Vestibular Rehab & Hearing Loss

Key Functions of the Vestibular System

• Balance & stability: keeps you upright & prevents falls

• Spatial Orientation: tells you if you're moving up/down, left/right, or spinning

• Gaze Stabilization: adjusts eye movements (vestibulo-ocular reflex) so you can see clearly while moving 

• Coordination: integrates with other senses (vision & touch) for overall body awareness

What Happens:

• senses motion --> signals to brain --> brain's response

Semicircular Canals

• Responsible for rotational movements

• Anterior (superior) canal: detects forward/back head movements - e.g. nodding "yes"

• Posterior canal: detects tilting head side-to-side - e.g. tipping ear toward shoulder

• Horizontal (lateral) canal: detects side-to-side head turns - e.g. shaking head "no"

Otolith System

• Spatial orientation: knowing your head's positive relative to gravity

• Motion sensing: detecting linear movements & changes in velocity

• Postural control: organizing motor behavior & helping you stay up upright

• Ocular control (otolith-ocular reflex): generating compensatory eye movements to stabilize vision during head tilt

• Utricle: detects horizontal linear acceleration & head tilt

• Saccule: detects vertical linear acceleration

• includes inferior vestibular nerve (IVN) & superior vestibular nerve (SVN) innervations

Structures:

• Each organ contains a macula with hair cells, a gelatinous layer, and an otolithic membrane embedded with heavy otoconia (ear crystals)

• Gravity Detection

  • when the head tilts, gravity pulls on the heavy otolithic membrane, shifting it and bending the underlying hair cells, signaling head tilt to the brain

• Linear Acceleration

  • when you move in a straight line (like in a car or elevator), the inertia of the otolithic membrane causes it to lag or shift, bending the air cells and signaling the change in speed

• Signal Transmission

  • bending hair cells generate electrical signals sent via vestibular nerves to the brain, which interprets the information for balance & orientation

• "Lost Crystals" - Benign Paroxysmal Positional Vertigo (BPPV): -

Concussions & mTBI

• Concussions are a process, not just an event

  • injury

  • ionic cascade

  • metabolic cascade

  • error signaling

  • signs, symptoms, deficits & outcomes

• Injury Types:

  • Direct impact

  • Acceleration-deceleration injury

  • Blast injury

En Bloc

En bloc movement refers to a motor pattern in which the head, neck, and trunk move together as one rigid unit, rather than rotating separately. It is commonly seen in individuals with neurological conditions such as Parkinson's disease.

Key Points:

• Movement occurs as a single unit (head, trunk, pelvis rotate simultaneously)

• Often due to reduced spinal flexibility and impaired motor control

• Considered a compensatory strategy when normal segmental movement is limited

• Turning is performed with multiple small steps instead of a smooth pivot

• Leads to decreased balance and coordination

• Associated with an increased risk of falls

• Visual cues can help improve anticipatory eye movements and turning ability

• Important for clinicians to address to enhance safety and functional mobility

Strategies to Implement when Experiencing En Bloc

Promote Segmental Movement

• Goal: Help the body relearn dissociation between head, trunk, and pelvis

  • Practice head-first turning (eyes → head → trunk → pelvis)

  • Use verbal cues like: “look, turn your head, then your shoulders”

  • Seated trunk rotation exercises before progressing to standing

Use External Cueing Strategies

• Goal: Improve motor planning and initiation

  • Visual cues (targets on wall to look at before turning)

  • Auditory cues (counting steps, metronome)

  • Floor markers to guide stepping during turns

Task-Specific Training

• Goal: Improve functional carryover into daily occupations

  • Practice turning during ADLs (e.g., turning in kitchen, bathroom mobility)

  • Simulate real-life tasks:

  • Turning to sit in a chair

  • Navigating tight spaces

  • Break tasks into step-by-step sequences

Balance & Fall Prevention

• Goal: Increase safety and confidence

  • Weight shifting exercises

  • Practice wide base of support during turns

  • Educate on avoiding quick pivots

Environmental Modifications

• Goal: Reduce risk and cognitive load

  • Remove clutter to allow larger turning space

  • Ensure adequate lighting for visual cueing

  • Arrange frequently used items within easy reach

Compensatory Strategies

• Goal: Work with the condition when needed

  • Encourage intentional, slower movements

  • Teach patients to pause before turning

  • Reinforce use of assistive devices if appropriate

Vestibular v. Non-vestibular Dysfunction

• Vestibular:

  • involves a vestibular apparatus & related structures dysfunction

  • Room is spinning (especially with head turns & rotations)

  • walking a plank

  • drunk sensation

  • woozy or floating

  • objects or words are moving

  • feeling pulled to one side or down

• Non-vestibular

  • typically result from dehydration, co-morbid conditions, deconditioning, anxiety, medication side effects, etc.

  • lightheaded

  • fatigued

  • unsteady

  • legs feel tired

  • sensation of swaying or rotating (more slowly)

  • sweating/temp increase, increased HR

• History

  • PMH - including recent traumas

  • occurrence situations (timing & triggers)

  • duration

  • type/frequency

  • resolution

• Visual Assessment

  • ocular position

  • acuity - static & any diplopia presence

  • oculomotor - saccades, convergence, smooth pursuits

  • Test of skew/Cover-uncover test - alignment of the eyes without fixation

• Proprioception & Balance Assessment

  • observation

  • somatosensorial testing

  • Romberg test

  • Timed up and go (TUG)

  • dynamic gait index

  • modified clinical test of sensory interaction in balance (mCTSIB)

• Vertebral Artery Test (VAT)

  • rules in/out vascular etiology

  • new or sudden onset of head/neck/jaw pain unfamiliar to patient

  • supine/seated position options

  • cervical extension with side bend and rotation away from side being tested

  • Look for 5 D's and 3 N's

    • dizziness

    • diplopia

    • dysarthria

    • dysphagia

    • drop attacks

    • ataxia

    • nystagmus

    • nausea

    • numbness

• Vestibular Assessment

  • vestibular ocular reflect (VOR)

    • ensures consistent vision while the head is in motion

    • HEAD turns 20 degrees to left, EYES move 20 degrees to the right at the same velocity

    • signals from one semicircular canal aides the eyes to move in a direction equal & opposition to the head in the same velocity

    • VOR Screen -

      • assesses peripheral cause of dysfunction

      • negative VOR dysfunction results in eyes staying fixed on target

      • positive VOR dysfunction results in loss of fixation and/or corrective saccade

  • vestibular ocular motor sensitivity (VOMS)

  • dynamic acuity test

  • Dix Hallpike & Supine Head Roll Tests

  • HINTS Test - Head Impulse Nystagmus Test of Skew

• Nystagmus - 

  • fast & slow component

  • at rest, beats toward intact side

  • during VOR testing, eyes fall off target on affected side

  • spontaneous or direction changing or vertical nystagmus --> center etiology

Vestibular Dysfunction Difference

• Central Dysfunction

  • severe imbalances; ataxic gait, dysmetria, dysarthria

  • constant dizziness (potential)

  • ocular misalignment

  • nystagmus (vertical or directional changing, doesn't fatigue)

• Peripheral Dysfunction

  • intense spinning triggered by head movements

  • tinnitus, hearing loss, ear fullness

  • nystagmus (horizontal & fatigues)

Main Vestibular Treatment Tenants

• Adaptation

• Habituation

• Body scheme & balance

• Substitution - substituting the structural loss with something to make up for it 

• *Consideration of cognitive load

Visual

• patching for diplopia

• timed gaze at target 

  • change backgrounds to increase challenge/focus

  • visual tracking (mazes, head laser, free movement laser)

  • Visual scanning, hart charts, accommodations

  • Brock string/dot cards for convergence insufficiency

  • computer programs/light up board

  • Functional tasks - reading, scanning

    • cross words, word searches, coloring/art

    • tracking movement on tv/videos (birds, butterflies, sports)

Habituation

• repetitive movements with minimally provoked symptoms

• weight shifting & surface changes with gaze stabilization

• head v. eye movments with trunk &  cervical positional changes

• neural grounding, task weighing, side weighing, 

• functional tasks - turning, rotation, shifting weight, bending, reaching

• timed reaching & bending - start with greater time & gradual decrease

• repetitive & frequent!!

Symptom Management

• movement transitions

• community mobility training

• home modifications

• habit & routine modifications

• performance of ADLs/IADLs

• work environment & equipment

• assistive devices

• health promotion education

Canalith Repositioning Maneuvers

• Epley Maneuver --> BPPV