported in general medical clinics1 and accounts for about 3%– 5% of visits across care settings.2 In the United States, this translates to 10 million ambulatory visits per year because of dizziness,3 with roughly 25% of these visits to emergency departments.2 Many patients have transient or episodic symptoms that last seconds, minutes or hours, but some have prolonged dizziness that persists continuously for days to weeks.4

▪ 1. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86:262–6 [PubMed] [Google Scholar] ▪ 2. Newman-Toker DE, Hsieh YH, Camargo CA, Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc2008;83:765–75 [PMC free article] [PubMed] [Google Scholar] ▪ 3. Kruschinski C, Hummers-Pradier E, Newman-Toker D, et al. Diagnosing dizziness in the emergency and primary care settings [letter]. Mayo Clin Proc 2008;83:1297–8 [PubMed] [Google Scholar] ▪ 4. Neuhauser HK, von Brevern M, Radtke A, et al. Epidemiology of vestibular vertigo: a neurotologic survey of the general population. Neurology 2005;65:898–904 [PubMed] [Google Scholar]

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 25 Ischemic Posterior Circulation Stroke:

Posterior circulation strokes (Posterior Fossa) patients exhibit many neurological symptoms including vertigo. They represent approximately 20% of all ischemic strokes. In contrast to the anterior circulation, several differences in presenting symptoms, clinical evaluation, diagnostic testing, and management strategy exist presenting a challenge to the treating physician. ▪ Ischemic Posterior Circulation Stroke: A Review of Anatomy, Clinical Presentations, Diagnosis, and Current Management Amre Nouh,1 Jessica Remke,2 and Sean Ruland1,*

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 26 Normal Anatomy & Physiology

▪ The peripheral vestibular system consists of:  3 semicircular canals  Otolithic apparatus (utricle and saccule) and  The vestibular, 8th cranial, nerve

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 27 Anatomy of Tympanic Cavity

Important Structures include: Int. Auditory meatus, Cochlea, SCC’s, Cn7, Cn 8, Eustachian tube anteriorly, Mastoid air cells post.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 28 Anatomy of Tympanic Cavity

The inner ear has two parts: the bony labyrinth and the membranous labyrinth. The membranous labyrinth is contained within the bony labyrinth, and within the membranous labyrinth is a K+ rich fluid called endolymph. Between the outer wall of the membranous labyrinth and the wall of the bony labyrinth is the location of perilymph.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 29 Bony Labyrinth

The bony labyrinth (also osseous labyrinth or otic capsule) is the rigid, bony outer wall of the inner ear in the temporal bone. It consists of three parts: the vestibule, semicircular canals, and cochlea. These are cavities hollowed out of the substance of the bone and lined by periosteum.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 30 Membranous Labyrinth

▪ The membranous labyrinth is a collection of fluid filled tubes and chambers within the bony labyrinth which contain the receptors for the senses of equilibrium and hearing.

Larry E. Masula, D.C. 2/1/2020 31 Cochlea “unraveled”

The middle ear functions as an amplifier. Sound enters the ear within the external auditory meatus (EAC) - sound energy moves the tympanic membrane (ear drum) which transfers this energy to the bony ossicles in the middle ear cavity. They in turn transfer compressed sound energy to the Oval window of the cochlea via the stapes bone. Frequency from the TM to the Oval window (force) increases. Mechanism one - TM is 17x larger than oval window. Mechanism two - Ossicles transfer one unit of energy by factor of 1.3. Therefore, 17 x 1.3 = sound amplified ~ 22x Pathologically, Ossicular sclerosis = dampened sound.

Larry E. Masula, D.C. 2/1/2020 32 Let’s Dive into the Anatomy

ANATOMY

Larry E. Masula, D.C., DACNB, FABVR,FAFICC 2/1/2020 33 Middle Ear - Dimensions

Dimensions of middle ear a) 1/3 of the middle ear is above TM -“Epitympanic Recess” b) Tympanic cavity proper (waist) c) The Head of the Malleolus and Incus lie in the Epitympanic Recess d) H = 15mm, AP = 15mm, Width-ETR = 6mmW, TC = 2mmW, Inf. Floor = 4mmW

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 34 The roof is small, and the floor is long. The tympanic Membrane is 9-10 mm thick and titled at 55° downward and forward toward the floor, which together predispose foreign objects to lodge at bottom. Clinical Note: Ear Lavage is best directed toward the roof for foreign body removal.

The Lateral Wall is made up o 2 parts. A membranous part and a bony part (Epitympanic Recess). The TM consists of 3 layers. External-skin – derived from ectoderm. Internal – mucosa of middle ear – derived from endoderm. Middle – fibrous layer is from Mesoderm.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 35 Lateral Wall – (Tympanic Wall)

Examination: of the tympanic membrane with an otoscope reveals various structures which include: Pars flaccida which is quite perforable due to infection, Handle of malleus and Umbro, Pars tensa – stiffer because it sits in a bony sulcus. Cone of Light which transmits downward and forward because of the 55° angle to the floor

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 36 Nerve Supply to Tympanic Membrane

The Auriculotemporal nerve (branch of mandibular div. of Cn5) exits the Foramen Ovale and supplies the pars tensa and the EAC . It also innervates the teeth which is the reason why teeth pain may cause referred otalgia. CN. VII, X innervate the pars flaccida. Clinical Note: when stimulated or wax irritates the TM, the patient can develop reflex bradycardia, cardiac arrest or a cough. CN. IX innervates (medial) inner TM surface, parts of the external ear and the posterior 2/3 of the tongue supplying touch, pain, and temperature. Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 37 Nerve Supply to Tympanic Membrane

▪ Clinical Gem: The glossopharyngeal nerve supplies the posterior 2/3 of the tongue and tonsillar region. I recently had a patient, Jim, who presented with vertigo, minimal ear and pharyngeal pain. He had developed tonsillar cancer. Cancer of either structure can refer symptoms via the glossopharyngeal nerve to the middle ear.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 38 These few nerve fibers within the middle ear are important in the differential of Stroke vs. Vestibular Pathology. Why is this important? Because later on we will learn that the Facial nerves Geniculate Ganglion can contain a latent Herpes Zoster virus.

Sometimes this virus can be activated. It enters the 7th fiber that travels through the middle ear to the skin of the tympanic membrane. In this case the patient will develop severe ear pain and/or hemi- facial paralysis like Bells Palsy or Stroke. During otoscopy there may be hemorrhagic blisters on the anterior 2/3 of the tongue, the TM or within the middle ear. “Ramsey Hunt Syndrome” Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020, 39 Note: Varicella Zoster (Herpes)– can affect CN.7 and create Hemi-facial paralysis often seen with stroke facies, Tympanic hemorrhagic blisters and may cause hearing loss and vertigo (Ramsey Hunt Syndrome)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 40 Medial Wall aka (Labyrinthine Wall)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 41 Medial Wall (labyrinthine wall) ▪ Most prominent feature is a circular inward bulge = Promontory, (Base of Cochlea), Tympanic Plexus of nerves. ▪ Foot Plate of Stapes attaches to Oval Window. Movement of Stapes: Annular lig. holds stapes to Oval window. Posterior part of annular lig, is shorter and thicker causing the stapes to tap the oval window like a door hinge and not a piston. Stepes is innervated by Cn. 7. ▪ Hook in the superior anterior wall – NOT SHOWN (processes cochleiformis) for the tendon of tensor tympani which bends the tendon to move it laterally to attach to the handle of malleus. During contraction the tensor tympani pulls the malleolus and the TM medially creating tension to dampen sound. It is innervated by a branch of the mandibular division of the trigeminal nerve.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 42 Medial Wall (Labyrinthine Wall) ▪ One of the most important structures is a longitudinal bulge (bony “Facial” canal) along the superior aspect of the Medial wall. ▪ It originates from the Facial Nucleus in the Pons and moves anteriorly and medially to enter the internal acoustic meatus. It exits and travels across the top of the Vestibule terminating in the Geniculate Ganglion which sits behind the superior anterior surface of the medial wall. Its first branch is the Greater Petrosal nerve before it enters through the boney (facial) canal in the petrous part of the temporal bone where it extends backwards to the posterior wall and within the posterior wall the facial canal and nerve turn downward. ▪ It is not exposed within the middle ear cavity. ▪ The superior bulge (upper left) is created by the Horizontal Semicircular canal.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 43 Posterior Wall (Mastoid Wall) Special window in superior medial aspect of posterior wall- “Aditus to antrum” - opening into the mastoid antrum. Facial Canal descends within the posterior wall. The bony “Pyramidal Eminence” - is hollow and contains the stapedius muscle with an exiting tendon which attaches to the neck of the stapes. Importance: dampen stapes movement and sound. Innervated by a branch of the Facial nerve. The Chorda Tympani nerve (CN.7) and the Posterior tympanic artery (not shown) also enter the posterior wall. The chorda tympani traverses through the middle ear to exit through the anterior wall. Not Shown- the short process of the Incus attaches to the posterior wall at the Fossa Incudis.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 44 Posterior Wall (Mastoid Wall)

The Facial nerve descends and will eventually emerge through the styloid mastoid foramen giving off the posterior auricular branch which supplies the stylohyoid and posterior belly of the digastric muscles, the occipital region and auricular muscles. Its terminal branches move forward in the face to the temporal, zygomatic, buccal, marginal mandibular and cervical muscles.

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020, 45 Anterior Wall (Carotid Wall) 2 Special Structures 1. Upper canal is a bony canal. Houses the Tensor Tympani muscle which takes 3 origins from the bony canal, w/ the superior cartilage of the eustachian tube, and from the undersurface of the greater wing of sphenoid (skull). It then enters the canal and then converts to a tendon which turns and moves laterally and attaches to the handle of malleus. Upon contraction it pulls the handle of the malleus inward to pull the TM and the ossicular chain tense. Purpose: contracts to dampen loud sounds. Innervation: mandibular division (motor) of CN5.

2. Eustachian Tube (petrotympanic tube) connects the tympanic cavity w/ lateral wall of pharynx.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 46 Anterior Wall (Carotid Wall)

▪ Which artery sits anteriorly? ▪ Int. Carotid. Covered by a sympathetic plexus from the superior cervical ganglion. Sympathetic fibers enter the middle ear as Superior and Inferior fibers.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 47 Anterior Wall (Carotid Wall) Summary

▪ How many features in the Anterior Wall?

1. Canal for Tensor Tympani 2. Opening of Eustachian Tube 3. Lesser Petrosal Nerve 4. Sympathetic Fibers 5. Chorda Tympani Nerve

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 48 Anterior Wall (Carotid Wall)

Jugular Fossa sits directly beneath the floor of middle ear. Contains the internal jugular vein, CN’s 9, 10, & 11.

CN.9 gives off a branch which enters the floor (not shown) bringing parasympathetic and sensory fibers to the tympanic plexus collectively supplying all walls of the middle ear including the eustachian tube and mastoid.

A branch from the tympanic plexus (lesser petrosal nerve) exits the anterior wall and ascends through the foramen Ovale and descends back downward carrying parasympathetic pre-ganglionic fibers from the tympanic plexus to the parotid gland.

Chorda Tympani nerve CN.7, traverses the middle ear and exits the anterior wall via Petrotympanic fissure and through which the anterior tympanic artery enters to supply the middle ear.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 49 Chorda Tympani - Middle Ear

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 50 Chorda Tympani – Branch of Facial N.

What is the relationship of the Chorda Tympani (facial n.) contents of the middle ear?

It passes completely through the middle ear between the neck of the Malleus and the Incus and is covered with mucosa. It supplies the anterior 2/3 of the tongue with taste receptors. Infections, strokes, and middle-ear operations may be damaging causing dysgeusia (distorted taste).cial

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 51 Eustachian tube

▪ Clinically Important: The initial 1/3 is bony and the last 2/3 is fibrocartilage. Angles 30º downward and 35º anteromedially to open in the nasopharynx.

Attached to the end of the tube are the Salpingopharyngeus, Tensor Veli Palitini muscles, and the Levator Palatini muscles (CN.10) Function: to elevate the soft palate and open the end of the tube to equalize pressure within the middle ear.

Reason why PICA strokes, can generate unilateral swallowing impairment or having food get stuck in the throat. Test: have the patient say AAH repeatedly and observe for a soft or complete impairment of palatal elevation. The unaffected side will elevate, and the palate may deviate in that direction

Larry E. Masula , D.C., DACNB, FABVR, FAFICC 2/1/2020 52 Inferior Wall (Jugular Wall)

▪ The floor is made by the petrous part of the temporal bone with one important cuniculus. ▪ Sympathetic fibers which start from the Inferior Salivatory nucleus travel with other fibers of the 9th nerve to enter the floor of the middle ear cavity and extend to the Promontory

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 53 Roof

▪ The roof is called the Tegmentum Tympani. The roof is very thin. Clinically it is important because middle ear infections may extend upward especially in children due to an overlying Petrous - Squamous suture which may not be ossified producing a subdural abscess, meningitis and a temporal lobe abscess or infection. Fractures likely resulting in CSF leak.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 54 Clinical Review

▪ If the horizontal SCC is affected from a middle ear infection, it will result in Vertigo. ▪ If the facial canal is damaged it will result in facial palsy. If it is damaged proximal to the nerve to the stapedius, it results in paralysis of the stapedius giving rise to hyperacusis. ▪ Middle ear infections may extend posteriorly creating life-threatening mastoiditis. If the infection exits the roof (Tegmentum Tympani) it can produce an extradural abscess, meningitis, or a Temporal lobe abscess. ▪ If it extends backward through the Mastoid, it can damage the Sigmoid Sinus resulting in thrombophlebitis, and further backward enter the cerebellum or brainstem.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 55 CSF Leak from Middle Ear

Fracture of the middle cranial fossa, typically damages the roof of the middle ear (Tegmentum Tympani which is a thin bone). This may also disrupt the ossicular chain, rupture the tympanic membrane and may damage the roof of the external acoustic meatus. Blood and CSF leak into the middle ear cavity and through the ruptured TM. ▪ This is called “Otorrhea”

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 56 Contents of Middle Ear summary

▪ Air ▪ Vessels (Anterior tympanic ▪ Ossicles (Malleus, Incus, artery, Posterior tympanic Stapes) all attached via artery) synovial joints ▪ All structures lined by ▪ Muscles (Stapedius, Tensor mucosa Tympani Tendon) ▪ Nerves

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 57 Understanding Vestibular Neurophysiology

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 58 Understanding Neurons – the Big Picture

▪ Stimulation of receptors results in activation of the 1st order afferent (sensory) neuron ▪ Activation of the 2nd order afferent neurons is dependent on the FOF of its pre-synaptic neuronal pool (1st order neurons). ▪ Activation of the thalamus and all cortical structures is dependent upon the FOF of ALL pre-synaptic neuronal pools of the somatosensory system). ▪ As a result, receptor injury will result in impaired cortical representation. (Head Maps)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 59 Central Integrative State (Health) of a Neuron and Cellular Immediate Early Gene Response –

There is a constant influx of neuronal membrane potential differences due to: 1. Spatial Summation (multimodal) on the receptor 2. Temporal Summation (high frequency unimodal) on the receptor 3. pH 4. Glucose 5. Oxygen tissue saturation 6. Temperature changes 7. Summation of all presynaptic (+) and (-) input which includes all cortical and segmental integration 8. In summary: stability or fragility of a neuron is based on the FOF of its presynaptic pools or receptor potentials

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 60 What Do We Do?

“Alterations in the neuron occur at the synapse, strengthening and increasing, or weakening and decreasing, the number of connections between the neurons.” (Michael Merzenich, considered the world’s leading researcher on brain plasticity)

Our rehabilitative purpose is therefore to: 1. Strengthen and enhance synaptic activity 2. Improve motor function 3. Improve brain activity via cortical re-organization

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 61 Cellular Survival is dependent upon

Fuel Glucose O2 Activation

Larry E. Masula, D.C., DACNB, FAVRB, FAFICC 2/1/2020 62 Summary: Cellular Survival is Altered by

▪ FOF of all presynaptic input (Activation) ▪ Identify and manage Dysglycemia, Hypoglycemia, Metabolic Syndrome, Insulin resistance. (Fuel - glucose) ▪ Identify and manage anemia (Fuel – O2) ▪ Adequate protein and fat intake ▪ Inflammatory conditions ▪ Infections ▪ Autoimmunity

Larry E. Masula, D.C., DACNB,FABVR, FAFICC 2/1/2020 63 Anatomy and Physiology of the Vestibular System

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 64 Vestibular Function: an Overview ▪ Expressed simply, the role of the vestibular sensory organs is to transduce the forces associated with head acceleration and gravity into a biologic signal. ▪ The control centers in the brain use this signal to develop a subjective awareness of head position in relation to the environment and to produce motor reflexes for equilibrium.

Larry E. Masula, D.C., DACNB, FABVR, FAFiCC 2/1/2020 65 Vestibular Function: Overview continued ▪ The force associated with head acceleration generates a signal in the labyrinth that is proportional to head acceleration, 1:1 ratio. ▪ The overall objective of the CNS is to compute head position by performing the equivalent of a mathematical integration of the labyrinthine and otolithic input signals.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 66 Larry E. Masula, D.C., DACNB, FABVR, FAFCC 2/1/2020 67 Vestibular Nerve Physiology

▪ The vestibular system monitors the forces associated with Angular and Linear accelerations of the head by means of 5 organs located within the labyrinthine cavity of the temporal bones on each side of the skull. ▪ The Cristae Ampularis sensory organ of the 3 semicircular canals senses angular acceleration of the head ▪ The Otolithic Organs (saccule and utricle) sensory organ the Maculae senses linear acceleration.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 68 The Semi-Circular Canals

The semicircular canals provide sensory input about head velocity, which enables the VOR to generate an eye movement that matches the velocity of the head movement. The desired result is that the eye remains still in space during head motion, enabling clear vision. Neural firing in the vestibular nerve is proportional to head velocity over the range of frequencies in which the head commonly moves (0.5 to 7 Hz).

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 69 2/1/2020 the Semi-circular canals

The fluid filled SCC is filled with K+ rich Endolymph which has a viscosity slightly greater than H2O.

The sensory epithelium of the cristae is covered by the gelatinous cupula.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 70 Cristae Ampularis - enlarged

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 71 Lateral Line System

A similar system is found in fish in which water passing over the tiny pores within the lateral line of the fish move the cupula resulting in depolarization of the nerve inducing a motor output and digestion

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 72 Semicircular Canals

▪ The cupula has the same density as the endolymph ▪ Semicircular canals do not respond to gravity in static head positions however, there is tonic firing of approximately 100 spikes/sec. ▪ The canals lie roughly in the same planes as the extraocular muscles ▪ Each canal excites a pair of muscles and inhibits a pair of muscles in its same plane. Its partner excites the muscles it inhibits, and vice-versa

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 73 Eye Muscles

The plane in which the eyes deviate are the result of vestibular activation by the canals stimulated

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 74 ▪ Once vestibular signals leave the vestibular nuclei - they divide into vertical, horizontal, and torsional components of a motor command. ▪ Lesion of the central vestibular pathways can cause a pure vertical, pure torsional, or pure horizontal nystagmus of the eyes

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 75 Canal Related Eye Movements

E.g. If I rotate my head horizontally to the right activating the right horizontal canal, I activate the right medial vestibular nucleus, which activates the right oculomotor nucleus and the left abducens nucleus activating the right medial rectus and the left lateral rectus. Right horizontal canal activation biases conjugate eye movements to the contralateral side, in this case to the left.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 76 Activation of the Sensory Hair Cells

▪ Angular movement of the head causes endolymph flow in one of the semicircular canals to deflect the cupula ▪ Deflection of the stereocilia toward the kinocilium results in depolarization, or increased firing rate ▪ Deflection of the stereocilia away from the kinocilium results in hyperpolarization, or a decreased firing rate

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 77 Semi-Circular Canals

The semicircular canals provide sensory input about head velocity, which enables the (VOR) vestibular ocular reflex to generate an eye movement that matches the velocity of the head movement. The desired result is that the eye remains still in space during head motion, enabling clear vision. Normal neural firing of the vestibular nerve is proportional to head velocity over the range of frequencies in which the head commonly moves (0.5 to 7 Hz).

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 78 Semi-Circular Canals

The coplanar pairing of the canals is associated with a push-pull change in the quantity of semicircular canals output. When angular head motion occurs, the endolymph of the coplanar pair of canals is displaced in opposite directions. This results in a neural firing increase in one vestibular nerve and a hyperpolarization (decrease) on the opposite side.

For the lateral canals, displacement of the cupula towards the ampulla (ampullopetal flow) becomes excitatory, whereas vertical canal displacement of the cupula away from the ampulla (ampullofugal flow) is excitatory.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 79 Semi-Circular Canals

Clinically, this push-pull mechanism is an important point which explains why patients with Unilateral Peripheral Vestibular loss avoid head motion towards the side of their lesion. More will be said about this when we discuss how the central nervous system compensates for overload.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 80 OTOLITHIC ORGANS: Utricle and Saccule

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 81 Otolithic System Even with the head at rest, the calcareous material, because of its mass, exerts a force upon the otolithic receptor equal to the product of its mass and acceleration due to the gravitational pull of the earth, which at sea level is 9.80 m/sec².

The Fg (force) acting upon the underlying sensory cells changes with different degrees of head tilt.

The otolithic system is sensitive to gravity and linear acceleration. Because of their orientation in the head, the utricle is sensitive to a change in horizontal movement, and the saccule gives information about vertical acceleration (such as when in an elevator). Remember Utricle is lateral forward and backward – the Saccule is Sit and Stand. Exception: both are subject to A/P acceleration

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 82 Otolith Function

The brain therefore has difficulty determining tilt vs translation without accessory input from the canals

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 83 Otolithic System

▪ Remnant of the lateral eyed animals ▪ Turned on by near vision ▪ Primes the legs ▪ Turned off by long axis distraction of the cervical spine ▪ Fires into midline Cb specifically the Nodulus

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 84 The Otolithic System An otolith also called statoconium or otoconium, is a structure in the saccule or utricle of the inner ear, specifically in the vestibular labyrinth of vertebrates

Each macula consists of a sensory membrane containing the receptor cells that supports a “heavy load,” the otoliths.

The otolith is composed of calcareous (calcium carbonate) material embedded in a gelatinous matrix. This is important because osteoporosis patients frequently are subject to otolithic degeneration resulting in BPPV.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 85 Vestibular Nerve Physiology

Each vestibular neuron fires tonically at a resting rate of approximately 90-100 spikes per second.

Upon activation these peripheral vestibular afferents have two main targets: the vestibular nuclear complex and the cerebellum

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 86 Vestibular Nuclei Complex

4 Major Nuclei 1. Superior Vestibular Nucleus  VOR relay center 2. Medial Vestibular Nucleus  VOR relay center  VSR relay center 3. Lateral Vestibular Nucleus  VSR relay center (major- ipsilateral LVST). Mainly LE extensor muscles for stability. Input is mostly from the Otoliths 4. Inferior Vestibular Nucleus  Connected to all other nuclei

Larry E. Masula, D.C. DACNB , FABVR, FAFICC 2/1/2020 87 Vestibular Nuclear Complex

The 4 vestibular nuclei are: Super Vestibular Nucleus, Medial Vestibular Nucleus, Lateral (Dieter’s) Vestibular Nucleus, and the Inferior (caudal) Vestibular Nucleus.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 88 2/1/2020 Vestibular Nucleus Function

The vestibular nucleus is a multi functional nucleus with two very important functions. 1. it tells you where your head is relative to gravity and where gravity is relative to your head. 2. it establishes appropriate postural reflexes i.e., the vestibular ocular reflex (VOR) and the vestibular spinal reflexes (VSR).

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 89 Vestibular Nuclei Projections

The vestibular nuclei receive projections from the cortex, the cerebellum, subcortical visual centers, and the spinal cord. Vestibular circuitry is therefore embedded within larger networks involved in the integration of vestibular, visual, and proprioceptive information. This provides an ongoing global control of eye and body orientation in the dynamic context of voluntary movement and external perturbations.

Larry E. Masula, D.C, DACNB, FABVR, FAFiCC 2/1/2020 90 Vestibular Nuclei Commissure

▪ Commissures link the vestibular nuclei from either side of the brainstem through mutually inhibitory connections ▪ This allows for information to be shared across the brainstem (push-pull) ▪ Which means that during active head rotation to the right, the right vestibular apparatus is excited and via the commissure and the left side becomes inhibited

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 91 VOR (vestibular ocular reflex)

VOR gives us the ability to move our head and maintain visual (foveal) fixation on a target without developing any retinal slip or blurring of vision. The VOR has a direct pathway and an indirect pathway which we will talk about that at another time. The main ascending tracks are from the superior and medial vestibular nuclei to the extraocular muscles traveling through the medial longitudinal fasciculus to drive oculomotor activity

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 92 VSR

The VSR has to do with maintaining balance and this is just one part of our balance systems. The distributive spinal reflexes are important when you become destabilized while walking on a sandy beach, wet slippery pavement, on ice or standing on a foam surface. Vestibular spinal reflexes are hard wired reflexes that keep us upright against gravity by allowing us to create an appropriate motor command to avoid a fall .

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 93 The medial vestibular spinal nucleus and tract The media vestibulospinal track I personally have had numerous interfaces with the ventral horn of patients over the years who have the spinal cord to create motor come into the office following activation for cervical spine physical therapy or chiropractic stabilization. it is therefore useful which the patient terminated in the rehabilitation of patients because they couldn't handle the with ligament laxity secondary to cervical exercises or mobilization. a traumatic cervical sprain and These same patients have done strain. exceptionally well by putting them in a rotational chair and rotating them while the head is stabilized, performing ocular motor therapy, implementing the SenMoCor head laser target maze, utilizing trigeminal stimulation, EMS and TENS stimulation

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 94 The medial vestibular spinal nucleus and tract As a chiropractor we often here of patients who repeatedly bang their head against the roof of the car when getting in and out of the vehicle. This is often secondary to poor head and neck maps in the brain. Improved head/neck maps may be obtained through vestibular rehabilitation. This can all be done without further traumatizing an unstable region. Stimulation in this manner is aligned at creating better cortical representation of their head and neck by generating better “Head/Neck Maps”

Larry E. Masula, D.C., DACNB,FABVR, FAFICC 2/1/2020 95 Lateral Vestibulospinal Nucleus and Tract The LVST also innervates the anterior horn to create motor activation. It extends further down the spine than the medial vestibular spinal tract to innervate the extensors of the trunk and legs. It is pretty much ipsilateral but there is some bilaterality to it but, for the most part it is strictly ipsilateral and important for postural responses and standing upright.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 96 The Caudal Vestibular Nucleus and Tract These guys innervate the dorsal columns (sensory) region of the spinal cord for the purpose of receiving an effort copy of the motor commands thus gating all incoming information that says the same thing and only allowing that information which is leftover (the errors) to ascend

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 97 CLASSIFICATION of VESTIBULAR REFLEXES ▪ Old thinking. Cristae is a kinetic receptor and maculae are static receptors ▪ Both receptor organs produce motor reflexes that cannot be totally differentiated ▪ It is therefore appropriate to differentiate the reflexes by categories based on their functional role

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 98 CLASSIFICATION of VESTIBULAR REFLEXES ▪ Vestibulo-Ocular Reflex, The VOR acts to maintain stable vision during head motion. This means that the eyes precisely counter-rotate to compensate for the head and keep the eye stable in space. ▪ Angular VOR, The angular VOR is primarily responsible for gaze stabilization ▪ Linear VOR, The linear VOR, is mediated by the otoliths, compensates for translation and acceleration in a linear direction (which is basically the same thing). The linear VOR is most important in situations where near targets are being viewed and the head is being moved at relatively high frequencies. ▪ Vestibulospinal Reflex, The purpose of the VSR is to stabilize the body. ▪ Vestibulocollic Reflex, this is not an ocular reflex but a neck reflex. The vestibulocollic reflex (VCR) acts on the neck musculature to stabilize the head. The reflex head movement produced counters the movement sensed by the otolithic or semicircular canal organs.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 99 Vestibular Reflexes summary

1. Maintain posture. 2. Evokes extensor musculature activity (tone) above T6 and below T6 to compensate for gravitational forces. 3. Produce “kinetic” contractions of muscles for maintenance of equilibrium and ocular stability during movement. Includes reflexes arising from BOTH the canals during angular acceleration and the otoliths during linear acceleration. 4. Help maintain muscular tone: a role of both maculae and cristae

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 100 Reflexes: continued

Labyrinthine contribution to skeletal-muscular tone is demonstrated following unilateral labyrinthectomy studies in cats which results in:  Tone is decreased in the ipsilateral extensors  Tone is increased in the extensor muscles of the contralateral extremities due to loss of inhibition Meaning that, a unilateral vestibular deficit (UVD) patient will present with ipsilateral extensor muscle hypotonia and contralateral hypertonia of the extensors. WOULD THIS AFFECT HOW YOU MANAGE YOUR CERVICAL SPINE PATIENTS?

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 101 Does my dizzy patient have a stroke? Craniocervical pain Narrative reviews have suggested that craniocervical pain may accompany dizziness in patients with stroke in the posterior fossa because of the stroke itself (mass effect or direct involvement of pain- sensitive structures) or its underlying cause (e.g., dissection or aneurysm of the vertebral artery).22 Two studies addressed this issue. Headache or neck pain was present in a minority of patients presenting with acute vestibular syndrome (38%, n = 9/24;9 and 29%, n = 29/1016). A statistically significant association with central causes (38% v. 12%, p < 0.05) was found in the larger study.

6. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009;40:3504–10 [PMC free article] [PubMed] [Google Scholar] 9. Norrving B, Magnusson M, Holtas S. Isolated acute vertigo in the elderly: Vestibular or vascular disease? Acta Neurol Scand 1995;91:43–8 [PubMed] [Google Scholar] 22. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol 2008;7:951–64 [PubMed] [Google Scholar]

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 102 DIFFERENTIAL DIAGNOSIS

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 103 Differential Diagnosis Should Include:

▪ A good diagnosis is not like a batting average where you play the percentages. You might strike out! A thorough examination is essential. You need to know whether you are looking at:  A One level lesion  Multifocal / multiple lesions  A Central Lesion  A Peripheral Lesion

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 104 Peripheral causes of vertigo ▪ 1. Benign paroxysmal positional vertigo ▪ 2. Vestibular neuronitis ▪ 3. Recurrent vestibulopathy ▪ 4. Meniere’s disease ▪ 5. Head trauma (labyrinthine concussion) ▪ 6. Otosclerosis ▪ 7. Herpes zoster oticus ▪ 8. Cholesteatoma ▪ 9. Perilymph fistula ▪ 10. Aminoglycoside (antibiotics) ototoxicity

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 105 Central causes of vertigo

▪ Vascular: vertebrobasilar ,TIA, cerebellar or brain stem stroke ▪ Cerebellopontine angle tumors: acoustic neuroma, meningioma, cholesteatoma, metastatic tumor ▪ Demyelinating disease: MS, postinfectious demyelination ▪ Cranial neuropathy: focal involvement of VIII nerve or in association with systemic disorders ▪ Intrinsic brainstem lesions: tumor, arteriovenous malformations ▪ Seizure disorders (rare) ▪ Spinocerebellar degeneration ▪ Hypertensive medications

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 106 Most Frequent Vertigo Syndromes Diagnosed in a Dedicated Neurological Dizziness Unit (N=4790) Vertigo and Dizziness by Brandt, Dietrich, and Strupp-2005 ▪ BPPV 18.3% ▪ Phobic Postural Vertigo 15.9% ▪ Central Vestibular Vertigo 13.5% ▪ Vestibular Migraine 9.6% ▪ Vestibular Neuritis 7.9% ▪ Meniere’s Disease 7.8% ▪ Vestibular Paroxysmia 2.9% ▪ Perilymph Fistula 0.4% ▪ Unknown 4.2%

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 107 You must be a lot like Sherlock Holmes

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 108 Nothing Replaces a Good Bedside Neurological Examination

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 109 ▪ History and physical examination provide the most important information ▪ Often, patients have difficulty describing the exact symptom experienced ▪ The first step is to define the symptom

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 110 A case history specific to balance may include the following: ▪ Collection of results from other health professionals ▪ Fall risk data ▪ Medical history including blood pressure and other vitals  history of dizziness ,balance problems or falls  Medication use  alternative medicines  presence of other comorbidities ▪ Nature of dizziness and or imbalance symptoms including the following :  Aggravating factors  Alleviating factors  Accompanying symptoms (e.g., Hearing loss, tinnitus aural fullness  Duration (seconds , minutes , hours , days )  Frequency  initial onset (How did it begin (gradual / sudden) ▪ Pattern (time of day , , activity symptomatic ) ▪ Quality and character ( spinning , imbalance , disorientation ) ▪ Patient questionnaire on dizziness

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 111 Physical Examination ▪ A general medical examination is important. Physical examination is very important in patients complaining of Vertigo because it can be the earliest symptoms of a neurodegenerative disorder ▪ Postural hypotension measurement ▪ Orthostatic hypotension – probably the most common ▪ Identifying an irregular cardiac rhythm may help ▪ Other measures to consider include a visual assessment and a musculoskeletal inspection (significant for arthritis and peripheral neuropathy) ▪ Vertigo can also be an important symptoms of stroke, tumor, demyelination, or other pathologies of the nervous system

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 112 Frenzel Goggles are a diagnostic tool used in ophthalmology, otolaryngology and audiovestibular medicine for the medical evaluation of involuntary eye movement (nystagmus). They are named after Frenzel, a German physician. The purpose of the goggles is to disable the patient's ability to visually fixate on an object while at the same time allowing the examiner to adequately visualize the eye. This is done by using high-powered (+20 diopters) magnifying glasses with an illumination system. With such a high-powered lens, it is unlikely that the patient can adequately focus and visually fixate on an object to suppress nystagmus.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020, 113 Videonystagmography (VNG) is a technology for testing inner ear and central motor functions. It involves the use of infrared goggles to trace eye movements during visual stimulation and positional changes. Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 114 Computerized Dynamic Posturography

Computerized Dynamic Posturography (CDP) is well documented in the clinical and scientific literature as an objective method of differentiating sensory, motor, and central adaptive functional impairments of balance.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 115 AireX Pad®

The Airex® Balance Pad is a reasonably priced product which has a smooth surface, making it ideal for barefoot balance testing and training. Due to the yielding foam, the body is constantly challenged to maintain balance. This pad is also great for balance, mobility, standing stability and motor-skill training.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 116 BESS Test with Airex Balance Pad

Larry E. Masula, D.C , DACNB, FABVR, FAFICC. 2/1/2020 117 While this test is frequently used for mTBI evaluation it is a very useful tool for vestibular evaluation by means of a Romberg test, Tandem Romberg and Unipedal stance. These tests are performed with eyes open and closed both on a compliant and then again on a non-compliant surface.

This form is downloadable from the Internet and serves as a great patient handout.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 118 Bedside Diagnostic Gems mnemonic

▪ V – Vascular ▪ I _ Infectious ▪ N – Neoplastic, Neurological ▪ D – Degenerative ▪ I – Inflammatory ▪ C – Connective tissue/muscle ▪ A – Autoimmune ▪ T – Trauma ▪ E – Endocrine/environmental ▪ S - Soft tissue

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 119 VINDICATES VASCULAR

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 120 VASCULAR: Cardiovascular Disease and Cerebrovascular Disease ▪ Many vascular disorders may generate dizziness or lightheadedness. Therefore, Everything should be Considered Vascular Until Proven Otherwise  Arrhythmias  Tachycardia  Bradycardia  Ischemic cardiomyopathy  Vasovagal syncope  Carotid sinus hypersensitivity  Conduction blocks w/ elongation of the PR interval  Brain ischemia  Etc.

06/21/2019 Larry E. Masula, D.C. DACNB, FAVRB, FAFICC. 121 Clinical Aspects of Brainstem Disorders Common symptoms found in the majority of brainstem lesions include diplopia, dysarthria, VERTIGO nausea and vomiting.

These lesions are typically vascular in nature but can be as result of other disorders such as MS and pontine gliomas etc.

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 122 Clinical Case. Your patient presents with the following: What is the diagnosis?

▪ Vertigo, nausea and vomiting ▪ Ipsilateral facial pain and temperature loss ▪ Ipsilateral Horner’s ▪ Ipsilateral Ataxia and dysmetria ▪ Weakness of palate, pharynx and larynx ▪ Dysphagia, hoarseness, diminished gag reflex ▪ Contralateral pain and temperature loss

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 123 2 Types Medullary Vascular Lesions

There are typically only 2 kinds of ▪ Dorsal lateral infarction causes medullary ischemic attacks, damage typically referred to as a Wallenberg syndrome. Typically, ▪ Dorsal lateral you will have: ▪ The paramedian and basil are ▪ Ipsilateral Horner’s syndrome, lumped together. loss of pain and temperature over the face on the same side of the lesion. There can be cerebellar findings on the ipsilateral side causing ataxia. ▪ Contralateral loss of pain and temperature with.. ▪ You can get severe nausea, vomiting, vertigo, and nystagmus due to vestibular influence. Hiccups may be common do to lesion in the 9th and 10th nerves with difficulty swallowing.

Larry E. Masula, D.C., DACNB, FAVRB, FAFICC 2/1/2020 124 Wallenberg Syndrome

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 125 Lateral Medullary Syndrome aka: Wallenberg Syndrome (posterior inferior Cb artery)

Regional territories

Larry E. Masula, D.C. DACNB., FABVR, FAFICC 2/1/2020 126 Lateral Medullary Syndrome “Wallenberg Syndrome”

Note the cranial nerve locations and their trajectories which become affected

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 127 Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 128 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 129 Labyrinthine Artery - Vascular Supply

It is important at this point to also review the clinically important Labyrinthine artery. 45% from AICA ▪ 24% superior cerebellar artery ▪ 16% basilar ▪ Two divisions:  anterior vestibular artery  common cochlear artery ▪ Vascular pathologies can give pulsatile tinnitus or deafness

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 130 Vestibular Migraine

I include vestibular migraines because of its seemingly neurovascular nature even though it is not necessarily an ischemic lesion. It is important to know due to the clinical presentation of headaches and dizziness.

Vestibular Migraine is associated with dizziness and vertigo as a common aura in migraineurs. It is estimated that about 30% of migraineurs will be affected with this form of aura.

You could get dizzy and have balance problems without having a migraine at all. Other times, the vertigo symptoms happen before, during, or after the headache. Sometimes, you might have migraines for years before the vertigo symptoms begin.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 131 Acute Vasculature Vestibular Syndrome

Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 132 Ocular Motor Assessment

1st step is to observe normal ocular movements and search for any Nystagmus of the eyes, with a fast movement in one direction and a slow movement in the other.”

Nystagmus can be classified as spontaneous, gaze-evoked, or positional. The direction of nystagmus – conventionally described by the direction of the fast phase, which is the direction it appears to be “beating” toward. Fast phase component may be horizontal, vertical, rotatory, or any combination of these.

Larry E. Masula, D.C.DACNB, FABVR, FAFICC, 2/1/2020 133 Acute Vestibular Syndrome H.I.N.T.S. to I.N.F.A.R.C.T.

▪ STROKE FINDINGS: “H.I.N.T.S.” Battery “I.N.F.A.R.C.T.” ▪ Head Impulse test -Normal 1. Head Impulse Test ▪ Fast-phase Alternating nystagmus 2. Nystagmus ▪ Re-fixation on Alternating 3. Test of Skew Cover Uncover Test ▪ Any ONE of these points to a Stroke

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 134 Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 135 Nystagmus Testing

▪ Performed in  Primary Gaze  Lateral Gaze  Vertical Gaze ▪ In a normal volunteer: there is No nystagmus in primary gaze. During lateral gaze some nystagmus may be normal. Learn to suppress this with fixation by placing a piece of paper between their head and the wall and ask them to look at the wall as if the paper was not present. Otherwise, you might see nystagmus which would not be there without the sheet of paper.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 136 Nystagmus

https://youtu.be/1q-VTKPweuk?t=105 Patient with vestibular neuritis. Note: here it is again, when he looks to the left see that the nystagmus increases. It is left beating and there is a rotatory component towards the left and it increases when he looks to the left and you can see the torsional component.

When he looks to the right it lessens but the fast component is still towards the left.

Unidirectional nystagmus, does not change direction and this exam is reassuring.

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 137 Nystagmus

https://youtu.be/1q-VTKPweuk?t=157 Compare to this lady who when she looks to the right, she has small horizontal nystagmus with the fast component to the right. Then, when she moves more central and to the left, you can see that the nystagmus beats towards the left. So, she has direction beating nystagmus or bidirectional nystagmus which is worrisome. Note: nystagmus is named for the direction of the fast phase

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 138 Test of Skew (Vertical)

Cover / Uncover test

https://youtu.be/1q-VTKPweuk?t=201 Examiner takes their hand and covers the eye and then quickly covers the other eye to observe if there is any vertical movement of the eye when it is uncovered.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 139 Test of Skew

https://youtu.be/1q-VTKPweuk?t=214

Observe that when the hand is taken away from the right eye, the eye will go medially and upward and when the examiners hand is taken away from the left eye it goes medially and downward.

This abnormal skew deviation is worrisome

Larry E. Masula, D.C., DACNB, FAVRB, FAFICC 2/1/2020 140 Head Thrust Test

A unilateral or bilateral vestibulopathy can be identified using the Head-Thrust test. The head thrust test is a test of vestibular function that is performed as part of the bedside examination. This maneuver tests the vestibulo-ocular reflex (VOR).

The patient sits in front of the examiner and the examiner holds the patient's head steady in the midline. The patient is instructed to maintain gaze on the nose of the examiner. The examiner then quickly turns the patient's head about 10–15 degrees to one side and observes the ability of the patient to keep the eyes locked on the examiner's nose. If the patient's eyes stay locked on the examiner's nose (i.e., no corrective saccade) (A), then the peripheral vestibular system is assumed to be intact. Thus in a patient with acute dizziness, the absence of a corrective saccade suggests a CNS localization. If, however, the patient's eyes move with the head (B) and then the patient makes a voluntary eye movement back to the examiner's nose (i.e., corrective saccade), then this suggests a lesion of the peripheral vestibular system and not the CNS.

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 141 Bedside Head Thrust Test

Larry E. Masula, D.C. 2/1/2020 142 Head Impulse Test

https://youtu.be/1q-VTKPweuk?t=295

Hold onto the patients skull while the patient fixates on examiners nose (or camera). Move head (maybe 20 degrees), slowly to the right, then BRISKLY to midline. What you are looking for are catch-up Saccades of the eyes

In this video her eyes remain fixed on the camera = NORMAL or Abnormal?

Larry E. Masula, D.C., DACNB, FABVR, FAFIICC 2/1/2020, 143 Head Impulse Test

▪ https://youtu.be/1q-VTKPweuk?t=324 Abnormal Notice that this man presents with nystagmus when he looks to the left and when his head is turned to the right. Do you see that there is a larger movement of the eyes from the right back to the midline? That is an abnormal HIT which is reassuring which shows that he has a peripheral nerve problem and probably does not have a brain problem.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 144 Head Impulse Test

https://youtu.be/1q-VTKPweuk?t=389

This lady has a rock-solid head impulse test. She is WORRISOME because she has acute vertigo and nystagmus and we cannot find a nerve problem. She probably has a BRAIN problem.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 145 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 146 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 147 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 148 VINDICATES INFECTIOUS

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 08/15/2019 149 Infectious Disorders Otitis Externa Pathophysiology Typically begins with otitis externa in elderly diabetics.

Infection spreads to surrounding tissues and adjacent temporo- occipital bones, almost always secondary P. aerugiosa.

Commonly affects the facial nerve in the fallopian canal or at the stylomastoid foramen and can spread across the dura to produce purulent meningitis.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 06/22/2019 150 INFECTIOUS DISORDERS: Malignant Otitis Externa Diagnosis – CT scan of the temporal bone may reveal: 1. External canal mass 2. Clouding of the mastoid air cells 3. Sequestra of the bony canal 4. Erosion at the base of the skull 5. Soft tissue masses within the parapharynx and nasopharynx

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 151 INFECTIOUS DISORDERS: Otitis Media Pathophysiology The middle ear is involved with most viral URI’s. The nasal, paranasal, and pharyngeal mucositis spreads to involve the Eustachian tube and middle ear mucosa, since the mucosa of the pharyngeal end of the Eustachian tube is continuous with mucociliary system of the middle ear. If the eustachian tube becomes inflamed it swells and closes. If the tube is closed / blocked, then the middle ear and mastoid system become disconnected with the air in the nasopharynx and atmospheric system. This results in the air within the middle ear and mastoid being absorbed by the mucosa and a negative pressure develops. The negative pressure causes the TM to become sucked inward and secondly the microcirculation within the tympanic cavity is encouraged to release fluid and mucus resulting in an inability for the TM to generate sound energy causing conductive deafness. Secondary bacterial infection may develop leading to otitis media.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 152 INFECTIOUS DISORDERS: ▪ Otitis Media (Inflammation of the middle ear) Is a common cause of conductive hearing loss, particularly in children. 2 Forms A- Suppurative Otitis (infected) B- Serous Otitis (non-infected)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 153 INFECTIOUS DISORDERS: Otitis Media Diagnosis Most common organisms: Streptococcus Pneumonia Hemophilus Influenza Translucency of TM is lost. The TM may be retracted and the middle ear- atelectic. Impaired mobility may be observed during pneumatic otoscopy.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 154 INFECTIOUS DISORDERS: Chronic Otomastoiditis Pathophysiology From an untreated / unresponsive acute Otomastoiditis. Characterized by thickened mucosa with obliteration of the mastoid air cell lumen, perivascular fibrosis, and osteitis. Polypoid granulomas may fill the mastoid antrum, the middle ear, and extrude through a tympanic perforation. Cholesteatoma (keratinized squamous epithelium) can invade the middle ear destroying the ossicles and labyrinth and pneumatized temporal bone cells. Producing conductive hearing loss and vertigo.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 155 INFECTIOUS DISORDERS: Cholesteatoma

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 156 INFECTIOUS DISORDERS: Mastoiditis

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 157 Intracranial Extension of Ear Infections

Background-from either acute otitis media or mastoiditis and bone destruction. Febrile patient w/ continued ear pain, mastoid pain, headache despite antibiotic treatment. ▪ Route of Spread may spread backward- ▪ 1. Direct extension 2. Hematogenous 3. Thrombophlebitis Resulting in:  Meningitis  Epidural Abscess  Sigmoid Sinus Thrombophlebitis  Brain Abscess Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 158 INFECTIOUS DISORDERS: Viral Vestibular Neuritis Pathophysiology-part of a systemic viral illness, i.e. measles, mumps and mono, HERPES SIMPLEX II A unilateral vestibular deficit (UVD), arising from a viral cause in most patients, results in either sudden deafness or acute prolonged vertigo with nystagmus rapidly beating (fast phase) toward the side of the lesion. This also results in a Yaw rotation toward the side of the lesion and a Roll tilt in the same direction. Acute symptoms usually abate within 3-5 days, but the patient may be left with the equivalent of a vestibular neuropathy. ▪ Diagnosis- 1. Caloric responses are decreased and/or absent on the side of the lesion. Ultra-high hearing loss. VNG abnormalities 2. Must be differentiated from other forms of labyrinthitis

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 159 INFECTIOUS DISORDERS Labyrinthitis

▪ A viral or bacterial infection of the fluid within the inner ear. ▪ Within one-week sufferers are usually able to sit up and after two weeks will begin to compensate for the dizziness/vertigo. Acute episodes usually end after one to two months. Although permanent vestibular damage may remain in some cases, most people recover fully from viral labyrinthitis. ▪ Labyrinthitis will classically affect hearing as well as balance which are also symptoms of an AICA stroke

Larry E. Masula, D.C., DACNB, FABVR,FAFICC 2/1/2020 160 Differential Diagnosis of Acute Peripheral Vestibulopathy

History Examination Laboratory Viral Developing over Normal except for ENG: caloric hypo Neurolabyrinthitis hours, resolving over signs of acute excitability days, prior flu-like unilateral vestibular Audio: may show illness loss ultrahigh frequency loss Bacterial Labyrinthitis Abrupt onset, hearing Signs of otitis media ENG: absent caloric loss, prior ear or meningitis Audio: sensorineural infections loss. CSF: Pleocytosis Labyrinthine Ischemia Abrupt onset w/ Signs of brainstem or ENG: absent caloric neurologic symptoms, cerebellar infarction Audio: sensorineural prior vascular disease loss Imaging: Brain infarction Perilymph Fistula Abrupt onset w/ head Positive fistula test, ENG: caloric hypo trauma, barotrauma, may be chronic otitis excitability or sudden strain w/ TM perforation Audio: usually lifting, coughing, sensorineural loss sneezing Imaging: CT may show erosion from cholesteatoma Larry E. Masula, D.C. 2/1/2020 161 Endolymphatic Hydrops (Meniere’s Syndrome)

Pathophysiology 1. An increase in the volume of endolymph distending the endolymphatic system 2. The labyrinth dilates until the saccular wall makes contact with the stapes footplate and the cochlear Scala 3. Hearing loss and vertigo are caused by ruptures in the membranes separating endolymph from perilymph causing a sudden increase in potassium which inhibits labyrinth receptors

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 162 Meniere’s cont.

Bacterial and viral. Majority unknown 1. Family history 50% of cases 2. Considered to be rare based on AMA epidemiological studies, perhaps as low as 1% of vertiginous patients ... Meniere's disease is an inner ear disease that typically affects one ear. This disease can cause a fullness, pressure or pain in the ear, severe cases of dizziness or vertigo, hearing loss and a ringing or roaring noise, also known as tinnitus.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 163 Perilymph Fistula’s

A perilymph fistula (PLF) may also cause vertigo, It is an abnormal connection (a tear or defect) in one or both of the small, thin membranes (the oval window or the round window) that separate the air- filled middle ear and the fluid filled perilymphatic space of the inner ear. This small opening allows perilymph (Na+ rich fluid) to leak into the middle ear. - See more at: http://vestibular.org/perilymph fistula#sthash.bcdq3m49.dpuf

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 164 Perilymph Fistula’s

Leaks through the round and oval windows can occur following; severe nose blowing, strenuous exercise, barotrauma, and surgical trauma.

The symptoms of perilymph fistula may include dizziness, vertigo, imbalance, nausea, and vomiting. Usually however, patients report an unsteadiness which increases with activities that elevate CSF pressure and which is relieved by rest. Some people experience ringing or fullness in the ears, and many notice a hearing loss. Most people with fistula’s find that they get worse with changes in altitude (fast elevators, airplanes, and travel over mountain passes.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 165 Perilymph Fistula Test

▪ The development of nystagmus in response to the application of pressure on the external auditory canal constitutes a positive result for the perilymph fistula test and suggests the presence of a fistula between the air- filled middle ear and the fluid-filled inner ear. ▪ Hosuk Chu, M.D., and Won-Ho Chung, M.D. N Engl J Med 2012; 366:e8 January 26, 2012 DOI: 10.1056/NEJMicm1010568

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 166 VINDICATE NEOPLASTIC - NEUROLOGICAL

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 167 Internal Acoustic Meatus for Facial Nerve and Vestibular Nerves

Acoustic neuromas are usually located in the angle between the cerebellum and the pons, in the back of the skull (posterior fossa) applying pressure in and around the internal acoustic meatus and may impair both Cn.7,8. Common symptoms are one- sided hearing loss, tinnitus, vertigo/dizziness and facial paralysis Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 168 NEOPLASM: Cerebellopontine Angle Tumors Lesions in the area of cerebellopontine angle cause signs and symptoms secondary to compression of nearby cranial nerves, including CN V, VII, VIII.

I.E., involvement of CN V from a cerebellopontine mass lesion often results in loss of the ipsilateral corneal reflex.

Patients with larger tumors can develop Bruns nystagmus due to compression of the cerebellar flocculi. Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 169 NEOPLASM: CPA Tumors

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020, 170 Br J Neurosurg. 2008 Jun;22(3):441-3. doi: 10.1080/02688690801911614. Cerebellopontine angle epidermoid tumor presenting with bilateral gaze nystagmus.

Han IB1, Huh R, Chung SS, Kim OJ. Abstract Vestibular symptoms have been rarely described in cerebellopontine angle epidermoid tumors. We report a case of CPA epidermoid tumor presenting with subacute onset of vestibular symptoms such as vertigo, gait ataxia, and nystagmus masquerading as acute vestibular neuritis or central vertigo. The vestibular symptoms disappeared after excision of the tumor. PMID: 18568737 [PubMed - indexed for MEDLINE]

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 171 Cerebellopontine angle epidermoid tumor

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 172 Clin Exp Otorhinolaryngol. 2012 Dec; 5(4): 234–236. Published online 2011 Sep 15. doi: 10.3342/ceo.2012.5.4.234 PMCID: PMC3506776 A Posterior Petrous Meningioma with Recurrent Vertigo Seong Jun Choi, MD,1 Jong Bin Lee, MD,1 Joon-Ho Bae, MD,1 Jung-Hee Yoon, MD,1 Ho-Jin Lee, MD,1 Chan-Ho Kim, MD,1 Keehyun Park, MD,2 and Yun-Hoon Choung, MD2 Abstract Meningioma's account for around 15% of all primary brain tumors with some 10% of meningioma's arising in the posterior fossa. In rare cases, a meningioma can form around the endolymphatic sac. When formed in the posterior fossa, meningioma tumors can produce vague, non-specific vertiginous symptoms. Research has observed that a subset of these lesions could produce symptoms indistinguishable from those of Meniere's disease. Therefore, we described the clinical features of a case of posterior petrous meningioma with recurrent vertigo as well as the substantial resolution of symptoms after tumor removal via transmastoid approach.

Larry E. Masula, D.C. 2/1/2020 173 NEOPLASMA: Acoustic Neuroma (vestibular schwannoma)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 174 Cerebellum: the Brain Behind the Brain

Larry E. Masula, D.C., DACNB, FABVR, FAFICC. 2/1/2020 175 Clinical Manifestations, (DDX)

▪ Tilting – ▪ Most likely cortical ▪ Falling forward or backward – ▪ Mesencephalic, medullary, Cb ▪ Exocentric Yaw axis ▪ Peripheral Nerve i.e. BPPV or (spinning) – vestibular nerve loss ▪ Egocentric Yaw axis (spinning) - ▪ Most likely cortical

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 176 Case report Rotational vertigo caused by cerebral lesions: Vertigo and areas 3av, 2v, and 7

▪ Eiichirou Urasaki, Akira Yokota ▪ Source Journal of Clinical Neuroscience > 2006 > 13 > 1 > 114-116 Abstract - We describe two patients complaining of vertigo associated with a small supra-tentorial convexity meningioma. Symptoms disappeared after tumor removal, providing evidence for an association between the vertigo and the cerebral cortical lesions. Tumors were located in the central and parietal areas, respectively, which are probably analogous to the vestibular cortex in the areas designated 3av, 2v, and 7 in animal studies *** Why you must check for non-vestibular cortical findings

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 177 Van Gogh

In an acute right sided process So, In Vincent's case on which such as vestibular neuritis, the side is the probable lesion? nuclei are initially excited, and The Right side. The slow phase the eyes exhibit a slow phase of gives an illusion that you are nystagmus pushing the eyes to moving to the right while the the left, the fast phase of world is moving left. nystagmus to the right. But, as time passes and the nerve dies Assuming that in his case it was the right side, is no longer an no longer an acute problem, the acute problem and the Left side Left side was no longer being that is no longer being inhibited inhibited by the right vestibular through the commissure appears nuclei and the left side appears overly active. The fast phase of overly active. nystagmus then switches, and The same is true in the acute the eyes beat Slow phase to the stage of a vascular insult right with a Fast phase back to the left. Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 178 Sir Gordon Morgan Holmes, (22 February 1876 – 29 December 1965) was a British neurologist. He is best known for his pioneering research into the cerebellum

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 179 Gordon Holmes, M.D.

1917, Dr. Holmes talked about the symptoms of acute cerebellar lesions due to WWI gun shot wounds and what he talked about is this,

“the brain (cortex) is fine but these people have these presentations that are very severe and involve aberrancies’ in the frontal cortex. It is also increasingly clear that there are extensive connections between the Cb and frontal associative areas of the cerebral cortex that fall well outside the classical sensory-motor circuit.”

▪ The Cerebellum. 2007; 6: 268-279

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 180 Functional Concepts A “BAD” Cb is known to be involved with:  Cognitive functions (ataxia of thought and represents erratic attempts to correct errors of thought or behavior)  Psychiatric Disturbances  Autonomic concomitants  Sensory Disturbances  Maintenance of Equilibrium  Breakdown in Coordination/Sequenced motor activity – walking, intention and terminal tremors (not at rest), eye movements w/ diminished pursuits and overshooting saccades. Intention tremors and terminal tremors.  Motor learning – motor skills  Monitor & predict  Horizontal & Vertical nystagmus w/ & w/o fixation  Scoliosis – genetic calcium channel mutation affecting midline Cb  Head tilt  Ocular deviations

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 181 Functional Concepts

▪ A “Bad” cerebellum may develop as a result of:  Alcohol degeneration  Thiamine deficiencies  Toxins  Concussion  Inflammation  Acute and hemorrhagic stroke  Inherited gene changes  Paraneoplastic disorders

Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 182 The cerebellum is organized anatomically and physiologically

▪ “ArchiCerebellum” Floculonodular Lobe ▪ “Paleocerebellum” Anterior Lobe ▪ “Neocerebellum” Posterior Lobe

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 183 Floculonodular Lobe Aka (ancient)ArchiCerebellum Aka Vestibulocerebellum ▪ Receives Input from the labyrinthine system with no involvement of the deep Cb nuclei ▪ This has influence over the axial musculature, some influence over Vestibular Ocular Reflexes and Vestibular Reflexes ▪ Flocculus/paraflocculus modulates the smoothness of pursuits and calibrates the rotational VOR ▪ Nodulus – calibrates VOR (from otoliths)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 184 Anterior Lobe Paleocerebellum (old-not ancient) Spinocerebellum

▪ Associated with upright stance, posture and bipedalism ▪ Limb coordination and feedback from extremities ▪ Controls proprioception related to postural muscle tone ▪ Axons extend to the deep Cb nuclei

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 185 Medial Zone (Vermis) ▪ Lesions in midline Cb (aka: Spinocerebellum) ▪ Gait instability ▪ Ataxia of trunk ▪ Titubation ▪ Breakdown in movements ▪ Saccadic dysmetria ▪ Vertiginous activity ▪ Note: findings may improve when lying down or with an increase in integrity into the system ▪ Ex: distract the patient’s neck and this fires midline Cb structures and the symptoms of the lesion reduce (ddx midline lesion versus lateral)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 186 Lateral Zone (aka Neocerebellum) Input: from the parietal cortex via the ponto-cerebellar mossy fiber projections

▪ The information is specific to the location of the body in space ▪ Integration of body position information, strength and speed

Output: Dentate nucleus projects to the cortex for cognition of movement. Aids in timing and planning and higher cognitive functions

 Note: no balance, equilibrium or gait disorders associated with the Neocerebellum

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 187 Comparing and Contrasting

Normal Cb Alcoholic Cb Note the folia atrophy

Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 188 Cerebellar Function

▪ Maintenance of Equilibrium  Balance, posture, eye movements ▪ Coordination/Sequenced motor activity  Walking gait ▪ Adjustment of Muscle Tone ▪ Motor Learning-Motor Skills ▪ Monitor & Prediction of Movement ▪ Cognitive Function-learning

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 189 Cerebellar Stroke

▪ A cerebellar stroke is one of the least common types of strokes. It occurs when a blood vessel is blocked or bleeding, causing complete interruption to a portion of the cerebellum. This type of stroke typically affects only one side or section of the cerebellum. It's also referred to as cerebellar stroke syndrome.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 190 Cerebellar Stroke

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 191 Clinical Signs: Ipsilateral Cerebellar Disease

(Flocculonodular Zone/Spinocerebellar lesions)

Abnormal Stance/Gait: a. Wide based, stumbling gait with truncal tremor, Falling/veering to side of the lesion, activities w/ increased speed/difficulty (tandem gait).

Titubation: rhythmic tremor of the body(trunk) and head. Note: must rule out BG lesion

Rotated/tilted head: not specific for side of lesion but related to eye movements

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 192 Clinical Signs: Cerebellar Disease

Dysdiadochokinesia: error in the rate of movements and completion of movement (rapid alternating) vs loss of smooth movement

Dysrhythmokinesis: errors in timing out a beat. Note: Interactive metronome used for both testing and rehab.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 193 Clinical Signs: Cerebellar Disease

Dysarthria: tremulous voice with errors in prosody and intonation (Vermal - medial zone lesions) Interference with articulation, respiration and phonation; slowness, scanning (stretch syllables)

Kinetic Tremor: (Cerebrocerebelar lateral zone lesions) greatly increases as movement nears target, when accuracy is most essential. Worse with fatigue

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 194 Clinical Signs: Cerebellar Disease

Abnormal Tone:  Hypotonia, joint laxity and pendular reflexes  Relates to the alpha-gamma co-activation

Abnormal check and rebound  Check - arms outstretched and tap wrist. Should return quickly to initial point  Rebound is excessive excursion during the attempted return to initial point

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 195 Clinical Signs: Cerebellar Disease Abnormal Ocular Motor Function: (Flocculonodular lobe lesions) Nystagmus: Gaze evoked Skew Deviation: in primary position, one eye is elevated () and other is depressed (hypotropia) Saccadic dysmetria: usually hypermetria due to failure to terminate the movement secondary to lesions in the Cerebellar Fastigium Impaired Smooth Pursuit Glissades (post saccadic drift) Alteration in VOR (due to improper termination/hypermetria)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 196 Cerebellar Tests

▪ Middle – Sharpened ▪ Intermediate - rapid Romberg’s, tandem gait, alternating movements w/ finger-nose-finger, saccade arms front, bent utilizing hypermetria, nystagmus, rapid pronation/supination, post rotational nystagmus, then windshield wiper head thrust tests, smooth motion, finger-nose-finger, pursuits heel to shin ▪ Lateral – piano playing, RAM w/ fingers, finer nose finger

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 197 Head tilts often have Cb lesions affecting their otolithic pathways

Normal Ocular tilt Reflex

Normally, tilt in the (YAW) roll plane to the right normally produces a reflex counter roll and Skew (hypertropic eye movement) towards the opposite side. If I lose my Cb Pathways on the Rt. the right eye remains extorted and what do I do to compensate for the extorsion? Tilt my head to the (left) opposite side.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 198 Head tilt

▪ You can no longer say that a left head tilt means a bad left Cb. I know some people instruct that from classes you may have taken but there are too many factors involved and that assumption is incorrect

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 199 Central Vestibular Disorders J Neurol (2007) 254:559-568

A tonic imbalance in YAW (rotation) is characterized by horizontal (torsional) nystagmus, lateralpulsion of the eyes, past-pointing, rotational and lateral body falls, and lateral deviation of the perceived straight-ahead. (Implicates a horizontal VOR type problem, i.e. vestibular nerve loss, Meniere’s, post vestibular neuronitis, or a Cb - fastigial n.). Turning ~ 35° in Fakuda test. DDX- CN8 entry into medulla, MVN, SVN, NPHypo., PPRF demyelination or ischemia)

A tonic imbalance in ROLL is defined by torsional nystagmus, skew deviation, ocular torsion, head tilt, body, and the perceived vertical. (Central...remember Van Gogh?, midbrain, paramedian thalamus or PIVC –parieto- insular- vestibular cx lesions)

Finally, a tonic imbalance in PITCH can be characterized by some forms of upbeat or downbeat nystagmus, for-aft tilts and falls, and vertical deviation of the perceived straight-ahead. (Central problem something in the midline dying off i.e. central flocculus, PPRF or bilat. medullary) WARNING…NOT GOOD!!!

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 200 EXAMINATION - VESTIBULAR ASSESSMENT

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 201 Tests performed in lighted room

▪ Identify any Spontaneous nystagmus Various tests are performed to ▪ Identify any (Gaze holding) evaluate the where and the nystagmus why the patient suffers ▪ Skew deviation ▪ Vergence vertigo. The following tests ▪ Decreased VOR are performed in a lighted i. Head thrust test room. ii. Dynamic visual acuity  Visual tracking i. Smooth pursuit ii. Saccadic eye movement iii. VOR cancellation  Gait and balance i. Feet together ii. Tandem iii. Single leg stance

Larry E. Masula, D.C.,DACNB, FABVR, FAFiCC 2/1/2020 202 Tests performed in dark

Tests performed using Frenzel lenses or infrared goggles (Real Eyes®)

 Spontaneous nystagmus  Gaze holding nystagmus  Decreased vestibular ocular reflex  Head thrust (head shaking nystagmus)

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 203 VOR

▪ The VOR maintains foveal fixation on a target during head movement. ▪ Head movement will not normally result in excessive eye movement and the eyes will remain focused on a target. This reflex functions to stabilize images on the retinas (when gaze is held steady on a target) during head movement by producing eye movements in the direction opposite to head movement, thus preserving the image on the center of the visual field(s). For example, when the head moves to the right, the eyes move to the left, and vice versa. ▪ Since slight head movement is present all the time, the VOR is necessary for stabilizing vision: patients whose VOR is impaired find it difficult to read print, because they cannot stabilize the eyes during small head movements, and also because damage to the VOR can cause vestibular nystagmus ▪ Patient symptoms of a bad VOR are therefore typically triggered by changes in head and or body position/movement in specific directions at specific speeds (frequencies) ▪ When Head and Eye coordination are out of sync during movement it is likely a sign of vestibulopathy.

Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 204 VOR (vestibulo-ocular reflex)

▪ A good Cb (flocculonodular lobe) is necessary for both suppression of the VOR during head movement and for slip-induced gain change i.e. OPK stimulation and head- thrust testing. ▪ VOR suppression. It can be suppressed by focusing on an object e.g., motion sickness, sea-sickness or ice skating. It is effective for peripheral lesions and has no effect on central pathologies

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 205 2 Forms of Nystagmus. Peripheral and Central

Peripheral Induced Nystagmus - Vertigo of peripheral origin generally manifests by horizontal nystagmus, rotatory nystagmus, or absent nystagmus, but horizontal nystagmus is not a specific sign of peripheral vertigo. Direction changing nystagmus (Central Induced Nystagmus) is the most common type of nystagmus observed in patients with cerebellar infarction. Vertical nystagmus is always considered specific for central pathology.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 206 Peripheral Causes of Nystagmus and

Vertigo Sequeala of Peripheral Vestibular BPPV-otoconia most often in the PC Dysfunction w/ down beating nystagmus Head tilt Acute Viral Labyrinthitis Cb dysfunction Vestibular system dysfunction Alcohol- lighter than blood so the hair Ipsi Neocortex dysfunction cells float in the endolymph and thins Torticollis blood affecting the anterior Difficulty compensating for perturbations of head position- functional imbalance Meniere’s Disease Worse with eyes closed because Toxins – especially antibiotics such a normal Cb and Frontal lobes as streptomycin and gentamycin can use vision to suppress the nystagmus

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 207 Here we seen in the far-left diagram, equal tonic input from both vestibular nuclei, equal 100 spikes/second, thus no perceived movement. In the middle diagram, during right head rotation, the right canal system and the right vestibular nuclei become excited and motion is detected rightward. In the far- right diagram there is a left sided vestibular deficit. The right side is no longer being inhibited and again the perception is a rightward rotation.

Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 208 Physiologic vs. Pathologic Nystagmus

Physiologic Pathologic Rotation-induced Spontaneous-the nystagmus is Caloric-Induced (cows) spontaneous and is best seen in remember fast phase names the darkness w/ goggles, because nystagmus the patient cannot fixate on Optokinetic stimulation objects in the room. The slow induced phase points to or looks at the lesion End Point- there is a point at which it usually slows and stops. The exception is a cupulolithiasis Central Nystagmus is not Fixating on a target suppresses the suppressed by fixating eyes on a nystagmus target

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 209 Central vs. Peripheral induced Nystagmus and vertigo ▪ Example – a patient presents with no nystagmus in light during fixation, but you see nystagmus in darkness without fixation ▪ Central or Peripheral lesion? ▪ Answer : fixation in light indicates central is ok therefore problem is peripheral ▪ If they cannot suppress it in the light with fixation= a central lesion

Larry E. Masula, D.C. DACNB, FABVR, FAFICC 2/1/2020 210 Oculomotor Examination Eye movement ROM (Cardinal Fields of Gaze)

Eye movement ROM Procedure (CFG): Hold patient’s head with one hand. Ask the patient to follow your finger (keeping it 18-24 inches away from the patient’s face) to test for full vertical and horizontal eye movements. Look for: • ROM • Conjugate eye movement Note: •  Vertical movements decrease slightly in older people  A small amount of “end point” nystagmus may be seen at the point of full ocular range in all directions, minimal in young people and increases with age

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 211 Tests performed in room light Spontaneous Nystagmus Procedure: Hold patient’s head with one hand. Ask patient to look straight ahead at a point several feet away. Look for: Nystagmus and note direction.

Gaze Holding Nystagmus Procedure: Hold patient’s head with one hand. Ask patient to follow your finger (keeping it 18-24 inches away from the patient’s face) while you move your finger 30 degrees to the left, right, up and down. Pause in each position to observe nystagmus, note direction.

Skew Deviation Procedure: Hold patient’s head with one hand. Cover one eye. Switch the cover from one eye to the other eye. Look for: a vertical corrective movement of the eye as it is uncovered. Note: Effect of direction of gaze on the skew deviation • Any spontaneous tilt of the head and the effect of tilt on the skew deviation

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 212 Oculomotor Examination Vergence Hold the patient’s forefinger in your hand about 2 feet away from the patient’s face. Ask the patient to focus on the finger while you move it toward the patient’s nose. Look for : Convergence of the eyes • Conjugate eye movement • Pupillary constriction

Head thrust test Used for evaluation of a decreased vestibular ocular reflex (VOR) Seated slow and fast-abnormal start pt. supine, progress to seated, then standing. Inform the patient that you will be moving their head very quickly, but only through a small range. Grasp patient’s head firmly with both hands on the sides of the head. Tilt the head forward 30 degrees so that the horizontal semicircular canal is level in the horizontal plane. Instruct the patient to look at your nose. Move the patient’s head side to side slowly. Then, suddenly move the patient’s head in one direction and stop. The head movement should be small amplitude with the position held at the end.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 213 Vestibular Ocular Pathway

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 214 As each FEF drive the eyes to the contralateral side, a lesion on the right will result in the eyes being deviated toward the side of the lesion

Larry E. Masula, D.C/, DACNB, FABVR, FAFICC. 2/1/2020 215 Dynamic Visual Acuity

While moving the patient’s head side to side at a frequency of 2Hz (2 complete side to side cycles per second) through a ROM of 1-2 inches in each direction, (so as to not restrict the visual field which may occur in patients who wear glasses) ask them to read the lowest line that they can until they cannot correctly identify all the letters on a given line.

Note the line and where this occurs and or the number of incorrect letters. A difference of less than or equal to 2 lines is normal. A difference of greater than or equal to 3 lines is abnormal. (likely vestibular deficit). If the patient has restriction of the cervical movement which limits your ability to perform the head movement the test cannot be properly performed and should be ceased.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 216 Smooth Pursuit eye movements Smooth-pursuit movements allow Ask the patient to follow your slowly moving finger (< 20 degrees per second) clear vision of a moving target by horizontally, 30 degrees from the center holding the image steady on the to the left and to the right fovea. Ask the patient to follow your slowly Smooth pursuit may be “jerky,” (ie, moving finger (< 20 degrees per second) inability to maintain the target on the horizontally, 30 degrees from the center fovea requiring a “catch-up” to the left and to the right saccade). Repeat vertically, moving 30 degrees above and below the horizontal. Patients with vestibular hypofunction Abnormal is jerky (or saccadic) Note: Eye who also have a central lesion exhibit movements may be saccadic if you are moving your finger too fast. Slow the impaired smooth pursuits. speed of your finger to see if the person Impaired smooth pursuit and can follow smoothly. optokinetic nystagmus is mainly seen Smooth pursuit eye movements become more and more saccadic with age. ipsilateral to pontine damage which Vertical eye movement is often is a crucial relay area between the interrupted by a saccades in younger cerebral cortex and the cerebellum . individuals.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 217 Saccadic eye movements

Hold the patient’s head with one hand. Hold your finger about 15 degrees to one side of your nose. Ask the patient to look at your finger and then at your nose several times. Perform this left, right, up and down. Look for: The number of eye movements it takes for the patient’s eyes to reach the target, normal is less than 2. Abnormal is several small movements or a big movement with an overshoot. (Hypermetria)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 218 VOR Cancellation

The test is used principally to assess whether patient symptoms are attributable to a vestibulocerebellar lesion. Remember visual fixation cancels the VOR if it is of peripheral causation. The nystagmus can often times be suppressed by visual fixation if the cause is peripheral

The VOR is essential for maintaining stable vision on a target when the head is moving but the brain must also have a mechanism for suppressing the VOR when it is necessary to move the head and eyes in the same direction. This task is managed by the vesstibulocerebellum (Flocculonodular lobe). Failure to suppress the VOR indicates probable vestibulocerebellar (central) contribution to the patient's vertigo.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 219 VOR Cancellation

Grasp the sides of the patient’s head firmly with both hands. Tilt the head forward 30 degrees so that the horizontal semicircular canal is level in the horizontal plane. Instruct the patient to look at your nose. Move the patient’s head from side to side approximately 30 degrees while you move in the same direction so that your face remains directly in front of the patient’s face. Look for: Patient’s ability to maintain visual fixation and/or if the patient makes saccadic eye movements.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 220 BESS Test The Balance Error Scoring System: provides a portable, cost‐effective, and objective method of assessing static postural stability. In the absence of expensive, sophisticated postural stability assessment tools, the BESS can be used to assess the effects of mild head injury on static postural stability. Information obtained from this clinical balance tool can be used to assist clinicians in making return to play decisions following mild head injury.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 221 While this is most often used for concussion assessment, it provides great patient feedback as to the integrity of their balance system

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 222 Optokinetic Eye Movements

The optokinetic (OPK) tape is an essential part of the functional neurologist's toolkit. It can be used to evaluate optokinetic nystagmus, which provides a window of assessment into the functionality of the frontal lobe, parietal lobe, cerebellum and other brain regions involved in the generation and control of optokinetic eye movements.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 223 Tests best performed using Frenzel lenses or IR goggles

Look for any horizontal nystagmus which is the most common form of nystagmus observed with cerebellar infarction.

Spontaneous nystagmus denotes movement of the eyes without a cognitive, visual or vestibular stimulus. Most commonly spontaneous nystagmus is caused by a vestibular imbalance. Normally, both vestibular nerves fire equally at a tonic rate.

Hold patient’s head with one hand. Ask patient to look straight ahead. Look for: Nystagmus and note direction.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 224 Head Shaking Nystagmus Test

Used to determine the presence of a decreased Vestibular Ocular Reflex (VOR)

Procedure: Inform the patient you will be moving their head from side to side. Grasp patient’s head firmly with one hand on either side of the head. Tilt the head forward 30 degrees so that the horizontal semicircular canal is level in the horizontal plane. Have the patient close their eyes. Move the head side to side 20 times, asking the patient to help with the movement.

Ask patient to open their eyes quickly. Look for: Nystagmus, noting direction . 1 or 2 beats of nystagmus is not significant. If horizontal head shaking induces persistent nystagmus the procedure should be repeated vertically, but only moving the patient’s head 10 times.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 225 Positional Testing

▪ Can help identify peripheral or central causes of vertigo. ▪ The most common positional vertigo is BPPV due to free- floating calcium carbonate debris from the otolithic organs which enters one of the semicircular canals – usually in the posterior semicircular canal – occasionally horizontal canal and rarely the anterior canal

▪ The characteristic burst of upbeat torsional nystagmus is triggered in patients with BPPV by a rapid change from the sitting-up position to supine head-hanging left or head-hanging right (Dix-Hallpike test for BPPV). ▪ A burst of nystagmus in the opposite direction (downbeat torsional) occurs when the patient sits up

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020, 226 Dix Hallpike Test for Posterior Canal BPPV Patient seated on table and head is rotated 450 The head and trunk are quickly taken straight back so the head is over the edge of the table. Hold 30-45 seconds, observing for nystagmus and question for vertigo. (latency of 5-10 sec.). Patient is then brought up slowly to a sitting position with the head maintained in 450 rotation. Again, observe for nystagmus and question for vertigo. Test is repeated with head rotated 450 in opposite direction. Look for: Up beating or down beating Nystagmus, indicative of central lesion. Note: Critical element is position of the head in space (not relative to the body).

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020, 227 Head roll test for Horizontal canal BPPV Procedure: patient is supine with the head flexed 20 degrees. Head is turned quickly to one side. Hold 30 seconds, observing for nystagmus and question for vertigo. Roll the head slowly back to the supine position, hold for 30 seconds. Roll the head quickly to the other side. Observe for nystagmus/vertigo. Observe nystagmus, noting direction, latency and duration. Ask the patient which side is worse.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 228 Imaging

▪ To rule out central causes of vertigo ▪ CT scan can rule out a large mass with exception of smaller lesions due to infarct and poor resolution in the posterior fossa. (Chalela et al. 2007) ▪ MRI imaging is the modality of choice especially if the patient has focal neurological symptoms or is having unexplained neurological deficits, direction changing nystagmus, or an otherwise rapid, unexplained progression of symptoms. ▪ BPPV, vestibular neuritis, or Meniere’s disease do not require imaging

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 229 Additional Testing

▪ Berg Balance Scale ▪ Dynamic Gait Index ▪ Modified Clinical Test of Sensory Interaction in Balance (mCTSIB)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 230 VESTIBULAR ASSESSMENT AND TREATMENT

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 231 VRT(vestibular rehabilitation therapy) Therapeutic Goals ▪ Enhance existing vestibular capabilities ▪ Strengthen compensatory mechanisms  By improving Proprioceptive input  By increasing Visual Input  Other sensory systems

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 232 Vestibular Adaptation and

Compensation Thomas P. Wellings*, Alan M. Brichta and Rebecca Lim School of Biomedical Sciences and Pharmacy, The University of Newcastle, and Hunter Medical Research Institute, NSW, Australia

The balance or vestibular system is often overlooked as a major sensory system (Goldberg et al. 2012). Even less appreciated is the vestibular system’s inherent plasticity and capacity for self repair.

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 233 Vestibular Adaptation (compensation) Exercises ▪ Vestibular adaptation describes the routine changes in sensitivity (gain) of reflexive eye movements (VOR) responsible for stabilizing images on the retina during head movements. ▪ This may not be possible with an MS patient who develops demyelination of the vestibular nerve and the medial longitudinal fasciculus which yokes eye movements and may result in (Yaw) rotation

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 234 Vestibular Habituation Exercises A large amount of end point nystagmus may be seen with increasing age. The goal of habituation exercise is to reduce the dizziness through repeated exposure to specific movements or visual stimuli that provokes the patients' dizziness. These exercises are designed to mildly, or at the most moderately, provoke the patients' symptoms of dizziness.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 235 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 236 Benign Positional Vertigo (BPPV) There are Two Forms: Canalithiasis and Cupulolithiasis. Canalithiasis (otoconia is free in the canal) and is the single most common cause of vertigo lasting less than 30 seconds with position change-typically when turning over in bed, getting in and out of bed, bending over and straightening up, and extending the neck to look up. Cupulolithiasis (otoconia stuck to the cupula) causes immediate vertigo and nystagmus and does not fatigue.

Barany- found lesions of the otolith organs. Dix-Hallpike- found unilateral degeneration of the utricular macula at necropsy. Schuknecht-found basophilic deposits on the cupulae of the posterior canal proposing otoconia from degenerating utricular macula settles on the cupula of the posterior canals Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 237 BPPV

▪ Most common cause of vertigo in the general population ▪ Patients typically experience brief episodes of vertigo when getting in and out of bed, turning in bed, bending down and straightening up, or extending the head back to look up ▪ Repositioning maneuvers are highly effective

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 238 It is important to realize that eye movement alone or head movements alone, will have extremely limited benefit. Introduction of head movement together with visual acuity, (within the frequency of the VOR) , is extremely beneficial at repairing a damaged system. Larry E. Masula, D.C., FABVR, FAFICC 2/1/2020 239 Management

He following therapies are specific for lesions in the affected canal system 1. Epley Maneuver - PC 2. Semont Maneuver – PC 3. Lempert Maneuver – HC 4. Gufoni Maneuver – HC 5. Reverse Dix Hallpike – AC 6. Reverse Epley - AC

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 240 Posterior Canal BPPV

Two most convincing pieces of clinical evidence supporting a posterior canal are: ▪ 1. The positional nystagmus is in the plane of the posterior canal ▪ 2. Sectioning of the ampullary nerve from the posterior canal stops BPPV ▪ Schuknecht’s cupulolithasis theory is supported by any type of damage to the inner ear (trauma, infection, ischemia, age related degeneration) which can lead to dislodging of the calcium carbonate crystals from the otolith and deposition on the cupula of the posterior semicircular canal

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 241 Posterior Canal BPPV

Diagnosis- 1. Rests on finding the characteristic fatigable paroxysmal positional nystagmus. The Nystagmus is torsional and in the plane of the affected canal. 2. Caloric hypo excitability is seen on the ipsilateral side presumably involving both the horizontal and posterior canals 3. Canals may also be tested w/o eye fixation in a Dis- Halpike position (Frenzel lenses) for better optimization

▪ Management- positional exercises. Epley or Semont. Resume upright position once the vertigo has ceased. Repeat x 3 - t.i.d.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 242 Dix-Hallpike Test for posterior canal BPPV Explain procedure to patient Positive test: – Rotatory beforehand that it might (torsional) nystagmus (& induce vertigo. Ensure that vertigo): • Diseased ear there are no neck/back downmost problems that would be 3 important features include: aggravated by sudden change in posture. Stand to the side ▪ Latency – delay of up to 20 of the patient • Pt sitting with seconds before onset of head turned to examiner • Pt nystagmus sat so that when supine, the ▪ Fatigueability – nystagmus head will be beyond the end fades if head held in of the couch • Patient lain flat provoking position in one quick, smooth ▪ Habituation – Repeating movement • Eyes must stay DH test produces less open • Repeat on other side. vigorous response

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 243 Interpretation of Dix Hallpike Test

Consider central problem if any of the following occur: ▪ Non-rotatory nystagmus ▪ No latency ▪ No fatiguability ▪ No habituation

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 244 Posterior Canal Rehab.

▪ Semont ▪ Epley

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 245 Epley Maneuver-posterior canal

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 246 Semont Maneuver - Right PC

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 247 Roll Test for Horizontal Canal BPPV (Herdman, 2007) Patient lies supine with neck flexed 20º, head is quickly rolled 90º to one side to orient the horizontal canal. Hold for up to one minute and observe presence & direction of nystagmus, and then return slowly to midline; maintaining the neck flexion, the procedure is repeated to the other side. Note patient report of vertigo.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 248 Roll Test, Interpretation

Horizontal canalithiasis – nystagmus is geotropic (toward the earth) when the head is rolled to the right and left, and lasts a short duration (approximately <60 seconds)

Horizontal cupulolithiasis – nystagmus is apogeotropic (away from the earth) when the head is rolled right and left, and it is persistent (>60 seconds)

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 249 Horizontal Canal Rehab.

▪ Gufoni Maneuver ▪ Lempert Maneuver

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 250 Gufoni Maneuver - Horizontal Canal rehab.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 251 Lempert Maneuver (BBQ Roll) Horizontal Canal rehab.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 252 Rehab. Gem

▪ Vestibular rehabilitation utilizing Otolith stimulation (A/P and Up/down) also provides lot of frontal lobe stimulation. This application may also useful for ADD kids with right frontal lobe problems. ▪ Special Note: All the testing maneuvers previously mentioned are aides to identify the canal most likely to be generating the vertigo, but they are also extremely beneficial and frequently used for canal rehabilitation as well.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 253 VOR Gaze stabilization rehab.

X1 viewing exercise, may be used for rehabilitating the dizzy patient with gaze holding failure. While seated keep eyes fixed on single stationary target held in hand or placed on wall move head side to side. Repeat while moving head up and down. This like all tests should be performed both sitting and standing.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 254 VOR rehab: X1 viewing

Head/eyes moving in same direction Holding a single target, keep eyes fixed on target. Slowly move target, head and eyes in same direction up-down/ side to side/diagonally

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 255 VOR rehab: X2 viewing

Head/eyes moving in opposite direction Holding a single target, keep eyes fixed on target. Slowly move target up- down/side to side/diagonally while moving head in opposite direction of target

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 256 Saccades Rehabilitation

Holding two stationary targets placed inches apart side-to- side/up-down/diagonally, move eyes quickly from target to target as head stays still.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 257 Cawthorne Cooksey Exercises

▪ Were devised in the 1940’s ▪ Mainly for vestibular lesions ▪ Initially, the exercises performed are slow gradually increasing speed as patient tolerates the movement ▪ The patient should experience an increase in symptoms with movement ▪ Exercises performed for at least 1 minute several times each day for adaptation to occur

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 258 Have a Vestibular Questionnaire

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 259 Additional Rehab. Strategies

▪ OPK ▪ Cb Rehab Exercises ▪ Head Laser Maze ▪ NSI Unit ▪ Metronome ▪ Simon ▪ Gaze Stability - Dots on Wall ▪ Wii ▪ Fit Ball ▪ Wobble Board ▪ Mini Trampoline

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 260 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 261 Thanks for taking Online Courses with Back To Chiropractic CE Seminars. I hope you enjoyed the course. Please feel free to provide feedback.

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