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

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By: Larry E. Masula, D.C., DACNB, FABVR, FAFICC Dipolmate American Chiropractic Neurology Board Neurology: The Fellow American Board of Vestibular Rehabilitation Fellow Academy of Forensic and Industrial Chiropractic Dizzy Patient Consultants Basic Version • [email protected]

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 3 • Carrick Institute for Advanced Neurological Studies: Frederick C. Carrick, PhD, Cambridge University. • Diplomate American Chiropractic Neurology Board • Fellow American Board of Vestibular Rehabilitation Larry E. • Fellow Academy of Forensic and Industrial Chiropractic Consultants Masula, DC, • Evaluation and Management of Dizziness and Balance Disorders, Neil T. Shepard , PhD, director of the Dizziness and Balance Disorders Program at the Mayo DACNB, 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 FABVR, Washington University School of Medicine, St. Louis, MO • American Institute of Continuing Medical Education, FAFICC Certified in 101 Vestibular Rehabilitation, 201 Ocular Motor Testing, 202 Gaze, Headshake and Positional Testing. Richard E. GANS, PH.D A basic overview of the clinical anatomy and physiology of the vestibular system and the Objectives posterior fossa (cavity) will be discussed with emphasis on diagnostics and chiropractic management. • 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 Recommended Cerebellar Dysfunction • Neurological Differential Diagnosis, 2nd Edition, John Patten, Reading 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 • Patient Care and Safety are Preeminent • As there are (9.47%) or 31 million Americans who experience lower back pain at any given time, www.acatoday.org/backpain, there are (21.1%) or 69 million US adults aged 40 years and older who have vestibular Why Study dysfunction. Disorders of Balance and Vestibular Function in US Adults. Data Dizziness From the National Health and Nutrition Examination Survey, 2001-2004 • There is a Great Need for Skilled Examiners What is Dizziness and Vertigo?

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 8 Vertigo and Either an unpleasant Disturbance of Spatial Dizziness Orientation are or The Illusory perception of body movement considered: (spinning, wobbling, or tilting) and/or of the surroundings • Dizziness refers to various abnormal sensations relating to perception of the body’s relationship to space. Dizziness / • Dizziness – may also represent a variety of symptoms which may include spinning, or Vertigo movement of the environment, light- headedness, presyncope, or imbalance while walking Centers for Disease Control and Prevention • Dizziness and its related balance system disorder frequently results in falls which are potentially 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 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 . 11 The Burden Dizziness and Vertigo Impose on the Community Dizziness is the third most common major medical symptom reported in general medical clinics1

• 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]

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 12 Assessment of a patient with dizziness and/or imbalance complaints must commence with a basic understanding of the vestibular system

Larry E. Masula, D.C., DACNB, FABVR, FAFICC • The vestibular system, in vertebrates, is part of the inner ear. In most mammals, the vestibular system is the sensory system that provides the leading contribution to the sense of balance and spatial orientation for the purpose of coordinating movement with balance. • As movements consist of rotations and translations, Vestibular the peripheral vestibular system comprises 3 components: System • 1. the semicircular canals which indicate rotational movements; • 2. the otoliths which indicate linear accelerations. • 3. the vestibular (8th) cranial nerve which transmits this information to central structures

• Larry E. Masula, D.C., DACNB, FABVR, FAFICC The ear is made up of three parts: 1. the outer or external ear 2. the middle ear 3. the inner ear. Anatomy of All three parts of the ear are important for detecting sound by working together to move sound from the outer part through the middle and into the inner part of the the ear. Ears also help to maintain balance. Outer Ear, Middle Ear, and Inner Ear

• Larry E. Masula, D.C., DACNB, FABVR, FAFICC The Outer “External” Ear

• The outer ear includes: • Auricle (cartilage covered by skin placed on opposite sides of the head) • External auditory canal (also called the ear canal) • Eardrum outer layer (also called the tympanic membrane) • The outer part of the ear collects sound energy. Sound travels through the auricle and the external auditory canal which is a short tube that ends at the eardrum (tympanic membrane).

Larry E. Masula, D.C., DACNB, FABVR, FAFICC The Middle Ear (also called the tympanic cavity)

• The middle ear includes: • Eardrum (tympanic membrane) • Eustachian Tube (auditory tube) - drains fluid from the middle ear into the nasopharynx behind the nose and equalizes pressure with the external environment. • Ossicles (3 tiny bones that are attached) • Malleus (or hammer) - long handle attached to the eardrum • Incus (or anvil) - the bridge bone between the malleus and the stapes • Stapes (or stirrup) - the footplate; the smallest bone in the body

Larry E. Masula, D.C., DACNB, FABVR, FAFICC The Inner Ear

• The inner ear includes: • Oval window - connects the middle ear with the inner ear • Semicircular ducts - filled with fluid; attached to cochlea and nerves; send information on balance and head position to the brain • Cochlea - spiral-shaped organ of hearing; transforms sound into signals that get sent to the brain

Larry E. Masula, D.C., DACNB, FABVR, FAFICC The Vestibular System

As head and body movements consist of rotations and translations, the vestibular system comprises two components: 1. the semicircular canals which sense rotational movements 2. the otoliths which sense linear accelerations. Important Structures include: Int. Auditory meatus, Cochlea, SCC’s, Cn7, Cn 8, Eustachian tube anteriorly, Mastoid air cells post.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 19 The Inner Ear contains both a Bony Labyrinth and a Membranous Labyrinth. Think of it as a bony shell (formed by the Temporal bones of the skull) and within this shell there is a membranous duplication. 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 Membranous and Bony periosteum. Labyrinth

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

Membranous Labyrinth

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 21 • Between the bony labyrinth and the membranous labyrinth there is a collection of fluid called Perilymph which is rich in sodium (Na+)

• The fluid contained within the membranous labyrinth is called Endolymph which is rich in Perilymph and potassium (K+) Endolymph

• Larry E. Masula, D.C., DACNB, FABVR, FAFICC In this slide, the Cochlea is “unraveled”.

The middle ear functions as an amplifier to the cochlea.

Sound enters through the external auditory canal (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 Cochlea via the stapes bone.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 23 Let’s Dive into the Anatomy

ANATOMY

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR,FAFICC 24 The middle ear is composed of 4 walls, a roof and floor. Contents include the ossicles: • Hammer (malleolus) • Anvil (incus) Larry E. Masula, D.C., DACNB, FABVR,FAFICC • Stirrup (stapes) Lateral Wall of Middle Ear aka (Tympanic Wall)

The Ear drum (tympanic membrane) comprises the lateral wall of the middle ear. Examination: of the tympanic membrane with an otoscope reveals various structures which include: Pars flaccida which 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 2/1/2020 Larry E. Masula, D.C. 26 , , Nerve Supply to (ear drum) Tympanic Membrane

• Sensory innervation of the skin on the outer surface of the tympanic membrane is primarily by the trigeminal nerve (V) with additional participation of the facial (VII) and the Vagus (X) nerves.

• Sensory innervation of the mucous membrane on the inner surface of the tympanic membrane is carried entirely by the glossopharyngeal (IX) nerve •

27 Medial Wall aka (Labyrinthine Wall)

Here we are looking into the middle ear with the lateral wall (ear drum) removed. The ossicles are also removed to better view the additional structures. Understanding the existence of the internal contents will greatly improve your diagnostic skills, as you will see later.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 28 Contents of • Air • Vessels (Anterior • Ossicles (Malleus, tympanic artery, Middle Ear Incus, Stapes) all Posterior tympanic attached via synovial artery) summary joints • All structures are lined • Muscles (Stapedius, by mucosa Tensor Tympani Tendon) • Nerves

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 29 Understanding Vestibular Neurophysiology

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 30 Cellular Survival is dependent upon

• Normal survival of all neuronal structures including those of the vestibular system are most dependent upon adequate Fuel (in the form of glucose and oxygen) and Activation • This principle must be taken in context as an abnormal metabolic demand, a toxic or inflamed environment may alter the central integrative state of the neuron.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC • We are talking specifically about the dizzy patient; therefore it is important to understand the frequency of activation of All presynaptic input into the vestibular system specifically the vestibular nucleus which resides in the medulla. • It is also very important to identify and manage any Dysglycemia, Hypoglycemia, Metabolic Syndrome, Insulin resistance. (Altered fuel – glucose) may negatively impact normal function and significantly impact recovery. • This also applies to (fuel – O2). It is essential to rule Altered out any underlying anemias. • Improper fat and protein intake may similarly alter Cellular neuronal membrane structure and function. When evaluating and treating the dizzy patient, dietary intake must be evaluated as to avoid less than Survival optimal results • Inflammatory conditions, infections and autoimmunity likewise may result in abnormal cellular function and therefore must be viewed as a potential cause. • These issues must be addressed if you are to treat the dizzy patient. • A less understood complication of diabetes is the effect on the vestibular system. It is noteworthy that diabetes has been reported to Altered affect vestibular function in both animal and clinical studies. Cellular • Pathophysiological changes in peripheral and central vestibular structures due Survival to diabetes have been noted. • Impact of Diabetic Complications on Balance and Falls: Contribution of the Vestibular System. Phys Ther. 2016 Mar; 96 (3) 400-409 34

Anatomy and Physiology of the Vestibular System Expressed simply, the role of the vestibular sensory organs is to transduce the forces associated with head acceleration and gravity into a biologic Vestibular signal. Function: The control centers in the brain use this signal to develop a subjective awareness of head position in relation to the body and to the environment to produce motor reflexes for equilibrium.

Larry E. Masula, D.C., DACNB, FABVR, FAFiCC 2/1/2020 35 The force associated with head acceleration generates a signal in the labyrinth that is proportional to head acceleration, meaning there is a 1:1 ratio between movement of the Vestibular canals and movement of the head. Function: Overview The overall objective of the CNS is to compute this head position by performing the continued equivalent of a mathematical integration of the labyrinthine and otolithic input signals into the brainstem and cerebellum.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 36 2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFCC 37 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.

Vestibular The Cristae Ampularis, the sensory organ of the 3 semicircular canals senses angular Nerve acceleration of the head Physiology

The Otolithic Organs (saccule and utricle) sensory organ the Maculae senses linear acceleration.

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 38 The semicircular canals provide sensory input about head velocity, which enables us to generate an eye movement that matches the velocity of the head movement which is The Semi- also a 1:1 ratio. This is called the vestibular ocular reflex Circular (VOR). Briefly, this mechanism results in the eye remaining still in space during head Canals motion, enabling clear vision. If this was not present our eyes would bounce with every step. When the VOR is impaired we cannot move our head rapidly without getting dizzy.

Semi-Circular Canals • 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 41 2/1/2020 Cristae Ampularis - is the sensory organ for the canals

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 42 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

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 43 • Angular movement of the head causes endolymph flow in one of the semicircular canals to move opposite canal movement to deflect the cupula. • There are 2 types of hair-like fibers within the cupula. Stereocilia and a Large Kinocilia. Activation of Deflection of the stereocilia toward the kinocilium results in depolarization or firing of the Sensory the vestibular nerve. • Deflection of the stereocilia away from the Hair Cells kinocilium results in hyperpolarization, or a decreased firing rate of the vestibular nerve. • For this reason, understanding function is key to providing treatment which will result in either a good outcome or no outcome at all. To say it differently, the coplanar pairing of the canals is associated with a push- pull change in the semicircular canals Semi- output. When head motion occurs, the endolymph of Circular the coplanar pair of canals is displaced in opposite directions with respect to their Canals ampullae. This results in a neural firing increase in one vestibular nerve and a decrease (hyperpolarization) on the opposite side. • When the canals become activated via a head motion, the activated canals each fire the VOR vestibular nerve to the vestibular nucleus to move coplanar pairs of eye muscles for stabilization. Identifying abnormal eye movements is often key to determining the impaired canal which requires treatment

Otolith Function

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

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 49 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.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 50 Vestibular Ocular Reflex and Vestibular Spinal Reflex • When activated both the semicircular canals and the otolithic organs through the vestibular nucleus activate eye muscles and they activate spinal musculature for stabilization purposes. • More about this later Vestibular Nerve Physiology

Let’s understand a little about the circuitry which makes this all work. Each vestibular neuron fires tonically (all the time) at a resting rate of approximately 90-100 spikes per second. Upon activation these peripheral vestibular nerves have two main targets: 1. the vestibular nuclear complex 2. the cerebellum

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 52 Vestibular Nuclei Complex

4 Major Nuclei 1. Superior Vestibular Nucleus 2. Medial Vestibular Nucleus 3. Lateral Vestibular Nucleus 4. Inferior Vestibular Nucleus

2/1/2020 Larry E. Masula, D.C. DACNB , FABVR, FAFICC 53 The vestibular nucleus on either side of the brainstem is a multi functional nucleus with two very important functions. 1. it tells you where your head is relative to Vestibular gravity and where gravity is relative to your head. Nucleus 2. it establishes appropriate postural reflexes i.e., the vestibular ocular reflex (VOR) and Function the vestibular spinal reflexes (VSR). 3. The vestibulocollic reflex. The VCR acts on the neck musculature to stabilize the head. 1. Maintain posture. 2. Evoke extensor musculature activity above T6 and below T6 to compensate for gravitational forces. A patient with a unilateral vestibular loss will therefore most likely exhibit ipsilateral extensor hypotonia Vestibulospinal 3. Produce “kinetic” contractions of muscles for Reflexes 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 • The VOR normally acts to maintain stable clear vision when the head moves. This means that the eye must precisely counter-rotate to compensate for the head and keep the eye stable in space. • We live in a world where we can both rotate and translate (i.e. move along a line), along 3 axes. Thus, Vestibular the VOR has two components, angular and linear. • An abnormal VOR results in a retinal slip. When the eyes slip off a target , the result is a sensory Ocular mismatch and the patient feels dizzy. • Visual motion sensitivity and symptoms of Reflex dizziness in large crowds, cars, grocery stores or shopping malls are extremely common for people suffering from a concussion or persistent symptoms. • We will later learn how to identify a bad VOR and what to do for it. Differential Diagnosis

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 57 • Benign paroxysmal positional vertigo There are • Vestibular neuronitis various • Recurrent vestibulopathy conditions • Meniere’s disease which affect • Head trauma (labyrinthine concussion) • Otosclerosis our peripheral • Herpes zoster oticus vestibular • Cholesteatoma system that • Perilymph fistula lead to vertigo • Aminoglycoside (antibiotics) ototoxicity Peripheral and • We have a peripheral vestibular system which is everything up to the brainstem meaning the Central semicircular canals, the otolithic organs and the Vestibular vestibular nerve. • We also possess a central vestibular system System which comprises the brainstem, cerebellum, Structures pathways to the thalamus and the cortex • Central vertigo may be caused by hemorrhagic or ischemic insults to the cerebellum (see the image below), the vestibular nuclei, and their connections within the brain stem. Other causes include CNS tumors, infection, trauma, and multiple Central Causes sclerosis. of Vertigo

• Larry E. Masula, D.C., DACNB, FABVR, FAFICC BPPV 18.3%

Phobic Postural Vertigo 15.9% Most Frequent (Peripheral induced) Central Vestibular Vertigo 13.5% Vertigo Syndromes Vestibular Migraine 9.6% Diagnosed in a Dedicated Neurological Vestibular Neuritis 7.9% Dizziness Unit (N=4790) Vertigo and Meniere’s Disease 7.8% Dizziness by Brandt, Dietrich, and Strupp- Vestibular Paroxysmia 2.9% 2005 Perilymph Fistula 0.4%

Unknown 4.2%

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 61 Nothing Replaces a Good Bedside Neurological Examination for determining the cause of a patient’s dizziness

2/1/2020

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 62 History and physical examination provide the most important information

Often, patients have difficulty describing the exact symptom experienced Case History The first step is to define the symptom. Helpful hint: I often ask the patient to describe their symptoms without using the word dizziness

Case history information may indicate a need for modification of screening or evaluation procedures. Because the term dizziness can describe varying symptoms, and each patient may have a different idea of what dizziness means, a thorough case Larry E. Masula, D.C., DACNB, FABVR, FAFICC history is vital (Dye, 2008) 2/1/2020 63 • Collection of results from other health professionals A case • Fall risk data (number of previous falls, gait, history, mentation, reaction time, vision ) specific to • Symptoms constant or episodic • Accompanying symptoms balance, • How did it begin (gradual / sudden) may include • Aggravating or alleviating factors • If episodic, what was the duration and the following: frequency of attacks, and what were the triggers • A general medical examination is important • Postural hypotension measurement • Orthostatic hypotension – probably the most common Physical • Identifying an irregular cardiac rhythm may Examination help • Other measures to consider include a visual assessment and a musculoskeletal inspection (significant for arthritis and peripheral neuropathy) • Performing appropriate screening measures may determine the need for further assessment, referrals and/or a management plan when a patient reports dizziness or balance problems . Screening

• Larry E. Masula, D.C., DACNB, FABVR, FAFICC • Physical examination is very important in patients complaining of Vertigo because it can be the earliest symptom of a neurodegenerative disorder. • Vertigo can also be an important symptoms of stroke, tumor, demyelination, or other pathologies of the nervous system. • The cranial nerves should be assessed. • V – Vascular • I _ Infectious • N – Neoplastic, Neurological Bedside Diagnostic • D – Degenerative “Gems” mnemonic. • I – Inflammatory The following is a near fool-proof • C – Connective tissue/muscle method for patient • A – Autoimmune assessment. • T – Trauma • E – Endocrine/environmental • S - Soft tissue 69

Vascular “VINDICATES” We will now look at various vascular syndromes which may contribute to dizziness • Using the mnemonic VINDICATES vascular is always your first consideration. Many vascular disorders may generate dizziness or lightheadedness. Therefore, Everything should be Considered Vascular Until Proven Otherwise VASCULAR: • Arrhythmias Cardiovascular • Tachycardia Disease and • Bradycardia • Ischemic cardiomyopathy Cerebrovascular • Vasovagal syncope Disease • Carotid sinus hypersensitivity • Conduction blocks w/ elongation of the PR interval • Brain ischemia • Etc. Common symptoms found in most brainstem lesions include diplopia, dysarthria, Vascular 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. • Overall, dizziness and vertigo are the symptoms most tightly linked to missed stroke. Given their Dizziness and low sensitivity (7%–16%),12 computed tomography (CT) scans are of little use for Stroke identifying acute ischemic strokes,13 particularly in the posterior fossa. Feb 19, 2018 Clinical Case. Your patient presents with the following: What is the diagnosis? Wallenberg Syndrome

• 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

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 73 Lateral Medullary Syndrome aka: Wallenberg Syndrome (posterior inferior Cb artery)

This is reasonably the most common form of stroke that enters the chiropractic office

Larry E. Masula, D.C. DACNB., FABVR, FAFICC 74 2/1/2020 • A rapid, bedside test to help differentiate central from peripheral vertigo would therefore have great value. The HINTS exam has been proposed as just such a HINTS to test. HINTS stands for Head Impulse, Nystagmus, and Test of Skew, and is a INFARCT three-part oculomotor test. If any portion of the test indicates a central etiology, the test is considered positive and further evaluation for stroke (or other central pathology) is warranted. H.I.N.T.S Testing Battery

1. Head Impulse Test - Patients with peripheral vertigo will have abnormal (positive) head impulse testing, while patients with central vertigo typically have a normal (negative) head impulse test. 2. Nystagmus – Patients with peripheral vertigo will have unidirectional, horizontal nystagmus, while patients with central vertigo can have rotatory or vertical nystagmus, or direction-changing horizontal nystagmus. 3. Test of Skew - Alternate eye cover testing may reveal skew deviation in patients with central vertigo and should be absent in peripheral vertigo. • Any ONE of these points to a Stroke 2/1/2020 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 77 2/1/2020 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 78 • 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 Vestibular and vertigo as a common aura in migraineurs. It is estimated that about 30% of migraineurs will be Migraine 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. INFECTIOUS causes of dizziness “VINDICATES”

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 08/15/2019 80 Otitis Media (Inflammation of the middle ear) is a common cause of dizziness, it is also responsible for conductive hearing loss, particularly in children. 2 Forms A- Suppurative Otitis (infected) B- Serous Otitis (non- infected) INFECTIOUS DISORDERS:

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 81 Clinical Review

• Looking into the middle (slide 27), If the horizontal SCC is affected by a middle ear infection, it will result in Vertigo. • If the facial canal is damaged as a result of middle ear infection 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 (sensitivity to loud noise). • 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.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 82 Pathophysiology-part of a systemic viral illness, i.e. measles, mumps and mono, INFECTIOUS HERPES SIMPLEX II DISORDERS: A one-sided “unilateral” vestibular deficit (UVD), arising from a viral cause in most Viral patients, results in either sudden deafness or acute prolonged vertigo with nystagmus Vestibular rapidly beating (fast phase) toward the Neuritis side of the lesion. • 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 INFECTIOUS compensate for the dizziness/vertigo. • Acute episodes usually end after one to two DISORDERS months. Although permanent vestibular Labyrinthitis 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 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 2/1/2020 Larry E. Masula, D.C. cholesteatoma 85 Endolymphatic Hydrops (Meniere’s Syndrome)

• Pathophysiology 1. Often considered an autoimmune disorder may cause an increase in the volume of endolymph distending the endolymphatic system. 2. The labyrinth dilates and may rupture or distends 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 86 • 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 Perilymph Fistula’s fistula#sthash.bcdq3m49.dpuf

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 87 The development of nystagmus in response to a Valsalva maneuver or the application of pressure on the external auditory canal constitutes a positive result for the perilymph Perilymph fistula test and suggests the presence of a fistula between the air-filled middle ear and Fistula Test 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 Neoplastic & Neurological causes of dizziness VINDICATE

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 89 • In evaluation of the dizzy patient, the base of the skull there is a region prone to Acoustic neuromas which may apply pressure in and around the internal acoustic meatus and may impair both Cn.7,8 resulting in one-sided hearing loss, tinnitus, vertigo/dizziness and facial paralysis. Internal Acoustic Meatus for Facial Nerve and Vestibular Nerves

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 90 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.

91 NEOPLASMA: Acoustic Neuroma (vestibular schwannoma)

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 92 • Tilting – most likely cortical • Falling forward or backward –most likely mesencephalic, medullary, cerebellar Clinical • Exocentric meaning the patient feels as if the world is Yaw axis (spinning as if seated in a Manifestations, rotating chair) –most likely peripheral nerve i.e. (DDX) BPPV or vestibular nerve loss • Egocentric meaning the patient feels as if they are Yaw axis (spinning) - this is most likely cortical in nature • Eiichirou Urasaki, Akira Yokota • Source Journal of Clinical Case report Neuroscience > 2006 > 13 > 1 > 114-116 Rotational Abstract - We describe two patients complaining of vertigo caused vertigo associated with a small supra-tentorial convexity meningioma. Symptoms disappeared after by cerebral tumor removal, providing evidence for an association between the vertigo and the cerebral cortical lesions. lesions: Vertigo Tumors were located in the central and parietal areas, respectively, which are probably analogous to the and areas 3av, vestibular cortex in the areas designated 3av, 2v, and 7 2v, and 7 in animal studies • *** Why you must check for non-vestibular cortical findings Sir Gordon Morgan Holmes, (22 February 1876 – 29 December 1965) was a British neurologist. He is best known for carrying out pioneering research into the cerebellum Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 95 2/1/2020 96

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 Gordon increasingly clear that there are extensive connections between the Cb and frontal associative Holmes, M.D. 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 The cerebellum 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 • Balance and equilibrium • Breakdown in Coordination/Sequenced motor activity – walking, intention and terminal tremors (not at rest), eye movements w/ Functional diminished pursuits and overshooting saccades. Intention tremors and terminal tremors. Concepts • Motor learning – motor skills, muscle tone • Monitor & prediction of movement • Horizontal & Vertical nystagmus w/ & w/o fixation • Scoliosis – genetic calcium channel mutation affecting midline Cb • Head tilt • Eye movements • A “Bad” cerebellum may develop as a result of: • Alcohol degeneration • Thiamine deficiencies Functional • Toxins Concepts • Concussion • Inflammation • Acute and hemorrhagic stroke • Inherited gene changes • Paraneoplastic disorders Flocculonodular Lobe Aka (ancient)ArchiCerebellum Aka Vestibulocerebellum

• Receives Input from the labyrinthine system with no involvement of the deep cerebellar (Cb) nuclei. • This has influence over the axial musculature, some influence over Vestibular Ocular Reflexes and Vestibular Reflexes. • Flocculus/paraflocculus modulates the smoothness of smooth pursuit eye movements and calibrates the rotational VOR. • Nodulus – calibrates VOR (from otoliths)

2/1/2020 Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 99 Comparing and Contrasting

Normal Cb Alcoholic Cb Note the folia atrophy

2/1/2020 Larry E. Masula, D.C. DACNB, FABVR, FAFICC 100 • A cerebellar stroke is one of the least common types of strokes. It occurs when a blood vessel is blocked or bleeding, causing Cerebellar complete interruption to a portion of the cerebellum. This type Stroke of stroke typically affects only one side or section of the cerebellum. It's also referred to as cerebellar stroke syndrome. Cerebellar Stroke

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 102 Clinical Signs: Ipsilateral Cerebellar Disease

(Flocculonodular Zone/Spinocerebellar lesions)

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

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

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

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 103 (Flocculonodular lobe lesions) Abnormal Ocular Motor Function: • 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 Clinical Signs: Cerebellar drift) • Alteration in VOR (due to Disease improper termination

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 104 Head tilts often have vestibular nerve or vestibular nuclei dysfunction in their 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) on the opposite side. If I lose my otolithic function on the right, the vestibular nerve does not carry signals centrally, the right eye remains extorted (turned outward) and the left eye elevates (skew) and what do I do to compensate for the extorsion? Tilt my head to the right initially and then compensate by redirecting the head to the left in an effort to get the eyes Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 2/1/2020 105 level. • Lesions within the rostral pons and midbrain usually cause a head tilt away from the affected side. 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. Examination - Vestibular Assessment

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 107 • Screening of vestibular function and vestibular ocular reflexes (VOR) may be completed at bedside or in an office setting with little or no equipment. Normal VOR responses allow for clear vision during head and or eye movement. Basic eye muscle function may impact eye Vestibular and movement tasks or vestibular function screening. Balance Screening • Larry E. Masula, D.C.,DACNB, FABVR, FAFICC A basic vestibular and • Observation of nystagmus • Dynamic visual acuity test balance • Eye movement tests screening • Dix Hallpike maneuver battery may • Screening for differentiation of acute stroke • Screening measures for postural or gate include the observations following: • Rule out ortho static hypotension

• Larry E. Masula, D.C.,DACNB, FABVR, FAFICC Various tests are performed to evaluate the Examine patients gate and where and the why the balance by performing patient suffers vertigo. Romberg stance, Tandem Romberg stance and Tests The following tests are Single leg stance performed in a lighted room. VOR Cancellation by performed in performing: Head thrust lighted room Identify any spontaneous test and Head Impulse test nystagmus Smooth Pursuit eye movements Have patient move eyes Saccadic eye movements and stop (gaze) in all (looking at one target and planes. Observe for any then another) gaze holding nystagmus Decreased vestibular Identify and comment on ocular reflex (VOR) by performing: Head thrust any skew deviation of the test and Dynamic visual eyes (one eye higher acuity hypertropia or lower than the other-hypotropia) or any inward (esotropia) or outward deviation (exotropia) 11 0 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 ) Frenzel goggles. When Frenzel's goggles are placed on the patient, and the room lights darkened, nystagmus can easily be seen because the patient's eyes are well illuminated and magnified, and because fixation is removed as the patient can hardly focus through magnifying glasses in a dark room.

2/1/2020 Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 111 • Example – a patient presents with no nystagmus in light during ocular fixation, but you see nystagmus in darkness without fixation, Central vs. is this a Central or Peripheral lesion? • Answer : ocular fixation in light normally Peripheral suppresses nystagmus which indicates that there is a peripheral disorder which is ok and induced therefore the problem is most likely treatable. Nystagmus • If they cannot suppress nystagmus of the eyes by fixating on a target in the light typically and vertigo indicates that there is a central lesion. • Nystagmus seen in the dark only, is most likely the result of a Central disorder While moving the patient’s head side to side at a frequency of 2Hz (2 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 Testing the patients who wear glasses) ask them to read the lowest line on a Snellen Eye Chart. dizzy patient Note the line and where this occurs and or the number of incorrect letters. A difference of less using than or equal to 2 lines is normal. A difference of greater than or equal to 3 lines is abnormal and Dynamic likely the result of a vestibular deficit. Visual Acuity If the patient has restriction of cervical movement the test cannot be properly performed and should be ceased. • Smooth-pursuit movements allow clear vision Smooth of a moving target by holding the image steady on the fovea. Pursuit eye • Smooth pursuit may be “jerky,” (i.e., inability to maintain the target on the fovea requiring a jerky movements “catch-up” saccade). Patients with vestibular hypofunction who also have a central lesion exhibit impaired smooth pursuits. 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.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 115 While this is most often used for concussion assessment, it provides great patient feedback as to the integrity of their balance system

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 116 Optokinetic Eye Movements

• The optokinetic (OPK) tape is an essential part of the vestibular therapist'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. The optokinetic tape can also be used to rehabilitate functional deficits within the brain regions noted above, which also makes it a powerful treatment modality.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 117 Tests best Look for any horizontal nystagmus which is the most common form of nystagmus performed observed with cerebellar infarction. Spontaneous nystagmus denotes movement of using the eyes without a cognitive, visual or vestibular stimulus. Most commonly spontaneous Frenzel nystagmus is caused by a vestibular imbalance lenses or IR Hold patient’s head with one hand. Ask patient to look straight ahead. Look for: Nystagmus and goggles note direction. And those abnormalities with tests performed in room light Head Used to determine the presence of a shaking decreased Vestibular Ocular Reflex (VOR) nystagmus test. • 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 Positional canal Testing • 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. The most provocative test for BPPV. • A burst of nystagmus in the opposite direction (downbeat torsional) occurs when the patient sits up 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 Dix Hallpike the table. Hold 30-45 seconds, observing for nystagmus and question for vertigo. (latency Test for of 5-10 sec.). Patient is then brought up slowly to a sitting position with the head Posterior maintained in 450 rotation. Again, observe for nystagmus and question for vertigo. Test Canal BPPV 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). 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.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 122 • 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 Imaging neurological symptoms or is having unexplained neurological deficits or an otherwise rapid, unexplained progression of symptoms. • BPPV, vestibular neuritis, or Meniere’s disease do not require imaging • Berg Balance Scale Additional • Dynamic Gait Index Testing • Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) • Allergy • A/G ratio: > 1.8 • Albumin > 4.5 g/dL • ANA w/ reflex titer • B6 phosphate • B12 • CMP Laboratory • CBC W/ DIFF • C – reactive protein: CRP, produced in the liver in response to any type of inflammation. High sensitivity CRP more sensitive to distinguish optimal from mildly abnormal’s. Goal: tests for the highest density – CRP less than 0.9 mg/dL • Ferritin vertiginous • Folate • Glycohemoglobin A1c • Interleukin-6 (IL-6) IL-6 < 3pg/Ratio of omega-6 to omega-3: <3 but not below 0.5, which patient increases risk of hemorrhage • Lymes • Thyroid Panel • Tumor necrosis factor alpha (TNFa); TNFa < 6.0 pg/ml • Vitamin D (25 – hydroxy cholecalciferol) 50 – 80 ng/mL • Unexplained neurological signs • CNS signs • Hearing loss (unexplained or unilateral) • Inconsistencies in clinical exam of vestibular Conditions/Findings, function (see below), history, physical exam which indicate a (gait/stance), dynamic visual acuity, motion need for vestibular sensitivity or positional tests specialist referral: • Exam does not reveal cause of patient’s problems • No improvement after 30-day treatment period • Dead falls on dynamic posturography conditions 5 and 6 Vestibular Assessment and Treatment

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 2/1/2020 127 VRT(vestibular • Enhance existing vestibular capabilities rehabilitation • Strengthen compensatory mechanisms therapy) • By improving Proprioceptive input Therapeutic • By increasing Visual Input Goals • Other sensory systems Vestibular Adaptation and Compensation Thomas P. Wellings*, The balance or vestibular system is often Alan M. Brichta and overlooked as a major sensory system Rebecca Lim School of (Goldberg et al. 2012). Even less Biomedical Sciences appreciated is the vestibular system’s and Pharmacy, The inherent plasticity and capacity for self repair. University of Newcastle, and Hunter Medical Research Institute, NSW, Australia • Vestibular adaptation therapies are described by the routine changes in sensitivity of reflexive eye movements Vestibular (VOR) responsible for stabilizing images on Adaptation the retina during head movements. • This may not be possible with an MS patient (compensation) who develops demyelination of the vestibular nerve and the medial longitudinal Exercises fasciculus which yokes eye movements and may result in Yaw (lateral) falls. Vestibular Habituation Exercises

• A large amount of end point nystagmus may be seen with increased age. • The goal of habituation exercise is to reduce the dizziness through repeated exposure to specific movements or visual stimuli that provoke patients' dizziness. These exercises are designed to mildly, or at the most moderately, provoke the patients' symptoms of dizziness.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 131 2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 132 • 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 Benign up. Cupulolithiasis (otoconia stuck to the cupula) causes immediate vertigo and nystagmus and does Positional not fatigue.

Vertigo Pathophysiology-Not entirely understood although an abnormality of the posterior canal is strongly (BPPV) implicated. 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 He following therapies are specific for lesions in the affected canal system 1. Epley Maneuver - PC 2. Semont Maneuver – PC Management 3. Lempert Maneuver – HC 4. Gufoni Maneuver – HC 5. Reverse Dix Hallpike – AC 6. Reverse Epley - AC 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 Posterior the posterior canal stops BPPV • Schuknecht’s cupulolithasis theory is Canal BPPV 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 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 Posterior 3. Canals may also be tested w/o eye fixation in a Dis-Hallpike position (Frenzel lenses) for better Canal BPPV optimization

• Management- positional exercises. Epley or Semont. Resume upright position once the vertigo has ceased. Repeat x 3 - t.i.d. Explain procedure to patient beforehand that it might induce vertigo. Ensure that there are no neck/back problems that would be aggravated by sudden change in posture. Stand to the side of the patient • Pt sitting with head turned to examiner • Pt sat so that when Dix-Hallpike supine, the head will be beyond the end of the couch • Patient lain flat in one quick, smooth movement • Eyes Test for must stay open • Repeat on other side.

Positive test: – Rotatory (torsional) nystagmus (& vertigo): • Diseased ear posterior downmost 3 important features include: canal BPPV • Latency – delay of up to 20 seconds before onset of nystagmus • Fatiguability – nystagmus fades if head held in provoking position • Habituation – Repeating DH test produces less vigorous response Interpretation of Dix Hallpike Test

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

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 138 Posterior • Semont Canal • Epley Rehab. Epley Maneuver- posterior canal

2/1/2020 Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 140 Semont Maneuver - Right PC

2/1/2020

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 141 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.

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 142 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)

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 143 Horizontal • Gufoni Maneuver Canal • Lempert Maneuver Rehab. Gufoni Maneuver - Horizontal Canal rehab.

Larry E. Masula, D.C.,DACNB, FABVR, FAFICC 145 2/1/2020 Lempert Maneuver (BBQ Roll) Horizontal Canal rehab.

2/1/2020

Larry E. Masula, D.C., DACNB, FABVR, FAFICC 146 • Vestibular rehabilitation utilizing Otolith stimulation (A/P and Up/down) also provides a lot of frontal lobe stimulation. This application may also useful for ADD kids with right frontal lobe problems. Rehab. Gem • 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. 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.

VOR Gaze stabilization rehab. 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

VOR rehab: X1 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

VOR rehab: X2 viewing Holding two stationary targets placed inches apart side-to-side/up- down/diagonally, move eyes quickly from target to target as head stays still.

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

VERTIGO TYPE NYSTAG. DIRECTION NAUSEA DURATION ATAXIA VERTIGO SYMPTOMS

BPPV YES ROTARY YES 30-120 SEC YES/NO YES/NO ONSET LATENT CH. HEAD POSITION

VEST. NEURONITIS YES ROTARY YES 48-72HR YES YES ACUTE VERTIGO CH. HEAD POSITION OSCILLOPS.

MENIERE’S YES ROTARY YES 30MIN/ YES YES FULL, TIN, HEAR LOSS PRESSURE 24HR

FISTULA YES ROT/LINEAR YES SECONDS NO YES TINNITUS, TULIO

NERVE YES ROT/LIN YES SEC/MIN NO YES TINNITIS, HYPER -ACOUSIS CH. HEAD POSITION COMPRESSION

BILAT. VEST. LOSS NO NO NO PER. YES/ LOTS DRUGS

LABYRINTHITIS YES ROT YES YES YES ACUTE VERTIGO CH. HEAD POSITION

MAL DE EMBARKMENT YES CHRONIC YES/NO ROCK/SWAY MOVEMENT

WALLENBURG YES LIN YES YES YES CROSSED OSCILLOPSIA SENSORY LOSS HEAD POSIT.

OSCILLOPSIA YES CHRONIC NO SPONT. W/ EYE OPEN ILLUS. OF VISUAL

ANXIETY/ YES CHRONIC NO LIGHTHEAD FOATING DEPRESSION ROCKING Hd. CHANGE Have a Vestibular Questionnaire

2/1/2020 Larry E. Masula, D.C., DACNB, FABVR, FAFICC 154 OPK Cb Rehab Exercises Head Laser Maze NSI Unit Additional Metronome Rehab. Simon Strategies Gaze Stability - Dots on Wall Wii Fit Ball Wobble Board Mini Trampoline

Larry E. Masula, D.C, DACNB, FABVR, FAFICC. 2/1/2020 155 Larry E. Masula, D.C.DACNB, FABVR, FAFICC 2/1/2020 156 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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