EFFICACY OF VESTIBULAR

REHABILITATION IN PATIENTS
WITH VESTIBULAR DISORDERS
IN GERIATRIC PATIENTS
INTRODUCTION
 INTRODUCTION :
• Vestibular disorders are a heterogenous group of conditions , that occur
from dysfunction of the vestibular system.
• The vestibular system is a complex sensory system that regulates balance
and spatial orientation.
• Vestibular system located within the inner ear.
• The vestibular system can be classified into two main categories:
1. Peripheral vestibular system
2. Central vestibular system
• Peripheral system consists of – semicircular canals, otolith organs, hair
cells, otoliths, vestibular nerve.
 Central vestibular system consists of – Vestibular nuclei, Vestibulocerebellum, vestibular cortex.

 The peripheral vestibular system primarily detects motion and provides information about the position and movement of the head.

 The central vestibular system processes this information and coordinates responses to maintain balance and posture.

 Together, these components play a vital role in activities like walking, running, and maintaining posture.

 If disease or injury to this vestibular system can lead to vestibular disorders.

 Patients with vestibular disorders typically present with vertigo, although other symptoms including dizziness, unsteadiness,
nystagmus, vomiting and a sense of falling toward the side of injury.

 The Vestibular Rehabilitation protocols are considered effective at reducing dizziness and its consequences.

 Vestibular exercises improve balance, decrease risk of falling and improves quality of life.

• These are – Adaptation exercises, Habituation exercises, Substitution exercises, and Combined exercises.

 Vestibular rehabilitation can promote complete healing in 30% of patients and improvement in different degrees in 80% of patients.

 There are several protocols of vestibular rehabilitation, the most frequently used ones are those of Cawthorne & Cooksey, Herdman,
Italian association of Neuro-Otology, and Norre’.
DEFINITION
 DEFINITION

• Disorders of the body’s balance (vestibular) system in the inner ear due to a tremendous range of conditions including
vertigo, Minere’s disease, acoustic neuroma, multiple sclerosis, syphilis, trauma, ear infections, medications toxic to the ear
(ototoxic drugs), epilepsy (seizure disorders), etc.
ETIOLOGY
 ETIOLOGY

 Aging.

 Malfunctioning of the vestibular apparatus in the ears(peripheral) and its connection to central nervous system(central).

 Head injuries due to road traffic accidents.

 Infections.

 Drug induced cytopathic changes.

 Previous trauma.

 Falls.

 Impaired inner ear function.

 Orthostatic hypotension.

 Anxiety.

 Metabolic disorders-hypoglycemia, hyperglycemia, hyperinsulinemia and hyperthyroidism.

 Life style and environmental factors.

EPIDEMIOLOGY
 EPIDEMIOLOGY

 Vestibular disorder most commonly seen in women than men.

 The vestibular disorders rarely seen in children.

 The incidence of this disease in women about 65.4% and in men 34.6%.

 The disease increases with age, up to peak between 74 and 94 years.

CLINICAL FEATURES
 CLINICAL FEATURES

 Vertigo.
 Nausea.
 Vomiting.
 High fever.
 Headache.
 Dizziness.
 Feeling of fullness in the effected ear.
 Excessive drowsiness.
 Fatigue.
 Head motion intolerance.
 Abnormal gait.
 Postural instability.
 Hearing loss.

 Trouble with balance.

 Nystagmus.

 Difficulty in concentrating.

 Altered or mild disorientation.

 Blurred vision.

 Feeling like floating as if the world is spinning.

 Changes in cardiac rhythm.

 Fear of fall.
DIAGNOSIS
 DIAGNOSIS

 Magnetic resonance imaging (MRI) - An MRI of the brain can reveal the presence of tumors, stroke damage, and other soft-
tissue abnormalities that might cause dizziness or vertigo.

 MRIs of structures in and around the inner ear can be helpful in diagnosing vestibular disorders.

 Computerized axial tomography (CAT OR CT) – It is used to detect possible dehiscences of the semicircular canals,
congenital abnormalities, widened cochlear and vestibular aqueductus, and subarachnoid hemorrhage.

 Epley manoeuvre -
MANAGEMENT
 MEDICAL MANAGEMENT
 Calcium channel blockers- Nimodipine
Nitrendipine
Verapamil
 Vestibular suppressants - meclizine
Lorazepam
Clonazepam
Amitriptyline
 Anti-histamines-diphenhydramine
Promethazine

 Anti-cholinergic-scopolamine
 Anti-emetics drugs-dexamethasone
ondansteron
• SURGICAL MANAGEMENT
 Labyrinthectomy
 Neurectomy of vestibular nerve.
 Endolymphatic/peri lymphatic shunt-vestibulo-cochleosacculotomy.
 Canal partitioning.
 Acoustic neuroma removal.
• PHYSIOTHERAPY MANAGEMENT

• Vestibular rehabilitation exercises

• Adaptations exercises – Gaze stability exercises.

- Ocular control exercise

-Horizontal and diagonal head movements
• Habituation exercises – Balance exercises

-Gait exercises.

• Substitution exercises.
METHODOLOGY
 METHODOLOGY

 IMPORTANCE OF VESTIBULAR REHABILITATION EXERCISES:

 Reduces risk of falling.

 Improves balance.
 Reduces dizziness symptoms.
 Improves ability to stabilize vision.
 Increases body strength.
 Improves gait.
 Reduces fatigue.
 Improves feeling of drowsiness.
 Improves spinning/rotational movements of head.
 Improves postural instability.

•
•
 Reduces nystagmus.

 Improves concentration.

 Improves disorientation.

 Reduces headache.

 Improves hearing loss

 EXERCISES FOR IMPROVING THE VESTIBULAR DISORDERS:
 Adaptation exercises.
 Habituation exercises.
 Substitution exercises.
 ADAPTATION EXERCISES:
 Gaze stability exercises.
 Ocular control exercises.
 Horizontal and diagonal head movements.
 GAZE STABILITY:

• The purpose of these exercises is to improve vestibulo ocular reflex and other systems
 INDICATIONS:

• 1.Gaze stabilization exercises are a reasonable procedure for persons with

unilateral vestibular disturbances such as vestibular neuritis.

• 2.They are also used for bilateral vestibular loss.

• 3.Central vestibular disorders.

• EXERCISE – 1

1.While seated, focus eyes on a stationary object.

2.Move head from side to side while staying focused on the stationary object.

(10 repetitions twice in a day for few weeks)

• EXERCISE - 2

1.Hold your thumb out in front of you while seated.

2.Focus on your thumb while turning your chair side to side.

10. repetitions twice in a day for few weeks

1.While seated, grab a book.

2.Start by moving your head side to side as quickly as possible while still being able to read the words on the page.

(10 Repetitions twice in a day for few weeks)

 OCULAR CONTROL EXERCISES.

 For improving nystagmus and vision difficulty.

 Eye movements:

1. Close the eyes.

 Slowly move the eyes upward and then downward

 Slowly move the eyes to the left and then to the right

 Focus on finger moving from 3feet to 1foot away from face

 Focus on an area on the floor around 8feet away move the eye in the shape of a figure of 8.

 Trace the imaginary figure 8 for 30 seconds, then switch direction.

(10 Repetitions twice in a day for few weeks)

 HORIZONTAL AND DIAGONAL HEAD MOVEMENTS:

1. Improves head movements intolerance.

Head movements at first slow, then quickly: later with closed eyes.

a. Bending forwards and backwards.

b. Turning from side to side.

(10 Repetitions twice in a day for few weeks)

 HABITUATION EXERCISES:

 Balance exercises.

 Gait exercises.

 BALANCE EXERCISES:

 Improves balance and co-ordination.

1.Touching front wall.

2. Ankle sways.

3.Circle with a ball

4.Ball diagonals.

(10 Repetitions twice in a day for few weeks)

 GAIT EXERCISES:

Improves walking:

1.Walking exercise.

2.Sit to stand.

3.Gait with a focal point. (10 Repetitions twice in a day for few weeks)

 SUBSTITUTION EXERCISES:

SITTING

 Shoulder shrugging and circling.

 Bending forwards and picking up objects from the ground standing.
 Throwing a small ball from hand to hand (above eye level).

 Throwing ball from hand to hand under knee.

 Change from sitting to standing and turning around in between. (10 Repetitions
twice in a day for few weeks
CASE STUDY
 CASE STUDY

• SUBJECTIVE ASSESSMENT:

 Name: Mangamma

 Age: 69

 Gender: Female

 Occupation: Farmer

 Address: Thurkapally

 Chief complaints: Hearing loss,

Confusion,

Giddiness,

Blurred vision,

Feeling off balance.

• HISTORY:

• Present history: Abrupt onset of severe, debilitating vertigo with associated

unsteadiness.

• Past history: Fall

• Personal history: Normal

• Family history: Normal

• Medical history: Hypotension

• Socioeconomic history: Financially unstable

OBJECTIVE ASSESSMENT:

 Vitals

• Temperature: high

• Blood pressure: Low

• Respiratory rate: Normal

• Pulse rate: Normal

GLASGOW COMA SCALE: 9-12.

HIGHER MENTAL FUNCTIONS EXAMINATION:

a) Behaviour: Normal

b) Speech: Normal

c) Intelligence: Normal

d) Cognitive: Abnormal
CRANIAL NERVE EXAMINATION:

 8th cranial nerve (Vestibulocochlear nerve) examination by making noise.

 Weber’s test

 Rinne’s test

 OBSERVATION:

• Body built: Mesomorphic

• Attitude of limbs: Normal

• Speech: Normal

• Posture: instability

• Gait: sway
ON EXAMINATION:
 SENSORY EXAMINATION:

 SUPERFICIAL SENSATIONS:
• Touch: Normal
• Pain: Normal
• Temperature: Normal
• Pressure: Normal

DEEP SENSATIONS:
• Kinesthesia: Normal
• Vibration: Normal
• Proprioception: Normal
CORTICAL SENSATION:

• Stereognosis: Normal

• Barognosis: Normal

• Tactile localization: Normal

• Two-point discrimination: Normal

• Graphesthesia: Normal
 MOTOR EXAMINATION:

 Muscle tone: Normal

 Muscle power: Normal
 REFLEXES EXAMINATION:

SUPERFICAL EXAMINATION: Normal

DEEP EXAMINATION: Normal
• INVESTIGATION: MRI, CT scan.

• DIAGNOSIS: Epley manoeuvre.

• DIFFERENTIAL DIAGNOSIS:
•

•
 • MANAGEMENT:

a) Medical management: Meclizine

Diazepam

b) Surgical management: Labyrinthectomy

c) Physiotherapy management: Vestibular

rehabilitation exercises.
CONCLUSION
 CONCLUSION

 The studies concluded that the vestibular disorders which is caused due to aging, RTA, falls, metabolic disorders can be
managed by VESTIBULAR REHABILITATION in geriatric patients.

 By using Vestibular rehabilitation exercises – helps to improves balance and increases body strength and improves
spinning/rotational movements of head.

 Adaptation exercises are helps to Improve the gaze stability with head movement.

 Habituation exercises are helps to improve balance and coordination.

 Substitution exercises are helps to improve coordination.

 This study showed significant effect of vestibular rehabilitation in patients with vestibular disorders. Physiotherapy improves
managing the people with balance and co-ordination problems.
THANKYOU