How to effectively evaluate and treat Vestibular Dysfunction

Balance impairment is something that therapists see in their geriatric patients quite often and could be due to a variety of reasons, including central vestibular dysfunction

Why does vestibular dysfunction happen?

As we age, we usually aren’t riding as many roller-coasters or doing as many cartwheels in the lawn… so our vestibular system is not stimulated as much as when we are young.  This tends to cause a sort of hypo-function of our vestibular system over the years. “Normal” everyday activities like looking both ways to cross the street or walking through a busy grocery store could cause dizziness, as the parts of the brain involved in processing the sensory input from our eyes and inner ears has been “muted” due to the vestibular dysfunction that has happened over time.  Thankfully, we as skilled clinicians have the tools at hand to help our patients overcome! 

Looking for oculomotor dysfunction is a quick, easy way to identify if this is a missing piece of their balance puzzle.  Including a simple 10 min assessment in your evaluation is a great place to start!  Click here to find our Oculomotor Assessment and get on your way to providing more skilled and specific care to your patients!

Is vestibular dysfunction peripheral or central? 

Vestibular dysfunction can be peripheral or central in nature.

Peripheral vestibular dysfunction in general is anything that affects the structures of the inner ear.  This could be Labyrinthitis (or inner ear infection), Vestibular Neuritis, or Benign Paroxysmal Peripheral Vertigo (BPPV)… which patients often refer to as having “the crystals”.  BPPV often has very specific symptoms and should be fairly easy to diagnose and treat with use of the Dix-Hallpike and Epply Maneuver (or other interventions depending on which semi-circular canal the crystals are in).  

Central vestibular dysfunction is when the integration and processing of sensory input is disrupted or absent.  This can also be from a variety of mechanisms, such as brainstem stroke, head trauma, multiple sclerosis, and cerebellar degeneration.  As mentioned previously, this is a system that may be naturally less active as we age, so when demands are placed on it, performance will be slower and our bodies will not have the responses they need to maintain or recover balance.

How do I assess vestibular dysfunction?

Subjective Report

As we start our evaluation process, it’s important to acknowledge that the patient may perceive what’s happening to them differently than what we see from an objective point of view. 

Subjective report is always a helpful tool – we really want to make sure to listen to what our patients say!  They know things that we don’t.  And, having feelings of being unbalanced (for any reason) can be quite frightening!  If we take the time to make sure we understand their comfort level and how they perceive this as a disability, we will be far more successful with treatment and get the outcomes we and the patients are looking for.  Fear-avoidance behavior can be a powerful foe to a therapist… and knocking it down from the start is key!

The Dizziness Handicap Inventory can help us do just that. This allows us and the patient to see where they stand at the beginning, middle, and end of the treatment course with how their balance and dizziness affects various aspects of their daily life. 

Clinical Test of Sensory Integration (CTSIB-m)

Dizziness, decreased balance, and falls can come from either type of vestibular dysfunction.  When looking at how we integrate and process information with our central system, the three things that help all of us balance are our visual system, our somatosensory system, and our vestibular system, all of which may start to decline as we age. 

It’s important in your evaluation process that you are taking a look at what may be going on for each individual patient as a whole in order to determine if there is visual, somatosensory, or vestibular dysfunction (or a little bit of each).  This will allow you to determine the exact course of treatment in order to achieve the best outcomes. 

There are several ways a therapist can help narrow it down and see what system may be affected the most.  If you determine that the vestibular dysfunction is most likely central in nature, you want to try to parse out which system is the trouble maker!  There is a great tool that can help you do this called, the Modified Clinical Test of Sensory Integration in Balance (CTSIB – m).

During this test, you will time your patient as they stand under four different conditions.  Each condition may give you insight into where the breakdown in balance is occurring. 

  1. The first one is instructing them to keep their eyes open while they are standing on a firm surface.  In this condition, all three of their systems are available to give input to their vestibular cortex.  If they have trouble maintaining their balance in condition one, it’s safe to say you’re going to have a lot of work on your hands!  You would want to complete further assessment looking at each system separately, to find the impairments. 
  2. Next in the CTSIB-m, you would have them complete condition two – they will balance on a firm surface with their eyes closed.  In this condition, you have removed the visual system so now they must rely on their vestibular and somatosensory systems to balance.  If they cannot maintain balance here, they may be too visually dependent and will need to build up the strength of the other two systems to compensate for this dependence. 
  3. In condition three, the patient will stand on a foam surface with their eyes open.  Here you have compromised their somatosensory system, so the visual and vestibular systems are working harder to gather input and help them keep their balance. 
  4. In condition four, the patient is standing on a foam surface with their eyes closed.  This requires an intact vestibular system to keep balance, as it is the only one that is still fully available.  If your patient has trouble maintaining balance in either condition three and/or four, further assessment is warranted to determine the extent of vestibular dysfunction they may be experiencing.

Vestibulo-Ocular Reflex

One of the most commonly used assessments to determine central vestibular dysfunction is found on the Oculomotor Assessment cheat sheet you downloaded earlier… Vestibulo-ocular reflex (VOR).  When the VOR is intact this reflex allows us to maintain visual focus on whatever we are looking at while our head is moving.  If this (or any other oculomotor function) is impaired, your patient will complain of dizziness, blurred vision, nausea, feeling unbalanced, or may have reports of falling.  

During VOR testing, you would want to make sure that your patient understands that what you are doing may cause some of these symptoms.  You also want to make sure they understand that reproducing their symptoms is actually a good thing – because you’ve found the weakness that will become stronger with treatment!  The great thing about many of the oculomotor assessments is that you can use them as vestibular exercises as well!  With VOR, the exercise is the same movement as when you do the test.  Then there are all sorts of ways that you can upgrade and challenge your patients while completing their vestibular exercise routine.  Some ways you can do this with VOR would be: changing position (go from sitting to standing), stand on various surfaces or with narrow BOS, complete with a near target or a far target, place a busy background behind your target, etc.  These upgrades can also be used with some of the other vestibular exercises you may chose to put together for your patient!

How can I treat vestibular dysfunction?

Start with the assessment!

An oculomotor assessment is not something that most clinicians are used to including in their evaluations, but once you get started you will find that it is one of the easiest things to add to your tool box.  VOR is where you want to start.  Simply include this assessment in your evaluation of anyone with balance impairment.  If you work in any type of inpatient setting or home care, most of our patients will be older and will most likely present with a central vestibular dysfunction of some sort.  Once you get comfortable including VOR into your evaluation, you can add one or two more pieces of the oculomotor puzzle.  The next ones in line could be smooth pursuit and saccades.  At the end of the day, you should be able to complete a whole series of oculomotor tests in 5-10 min. 

In that short amount of time, you will be able to gather tons of information that will be useful in coming up with the plan of care and interventions that will be the most useful in assisting your patient to achieve their goals!  Seems like a no brainer, right?

Once you have your assessment completed, the results will point you to what you want to work on in treatment. VOR, gaze stabilization, or saccades- the answer is right there in your assessment! Take a look at the HEP examples on your cheat sheet to be able to see how you would incorporate these goals into your Plan of Care.

Learn more!

If balance rehab is something that you’re interested in, we’ve got more where that came from!  Check out some of our other balance-related blog articles here:

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