EFFECTIVENESS OF VESTIBULAR REHABILITATION FOR

THE PATIENTS WITH DIZZINESS AND BALANCE DISORDERS

A Dissertation submitted to
THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY.
In partial fulfilment of the requirements for the award of
the degree of BACHELOR OF PHYSIOTHERAPY, AUGEST
2022.

Submitted by

G. YOGHENDRA
REG.NO:741814020

GOVERNMENT COLLEGE OF
PHYSIOTHERAPY TIRUCHIRAPALLI-1
 THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY
CHENNAI

CERTIFICATE
This is to certify that the project entitled “EFFECTIVENESS
OF VESTIBULAR REHABILITATION FOR THE PATIENTS WITH
DIZZINESS AND BALANCE DISORDERS “is the bona fide
record of work done by G. YOGHENDRA,
Reg.No.741814020 in partial fulfilment of the requirement
for the award of the degree of BACHELOR OF
PHYSIOTHERAPY during final year 2021-2022.

STUDENT'S SIGNATURE GUIDE'S SIGNATURE

PRINCIPAL

Prof.S.A.KARTHIKEYAN, M.Sc., MIAP, PhD

 THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

CHENNAI

CERTIFICATE

This is to certify that the project entitled “EFFECTIVENESS

OF VESTIBULAR REHABILITATION FOR THE PATIENTS WITH
DIZZINESS AND BALANCE DISORDERS “is the bona fide
record of work done by G. YOGHENDRA,
Reg.No.741814020 in partial fulfilment of the requirement
for the award of the degree of BACHELOR OF
PHYSIOTHERAPY during final year 2021-2022.

PRINCIPAL
Prof.S.A.KARTHIKEYAN, M.Sc., MIAP, PhD
 THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY

CHENNAI

UNIVERSITY EXAM : PROJECT WORK

/ STUDENT NAME : G. YOGHENDRA
REG.NO : 741814020

TOPIC
EFFECTIVENESS OF VESTIBULAR REHABILITATION FOR
THE PATIENTS WITH DIZZINESS AND BALANCE
DISORDERS

INTERNAL EXAMINER EXTERNAL EXAMINER

 ACKNOWLEDGEMENT

I would render gratitude to MY FATHER Mr. S .GANESAN AND MY

MOTHER Mrs G. USHARANI and MY SISTER S.G . SRIDEVI who had
given me the opportunity, encouragement and support throughout
my course of the study.
I express my thanks to my GUIDE PRINCIPAL S.A.KARTHIKEYAN,
M.Sc., MIAP, Ph.D, PRINCIPAL, Government College of
physiotherapy, Trichy-1 for his support and help to complete this
project.
I express my thanks to MR.M. SIVAKUMAR, B.P.T., MIAP,
Physiotherapist, Government College of Physiotherapy, Trichy-1 for
his support and his valuable guidance that motivated me towards
this project.
I soulfully thank Mrs. SHANTHI, B.P.T., MIAP, Senior physiotherapist,
Government College of Physiotherapy, Trichy-1 for her help to
complete this project work.
I soulfully thank Mrs. A. MANIMEKALAI B.P.T., DSPT, DYT,
Physiotherapist, Government College of Physiotherapy, Trichy-1 for
her help to complete this project work.
I am also indebted to my administrative staffs and my friends
(2017,2018 batch) and my seniors who were helpful to complete this
project successfully.
I am also indebted to my friends and patients who were helpful to complete this project successfully
 CONTENTS

S.NO TOPICS PAGE NO

1. INTRODUCTION
ANATOMY OF VESTIBULAR
2. SYSTEM
PHYSIOLOGY OF VESTIBULAR
3. APPARATUS

4. VESTIBULAR REFLEXES
PATHOPHYSIOLOGY OF VESTIBULAR
5. SYSTEM

CLINICAL VIEWS ABOUT DIZZINESS

6. AND BALANCE DISORDERS
i)PERIPHERAL BALANCE DISORDERS
ii)CENTRAL BALANCE DISORDERS
7. INVESTIGATIONS
TESTS FOR VESTIBULAR
8. DYSFUNCTIONS
MANAGEMENT
9. i)PHARMACOLOGICAL MANAGEMENT
ii)SURGICAL MANAGEMENT
PHYSIOTHERAPY MANAGEMENT –
10. VESTIBULAR REHABILITATION
11. METHODOLOGY
12. PHYSIOTHERAPY ASSESSMENT
13. CASE STUDIES
14. CONCLUSION
15. BIBLIOGRAPHY
INTRODUCTION
 INTRODUCTION

Vestibular rehabilitation is an evidence-based approach to manage

dizziness, vertigo, motion sensitivity, balance and postural control
that occur due to vestibular dysfunction.
Patients with vestibular impairment typically experience issues
with gaze stability, balance and postural control. Vestibular
rehabilitation is therefore, focused on addressing these areas of
pathology or dysfunction. However, the specific treatment approach
will depend on the pathology and each patient’s unique
presentation.
Physical therapists are likely to encounter patients with
vestibular disorders in a variety of clinical settings. The reported
prevalence of dizziness as a medical symptom in community dwelling
adults varies based on subjects age, gender and definition of the
complaints.
Dizziness is one of the most common complaints of adults
report to their physicians and prevalence increases with age. A cross
sectional study of emergency department visits for dizziness found
that otologic /vestibular pathology was the number one cause (32%).

Patients who experience dizziness report a significant disability

that reduces their quantity of life. Further more it has been reported
that greater than 70% of patients with initial complaints of dizziness
will not have a resolution of symptoms at a 2 week follow up. Of
patients with dizziness ,63%. reported recurrent symptoms
continuing beyond 3 months.
 Most peripheral vestibular lesions have a benign aetiology and
undergoes spontaneous resolution due to the self-limiting nature of
the condition and the process of central nervous system
compensation. Vestibular compensation results from active
neuronal changes in the cerebellum and brainstem in response to
sensory conflicts produced by vestibular pathology. Dizziness and
associated postural imbalance have been shown to increase the risk
of falls with a resulting significant impact on quantity of life,
mortality and the economic burden of associated costs.

The earliest vestibular rehabilitation therapy called the

cawthrone cookery exercises, was developed by CAWTHRONE AND
COOKSEY to treat patients with labyrinth injury resulting from
surgery/ head injury. They found that exercises designed to
encourage head and eye movements.

The main aim of my project is to investigate “THE EFFECTIVENESS

OF VESTIBULAR REHABILITATION FOR THE PATIENTS WITH
DIZZINESS AND BALANCE DISORDERS”
 To enhance gaze stability
 To enhance postural disability
 To improve the activities of daily living.

EPIDEMIOLOGY
 Vestibular disturbance is a significant issue globally. It is
estimated that 35.4 % of American ‘s aged over 40 have experienced
some form of vestibular dysfunction. The likelihood of experiencing
vestibular dysfunction increases with age.

80% of people aged over 65 years experience dizziness – in 30 –

50 % of cases this dizziness is caused by benign paroxysmal positional
vertigo.

75% of adults aged over 70 years have a balance impairment.

Nearly 85% of adults aged over 80 years have vestibular
dysfunction.

Individuals with vestibular dysfunction are eight times more

likely to experience a fall, which is significant morbidity and
mortality and economic cost. Moreover, the number of people
experiencing the expected to grow due to our ageing populations.
ANATOMY OF VESTIBULAR
SYSTEM
 Vestibular system can be broadly classified into peripheral
vestibular system and central system.

VESTIBULAR SYSTEM
PERIPHERAL SYSTEM
 Three semicircular canals
 Utricles
 Saccules.

CENTRAL SYSTEM
 Pathways from the vestibular nuclei to the midbrain.
 Thalamus
 Cortex
 Cerebellum

Vestibular apparatus plays important role in maintaining

posture and equilibrium. It is a part of inner ear/ labyrinth. The
other part of labyrinth is the cochlea concerned with sensation of
hearing.
Vestibular apparatus – sense of hearing
Cochlea – sense organ for hearing.
The vestibular system is located within the inner ear. Laterally,
it is bordered by the middle ear and medially, lies adjacent to the
temporal bone. The main components of vestibular apparatus are
peripheral apparatus, central process and motor output.
 In conjunction with the other sensory inputs such as vision and
proprioception, information from the vestibular system coordinates
movement between the eyes and head provides important
information about postural orientation.

EAR DIAGRAM:

BLOCK DIAGRAM: ORGANIZATION OF VESTIBULAR SYSTEM

Sensory input Central processing motor output

Visual Primary processor Motor neurons Eye Movements

Vestibular (Vestibular nuclear
Proprioceptive complex)
Positional

Movements
 Adaptive processor
(cerebellum)

INTERNAL EAR:
The internal ear or labyrinth consists lies in the petrous part of
the temporal bone.
It consists of
Bony labyrinth
Membranous labyrinth
It consists of bony labyrinth within the memberanous labyrinth.
The memberanous labyrinth is filled with fluid called endolymph. It is
seperated from the bony labyrinth by another fluid called the
perilymph.
INTERNAL EAR:
 BONY LABYRINTH:
It is a sense of cavities or channels present in the petrous part of
temporal bone. The bony labyrinth is filled with perilymphatic fluid
which has a chemistry similar to that of cerebrospinal fluid (high Na:
k ratio). perilymphatic fluid communicates via the cochlear aqueduct
with cerebrospinal fluid. Because of this communication, disorders
that affect spinal fluid pressure (such as Lumbar pressure) can also
affect the inner ear function.
 Bony labyrinth consists of three parts,
 Cochlea, anteriorly
 Vestibule, in the middle
 Semicircular canals, posteriorly
COCHLEA:
The cochlea resembles the shell of a common snail. It forms the
anterior part of the labyrinth. It has a conical axis Known as the
modiolus around which the cochlear canal makes two makes two-
and three-quarter turns.
Modiolus – directed forwards and laterally.
Apex- towards the anterosuperior part of the medial wall of
the middle ear.
Base- towards the fundus of the internal acoustic meatus.
The Scala vestibuli communicates with the Scala tympani at the
apex of the cochlea by a small opening called the helicotrema.
VESTIBULE:
This is the central part of the labyrinth. It lies medial to the
middle ear cavity. Its lateral wall opens into the middle ear at the
fenestra vestibuli which is closed by the footplate of the stapes.
Three semicircular canals opens into its posterior wall. The medial
wall is related to the internal acoustic meatus, and presents the
spherical recess in front, and the elliptical recess behind. The two
recesses are separated by vestibular crest which splits inferiorly to
enclose the cochlear recess.
SEMICIRCULAR CANALS:
There are three bony semicircular canals.
 Anterior semi-circular canal
 Posterior semi-circular canal
 Lateral semi-circular canal
They lie posterosuperior to the vestibule, and are set at right
angles to each other. Each canal describes two third of a circle and is
dilated at one end to form the ampulla. The three canals open into
the Vestibule by five openings.
The anterior or superior semicircular canal lies in a vertical plane
at right angles to the long axis of the petrous temporal bone. It is
convex upwards. Its position is indicated by the arcuate eminence
seen on the anterior surface of the petrous temporal bone. Its
ampulla is situated anterolaterally.
The posterior semi-circular canal also lies in a vertical plane to the
long axis of the petrous temporal bone. It is convex backwards. Its
ampulla lies at lower end. The upper end joins he anterior canal to
form the crus commune The lateral semi-circular lies in the
horizontal plane with its convexity directed poster laterally. The
ampulla lies anteriorly, close to the ampulla of the anterior canal.
MEMBRANOUS LABYRINTH:
It is in the form of complicated, but continuous closed cavity
filled with endolymph. The epithelium of the membranous labyrinth
is specialized to form receptors for sound that is organ of corti, for
static balance, the maculae and for kinetic balance, the cristae.
Like the bony labyrinth, membranous labyrinth also consists of
the three main parts, the spiral duct of the cochlea/ organ of corti
anteriorly. The utricle and saccule with maculae, the organs of static
balance, within the Vestibule. The semi-circular ducts with cristae,
the organs of kinetic balance, posteriorly.
DUCT OF THE COCHLEA OR THE SCALA MEDIA:
The spiral duct occupies the middle part of the cochlear canal
between the Scala vestibule and Scala tympani. It is triangular in
cross section. The floor is formed by basilar membrane, the roof by
the vestibular/ Reisner’s membrane, outer wall by the bony wall of
to the cochlea. The basilar membrane supports the spinal organ of
corti which is the end organ for hearing. It comprises of rods of corti
and hair cells.
Posteriorly the duct of the cochlea is connected to the saccule by
the narrow ductus reunions. The sound waves reaching the
endolymph through the Vestibular membrane make appropriate
parts of the basilar membrane vibrate, so that different parts of the
organ of corti are stimulated by different frequencies of sound.
OTOLITH ORGANS:
The otolith organs are located in the Vestibule. They take the
form of two sacs that detect linear acceleration of the head.
SACCULE;
The saccule lies in the anteroinferior part of the Vestibule, and is
connected to the basal turn of the cochlear duct by the ductus
reunions. The saccule serves to detect movement in the sagittal
plane. (Upward movement).

UTRICLE:
The utricle is larger than saccule and lies in the posterosuperior
part of the Vestibule. It receives the ends of the three semicircular
ducts through five openings. The duct of the saccule unites with the
duct of the utricle to form the ductus endolymphatic.
The medial walls of the saccule and utricle are thickened to form
a macula in each chamber. The macula is end organs that give
information about the position of the head. They are static balance
receptors. saccule gets stimulated by vertical linear motions for
example going in car.

SEMICIRCULAR DUCTS:
The three semicircular ducts lie within the corresponding bony
canals. Each duct has an ampulla, corresponding to that of bony
canals. In each ampulla, there is an end organ called ampullary
crest / crista/ cupola. Cristae corresponds to pressure changes in the
endolymph caused by movements of head.

RECEPTOR ORGANS OF VESTIBULAR APPARATUS:

The semicircular ducts and otolith organs contain a unique set of
sensory epithelium and hair cells. These cells function to convert
information about head acceleration into neurologic signals that are
later processed by central is cristae ampullaris. Receptor organ in
otolith organ is macula. Both of these consists of proprioceptors.

CRISTA AMPULLARIS:
Cristae ampullaris is crest like structure situated in ampulla. The
crest is formed by group of neuroepithelial cells which is surrounded
by epithelial cells which is surrounded by epithelial cells for planum
semilunatum. The neuroepithelium of cristae ampullaris has receptor
cells called hair cells. The corresponding tissue within the utricle and
saccule is known as the macula and is located on the floor and
medial wall of each organ, respectively. In both cases sensory
epithelium supports a set of hair cells that function as
mechanoreceptors.

MACULA:
Receptor organ in otolith organ macula. Macula is formed by
neuroepithelium and supporting cells. In utricle it is situated in
horizontal plane. So, cilia from hair cells are in ventricle. In saccule
situated in vertical plane so cilia from hair cells are situated in
horizontal plane.

STRUCTURE SURROUNDING RECEPTOR ORGANS:

In Semicircular canal a dome shaped gelatinous structure that
extent up to the roof of ampulla which encloses cilia of hair cells
called cupula.
In otolith organ a gelatinous membrane called otolith membrane
which certain some crystals called ear dust otoconia mainly
constituted by calcium carbonate.
HAIR CELLS:
Each hair cells consists of 70 – 100 processes called stereocilia.
The stereocilia form shows that short and progressively increase in
length until reaching the kinocilium a large single process that serves
as a reference point for cell excitation or inhibition. When head
Movement bends the stereocilia towards the kinocilium, excitatory
potentials to vestibular nerve fibres increases. The bending of
stereocilia away from the kinocilium reduces input to corresponding
Vestibular nerve fibres. Within the ampulla, a thick gelatinous
substance called the cupula overlies the cristae. These crystals play
an important role in bending hair cells (and therefore, detecting
linear acceleration) through initial drag and shearing.

BLOOD SUPPLY OF LABYRINTH:

 The anterior and posterior vestibular artery provide blood to the
peripheral Vestibular apparatus. The labyrinth artery supplies the
peripheral Vestibular system. TG he labyrinthine artery has a variable
origin. Most often it is a branch of the anterior inferior cerebellar
artery, but occasionally it is a direct branch of the basilar artery upon
entering the inner ear , the labyrinthe artery divides into the anterior
artery divides and the common cochlear artery. The anterior
Vestibular artery supplies the vestibular nerve, most of the utricle,
and anterior semicircular canals. The common cochlear artery
divides into the a main branch, the main cochlear artery and
vestibulocochlear artery. The main cochlear artery supplies the
cochlea. The main cochlear artery supplies the cochlea . The
vestibulocochlear artery supplies the cochlea, the ampulla of the
posterior Semicircular canal and the inferior part of the saccule. The
superior semicircular duct, the saccule, and a small part of the utricle
are supplied by the posterior vestibular artery.
NERVE SUPPLY OF VESTIBULAR APPARATUS:
Impulses from hair cells of crista ampularis & macula reach
the medulla oblongata & other parts of CNS through the fibres of
vestibular division of vestibular nerve.
FIRST ORDER NEURONS:
There are sensory pathway and are bipolar. Some of the
bipolar cells are in vestibular ganglion & are in internal auditory
meatus.
❖Dendrites of bipolar cells reach the receptor organs.
❖Branches of dendrites are in close contact with basal part of hair
cells and herminare mainly in type 1 and type 2
❖Axons of 1st order neuron forms the vestibular division of 8th nerve
.
 The fibres from the bipolar cells reach the medulla oblongata and
terminate in Vestibular nuclei.
The fibres are called primary vestibular fibres.
VESTIBULAR NUCLEI:
Superior and medial Vestibular nuclei are reached the fibres
from cristae ampullaris
Interior Vestibular nuclei receive the fibres from macular of
otolith organ.
FIBRES TO CEREBELLUM:
Axon of bipolar cells reach cerebellum directly and terminate in
flocconudular lobe or fastigial nucleus in cerebellum.

SECOND ORDER NEURONS:

Some of 2nd neuron is in a vestibular nuclei. Axon from nuclei from
secondary vestibular fibres from different tracts.
➢ Vestibular ocular tract
➢ Vestibulo spinal tract
➢ Vestibulo reticular tract
➢ Vestibulo cerebellar tract

VESTIBULO OCULAR TRACT:

Fibres from superior, medial, inferior nuclei descend with
vestibulospinal tract & ascend through medial longitudinal fasiculus
& terminate in 3Rd, 4Th, 5th cranial nerve forming VOT.
FUNCTION:
Movement of eyeball in relation to the position of head.
VESTIBULO SPINAL TRACT:
Fibres from lateral vestibulospinal tract descend
Downward to form vestibulospinal tract some ascend & join Medial
longitudinal fasiculus.
FUNCTION:
Relax movement of head & body during changes.

VESTIBULO RETICULAR TRACT:

Some fibres from vestibular nuclei reach reticular formation of
brainstem forming vestibuloreticular tract concerned with facitilation
of muscle tone.
VESTIBULO CEREBELLAR TRACT:
Some fibres from Vestibular nuclei reach to the cerebell and
terminate in flocconudular lobe and fastigial nuclei, involved in co
ordination of movements according to body position.
The vestibulo cochlar nerve travels from the Vestibular system of
the inner ear . The vestibular ganglion houses the cell bodies of the
bipolar neurons and extend processes to five sensory organs. These
of there are the cristae located in the ampullae of the semicircular
canals. Hair cells of cristae activate afferent receptors in response to
rotational acceleration.
The other two sensory organs supplied by the Vestibular neurons
are the macular of the saccule and utricle. Hair cells of the maculae
in the utricle activate afferent receptors in response to linear
acceleration which hair cells of the maculae in the saccule respond to
vertically directed linear force.
FUNCTION;
The is the nerve along which the sensory cells of the inner ear
transmit information to the brain. It consists of cochlear nerve ,
carrying details about hearing and vestibular nerve carrying
information about balance. It emerges from the pontomedullary
junction and exits the inner skull via the internal acoustic meatus in
the temporal bone.
PHYSIOLOGY OF VESTIBULAR
APPARATUS
FUNCTION OF VESTIBULAR APPARATUS:
Receptors of semicircular canals give response to rotattory
movements or angular acceleration of the head and receptors of
utricel and saccule give response to linear acceleration of head. Thus
the Vestibular apparatus is responsible for detecting the position of
head during different movements. It also causes reflex adjustments
in the position of eyeball , head and body postural changes.

FUNCTION OF SEMICIRCULAR CANALS:

Semicircular canals are responsible for the maintenance of
posture and equilibrium during rotatory movements of angular
acceleration of the head
Each Semicircular canal detects rotation to a particular plane and
sends information to brain centres.
Superior Semicircular canals give response to rotation in
anteroposterior plane that is front to back movements like nodding
the head while saying yes- yes .
Horizontal semicircular canal gives response to rotation in
horizontal plane ( vertical axis) that is side side movements.
Posterior Semicircular canal gives response to rotation in the
vertical plane by which head in rotated from shoulder to shoulder.
MECHANISM OF STIMULATION OF RECEPTOR CELLS IN CANAL:

At the beginning of rotation , receptor cells are stimulated by

movement of endolymph inside the Semicircular canals.
When a person rotates in clockwise direction (verticalAxis) at the
commencement of rotation, horizontal canal moves in clockwise
direction. But there is no corresponding movement of endolymph
inside the canal at the beginning of rotation.
Because of the interia , endolymph remains static .
This phenomenon causes relative displacement of endolymph in
the endolymph in the direction opposite to that rotation of head.
That is fluid pushed in anticlockwise direction.
Thus ,in the Right horizontal semicircular the endolymph flows
towards the ampuller and the fluid mores away from. The Canal in
the left canal ampulla.
Movement of endolymph turn causes corresponding in
semicircular canal in movement of gelatinous cupula. Thus in the
right horizontal canal, cupula moves towards the ampulla.In any
when cupula towards the ampulla stereocilia of hair cells are pushed
towards kinocilium leading to stimulation of hair cells.
Thus at the commencement of Rotation, in clockwise direction
around vertical axis , haircells at ampulla of horizontal canal in Right
ear are Stimulated . But, the hair cells in horizontal canal of left ear
are not stimulated.

ADAPTATION OF RECEPTORS IN SEMICIRCULAR CANAL DURING

ROTATION:

Hair cells of cristae ampullaris generate impulus even at rest.

But, the frequency of discharge is low at Resting condition. It is about
50-100 impulses per minute.

At the Commencement of Rotation, discharge of impulses

Reaches a higher frequency of 600-800 per minute depending upon
the speed of Rotation. However the Rapid discharge of impulses lasts
only for the first 20-25 seconds of Rotation . Afterwards even if
Rotation continues ,the frequency of impulses falls back to the the
resting level. It is because of adaptation of receptors during
continuous rotation.

CAUSE FOR ADAPTATION OF RECEPTOR CELLS:

At the onset of Rotation, endolymph inside the Semicircular canal

doesnot Move along with semicircular Canal because of inertia of
the fluid.so semicircular canal moves leaving the endolymph behind,
which is like moving in the opposite direction.
Now the endolymph in pushed into ampulla towards the utricle.
It causes Stimulation hair cells but. Of after about 20 seconds due
to the accumulation. Indolymph, a pressure of is developed in
ampulla.
Due to the back presssure, endolymph starts. Moving away from
ampulla,that is it starts moving along with semicircular canal at the
same speed. It causes adaptation of the hair cells.

Hair cells of crista ampullaris semicircular canals. Vertical are

stimulated during the Rotation head in anteroposterior or transverse
axis. However, the mechanism involved is similar to that of the
haircells of cristal ampullaris of horizontal canals.
NYSTAGMUS:
Nystagmus is the thythmic oscillatimg involuntary Movements of
Eyeball. It is common during Rotation . It is due to the natural
stimulaty effect of vestibular apparatus during Rotational
acceleration nystagmus occurs both in physiological and
pathological conditions .
VESTIBULO- OCULAR REFLEX AND NYSTAGMUS:
Nystagmus is a reflex phenomenon that occurs in order to
maintain the visual fixation. Since the movements of eyeball occurs
in Response to stimulation of vestibular apparatus ,this Reflex is
called vestibulo ocular reflex.
MOVEMENT OF EYEBALL DURING ROTATION:
Nystagmus has two components of which occur alternatively,
 Slow component
 Quick component
1) slow component
At the beginning of Rotation, since the eyes fired at a particular
object (point) the eye ball, rotate slowly in the direction opposite to
that of Rotation component of the head. It is called slow component
of nystagmus. It is due to vestibulo ocular Reflex. This reflex is
because of labyrinthine impulses reaching the ocular muscles via
Vestibular nuclei and 3, 4, 5 cranial nerves.
2) Quick component.
When the slow movement of eyeballs is limited, the eyeballs
move to a new fixation, point in the direction of rotation of head.
This movement to a fixation point occurs with a jerk. So it is called
the Quick Component . Quick components of nystagmus is due to
the activation of Some centres in Brainstem.
FUNCTION OF SACCULE:
Maccula of saccule is situated in vertical plane with the hair cells
in the horizontal plane.
 While moving vertically, as in the case of utricle, otoconia of
saccule more in opposite direction and pull the cilia Resulting in
stimulation hair cells.

ROLE OF OLOLITH ORGAN IN RESTING POSITION:

During resting condition (in the absence of Head movement), hair
cells continuously because of the pulling of gravitational force .

Stimulation of hair cells produces Reflex movements of head and

Limbs for the maintenance movements of posture in Relation to
Gravity. Because of this function, the receptors of otolith organ are
called gravity receptors.
EFFECT OF STIMULATION OF SEMICIRCULAR CANALS:
Under Experimental conditions, semicircular canals can be
stimulated by two methods,
 Rotational Movement
 caloric stimulation

ROTATIONAL MOVEMENT:
Semicircular canal can be stimulated by Rotational movement
with the help of barany chair.

BARANY CHAIR :
It is a revolving the chair .The subject is asked to sit on the chair
The head of the subject is titlted forward at 30 degree. The chair is
rotated at a speed of 30 RPM for about 20 seconds. Then the
Rotation is stopped.
EFFECT OF STIMULATION OF SEMICIRCULAR CANALS BY ROTATION:

The stimulation of semicircular canal by Rotation produces some

effects both during rotation and after the end of rotation .
POST ROTATIORY REACTIONS:
Twenty seconds after the stoppage of Rotation in barany chair,
following reactions occur.

1) POST ROTATORY NYSTAGMUS:

Eyes are closed during Rotation by Barany chair when eyes
are opened after the sudden stoppage of Rotation, nystagmus starts.
Post Rotatory nystagmus exists for about 30 sconds.
2) DIZZINESS:
Immediately after stoppage of rotation there is a feeling of
unsteadiness. It is called dizzines .It is associated with feeling of
Rotation in the opposite direction.
3) VERTIGO :
After the end of Rotation, there is a feeling of environment
whirling around or there is a feeling of Rotation in the person
himself.

4)OTHER EFFECTS:
 Rotation for a longer peroid causes Nausea and vomiting .BP
falls by about 10-15 mm hg and heart Rate Reduced by 10-12 beats.
Reaction during rotation with opened eyes:
If Barany chair is Rotated with opened eyes, nystagumus
occurs continuosly throughout the rotation.

CALORIC STIMULATION:

Semicircular canals can be stimulated by hot / cold water into the

Ear by using syringe. The Transmission of change in temperature
into labyrinth alters the specific gravity of endolymph. This is turn
causes movement of cupula and stimulation of Receptor cells.
EFFECT OF CALORIC STIMULATION:
Stimulation of semicircular canals by thermal stimulus develops
nystagmus, vertigo and nausea. During the treatment of fluid
instilled into the ear must be equal to body temperature, so that
such symptoms of caloric stimulation are avoided.

VESTIBULAR REFLEXES

The sensory, central, and motor outpus components of the

vestibular system have been described here. The main Reflexes are
VOR, VSR, VCR and also cervical, somato sensory, visual Reflexes.
Although not directly mediated by vestibular apparatus, these
Reflexes have a close interaction with vestibular reflexes.
VESTIBULO OCULAR REFLEX:

The VOR enables us to have gaze stability by maintaining stable

vision during head motion. The VOR has two components. The
angular VOR, mediated by the SCC’s, compensates for rotation. The
linear VOR, mediated by the otoliths, compensates for translation.
The angular VOR is primarily responsible for gaze stabilization. The
linear VOR is most important in situations where near targets are
being viewed and the head is being moved at relatively high
frequencies.
To have clear vision, the eyes must move in an equal and
opposite direction during head motion. If the VOR is not firing, you
will see a corrective saccade. In other words the eyes will move in
the same direction as head movement before correcting and moving
in the opposite direction.
Interestingly the output neurons of the VOR send information to
the extraocular muscles. The extraocular muscles are arranged in
pairs, which are oriented in planes very close to those of the semi-
circular canals. This geometrical arrangement enables a single pair of
canals to be connected predominantly to a single pair of extraocular
muscles. The result is conjugate movements of the eyes in same
plane as head motion.

VESTIBULO SPINAL REFLEX:

The VSR stabilises the body. As an example of a vestibulospinal
reflex, let us examine the sequence of events involved in generating
a labyrinthine reflex.

 When the head is tilted to one side, both the canals and
otoliths are stimulated. Endolymphatic flow deflects the
cupula and shear force deflects hair cells within the
otoliths.
 The vestibular nerve and vestibular nucleus are activated.
 Impulses are transmitted via the lateral and medial
vestibulospinal tracts to the spinal cord.
 Extensor activity is induced on the side to which the head is
inclined, and flexor activity is induced on the opposite side.
The head movement opposes the movement registered by
the Vestibular system.
 The output neurons of the VSR are the anterior horn cells of the
spinal cord gray matter, which drive skeletal muscle. However, the
connection between the vestibular nuclear complex and the motor
neurons is more complicated than for the VOR.

The VSR has a much more difficult task than the VOR, because
there are multiple strategies that can be used to prevent falls, which
involve entirely different motor synergies. For example, when shoved
from behind, one’s centre of gravity might become displaced
anteriorly. In order to restore “balance,” one might (1) plantarflex at
the ankles; (2) take a step; (3) grab for support; or (4) use some
combination of all three activities.

The VSR also has”to adjust limb motion appropriately for the
position of the head on the body. The VSR must also use otolith
input, reflecting linear motion, to a greater extent than the VOR. The
eyes can only rotate and thus can do little to compensate for linear
motion, whilst the body can both rotate AND translate.
VESTIBULO COLLIC REFLEX:

The VCR is a dynamic stabilizing system. This reflex maintains

neck musculature in relation to head position. This reflex head
movement produced counters the Movement sensed by the otolith
or SCC organs.
CERVICAL REFLEXES:
The cervical spine has an important, and often under-recognized
role as part of the vestibular system.

CERVICO OCOLLIC REFLEX:

The function of the cervico-collic reflex is to stabilize the head on
the body and, thereby, provide information about motion of the
head with respect to the trunk.
Afferent sensory changes caused by changes in neck position,
create opposition to that stretch by reflexive contractions of neck
muscles.
The CCR is a compensatory response of the neck muscles that is
driven by cervical proprioceptor inputs during motion of the body.

CERVICO OCULAR REFLEX:

The cervico ocular reflex interacts with the vor .The cor consists of
eye movements driven by neck proprioceptors to that can
supplement the vor under certain circumstances. Normally the gain
of the cor is very low. The cor is facilitated when the Vestibular
apparatus is injured.It is rare ,however for the cor to have the clinical
significance.
CERVICO SPINAL REFLEX:
Cervicospinal reflex refers to the changes in limb position driven
by neck afferent activity. The reticulospinal system plays a role along
with the vestibulospinal system in maintaining this.
VISUAL REFLEXES:
This visual system is a capable sophisticated sensory system that
influences vestibular central circuitry and drives visual after
responses that is smooth pursuit and postural reactions.
Because of intrinsic delays in multisynaptic visual mechanisms,
visual responses occur at a substantially longer latency and are much
less suited to tracking at frequencies about 0.5 hertz than Vestibular
responses. Visual tracking responses may be facilitated after
vestibular loss.
SOMATOSENSORY REFLEXES:
Somatosensory mechanisms appears to be involved in postural
stability as well. Bles and associates documented somatosensory
induced nystagumus ( stepping around nystagumus).
EWALD’S LAW:
Ewald is best remembered for his research of the vestibular
system of the inner ear, which largely involved experiments
performed on the semicircular canal system of pigeons. From these
studies the so-called “Ewald laws” are derived, which deal with the
effects of endolymph motion on body, head and eye movements and
also on the phenomena of excitation-inhibition asymmetries in the
vestibular system.
  Ewald’s first law: “The axis of nystagmus parallels the
anatomic axis of the semicircular canal that generated it”.
 Ewald’s second law: “Ampullopetal endolymphatic flow
produces a stronger response than ampullofugal flow in the
horizontal canal”.
 Ewald’s third law: “Ampullofugal flow produces a stronger
response than ampullpetal flow in the vertical canals
(anterior and posterior semicircular canal)

BALANCE

Balance is defined as the ability to maintain the centre of Mass

over the base of support to improve stability.
The ability to align body segments against gravity is to Maintain
or more the body within the available base of support , Without
falling, the ability to more the body in equilibrium with Gravity via
interaction of sensor and motor systems.
Balance is dynamic phenomenon that invoves the Combination of
stability and mobility. Balance is necessary to Hold a position in
space or move in a controlled and coordinated.
DYNAMIC BALANCE:
Static and balance is the rigid stability one part of the Body on
another and it is based upon isometric and co Contraction of
muscles. Stability and control of the head should be established as it
is vital in all positions.

DYNAMIC BALANCE:
 TheThe body unless it is fully supported and relaxed is in a
constant state of adjustment to maintain its posture and
equilibrium. Maintenance of normal balance:
• Peripheral
• Special sense
• Central

PERIPHERAL:

Muscular level
↓
Muscle spindle joint receptor
↓
Via spinal cord
↓
Reaches central mechanism

SPECIAL SENSE:
 Special sence

Vestibular system visual system

cerebellum visual system

thalamus

sensory cortex

association cortex

mortex cortex

CENTRAL MECHANISM:
 Sensory Cortex Association Cortex Motor Areas

Cerebellum Thalamus Pyramidal Tract Cerebellum

Brain Stem
Special Sense Peripheral Extra Pyramidal
Mechanism Tract

Integrated Movement to elicit balance reaction

A Properly functioning balance system allows humans to see

clearly while moving, identify orientation with respect to gravity,
determine direction and speed of movement, and make automatic
postural adjustments to maintain posture and stability in various
conditions and activities.

Balance is achieved and maintained by a complex set of

sensorimotor control systems that include sensory input from vision
(sight), proprioception (touch), and the vestibular system (motion,
equilibrium, spatial orientation); integration of that sensory input;
and motor output to the eye and body muscles. Injury, disease,
certain drugs, or the aging process can affect one or more of these
components. In addition to the contribution of sensory Information,
there may also be psychological factors that impair our sense of
balance.

EQUILIBRIUM

Equilibrium reaction cause body to adjust to a Change in body’s

orientation space. Equilibrium reactions cause Body’s movement
over the base of support or cause Enlargement reffered to as tilting
reactions.
For example, if the trunk is pushed sideways (laterally) a person
will reach out or take a step to stay up right.Equilibrium reaction
seem to emerge at each stage of Development (supine, prone,
sitting, quadraped and standing) ,before a child’s achievement of the
next development milestone.

EQUILIBRIUM REACTION – TILTING:

STIMULUS:
Displace the center of gravity by tilting or moving the Support
surface with a movable object such as an equilibrium beard / or ball.

RESPONSE:
Curvature of the trunk toward the upward side along With
extension and abduction of the extremities on that side, Protective
extension on opposite (downward) side.

Onset: Prone 6 months, supine 7-8 months, Quadruped 9- 12

Months, standing 12- 21 months.
Integrated: persists

EQUILIBRIUM REACTION – POSTURAL FIXATION:

STIMULUS:
Apply a displacing force to the body, altering the centre
Of gravity in its relation to the base of support can also be observed
During voluntary activity.

RESPONSE:
Curvature of the trunk toward the external force with Extension
and abduction of extremities on the side to which the force was
applied.

Onset: Prone 6 months, Supine 7-8 months, Sitting 7- 8 months,

Quadruped 9 – 12months, Standing 12- 21 months.
Integrated: persists.
PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
 To understand the cause of vestibular system dysfunction is
helpful to understand how the inner car works the human car is
divided into three parts
1.Inner Ear
2. Middle Ear
3.External Ear

The middle Ear includes Ear drum (tympanic membrane) and 3

bones or ossicles of the middle car, the mallard (hammer), incus
(anvil) and stapes(stirrup).
The Inner ear is fluid filled series of chambers the cochlea is
responsible for conducting sound vibration into nerve impulses that
the human brain interprets as sound and what we call hearing.
The inner car also contain three semicircular canal which are
responsible for sensing movement and maintaining balance there are
canal named anterior-lateral and posterior are oriente at roughly
right angles to one another. The movement of the fluid within these
canals allows the brain to sense rotation of the head through all
these direction in space (eg) left-right backward-up-down.

It has been discovered that the probable cause of vestibular

dysfunction in dislodgement of small calcium carbonate crystals that
float through the inner ear fluid and sticks against sensitive nerve
endings (the cupula) within the balance apparatus at the end of each
semicircular canal (the ampulla).
These crystals known as otoconia usually dissolve or fall back into
the vestibule within several weeks and no longer cause any
symptoms. However in some patients there crystals be trapped in
the fluid of the balance chamber and periodically cause symptoms as
gravity and he movements cause then to repeatedly strike against
the cupula. In these patients the symptoms a not subside and they
become severely incapacitated.

Interestingly the loose otoconia tend too set the preferentially

within the posterior semicircular canal. As the imagine from looking
at the illustration above, this is because of the posterior canal hangs
down like the water trap in a drain pipe allowing the crystals to settle
inl bottom of canal.

Each inner ear contain three semicircular canal medial spatial

orientation. Each canal consists of tubular arm (crura) that sprouts
from a large barrel like compartment much like the of a coffee mug
sprouts from the mug. Each of these arms has a dilated (ampullary)
and located the top or front portion that houses the crista ampullaris
(nerve receptor).

The crista ampullaris has sail like tower that detects the flow of
fluid within semicircular canal. If a person turns suddenly to the right,
the fluid within the right horizontal canal lags behin causing the
cupula to be deflected towards (the ampula or appropriately). This
deflection is translated into nerve signal that confirms the head is
rotating to the right.
In simple terms cupula act as a three-way switch that when
pressed one way appropriate gives the body a sense of motion. The
middle ear neutral position reflects no motion. When the switch is
moved the opposite way. The sensation of motion is in the opposite
directions
 Particles in the canal slow and even results the movement of the
cupula switch and created signals that are incongruous with the
actual head movements. This mismatch of sensory information
results in the sensation of vertigo.

Balance Requires,
 Normal functioning of vestibular system.
 Input from visual system (vestibular-ocular)
 Input from proprioceptive system (vestibulo- spinal).
Disruption of balance between input results in vertigo. Goal of
different- Restore balance between 4 different inputs.
CLINICAL VIEWS ABOUT
DIZZINESS AND
BALANCE DISORDERS.
 DIZZINESS

Dizziness is a term used to describe a range of sensations, such as

feeling faint, woozy, weak or unsteady. Dizziness that creates the
false sense that you or your surroundings are spinning or moving is
called vertigo.
Dizziness is one of the more common reasons adults visit their
doctors. Frequent dizzy spells or constant dizziness can significantly
affect your life. But dizziness rarely signals a life-threatening
condition.
Symptoms:
People experiencing dizziness may describe it as any of a number
of sensations, such as:

 A false sense of motion or spinning (vertigo)

 Lightheadedness or feeling faint
 Unsteadiness or a loss of balance
 A feeling of floating, wooziness or heavy-headedness
These feelings may be triggered or worsened by walking, standing up
or moving your head. Your dizziness may be accompanied by nausea
or be so sudden or severe that you need to sit or lie down. The
episode may last seconds or days and may recur.
Causes:
Dizziness has many possible causes, including inner ear
disturbance, motion sickness and medication effects. Sometimes it’s
caused by an underlying health condition, such as poor circulation,
infection or injury.
 The way dizziness makes you feel and your triggers provide clues
for possible causes. How long the dizziness lasts and any other
symptoms you have also help pinpoint the cause.
Inner ear problems that cause dizziness (vertigo):
The sense of balance depends on the combined input from the
various parts of your sensory system. These include your:

 Eyes, which help you determine where your body is in space

and how it’s moving
 Sensory nerves, which send messages to your brain about body
movements and positions
 Inner ear, which houses sensors that help detect gravity and
back-and-forth motion
 Vertigo is the false sense that your surroundings are spinning or
moving. With inner ear disorders, your brain receives signals
from the inner ear that aren’t consistent with what your eyes
and sensory nerves are receiving. Vertigo is what results as
your brain works to sort out the confusion.

Benign paraoxymal positional vertigo (BPPV):

This condition causes an intense and brief but false sense that
you’re spinning or moving. These episodes are triggered by a rapid
change in head movement, such as when you turn over in bed, sit up
or experience a blow to the head. BPPV is the most common cause of
vertigo.
Infection:
A viral infection of the vestibular nerve, called vestibular neuritis,
can cause intense, constant vertigo. If you also have sudden hearing
loss, you may have labyrinthitis.
Meiner’s disease :
This disease involves the excessive buildup of fluid in your inner
ear. It’s characterized by sudden episodes of vertigo lasting as long as
several hours. You may also experience fluctuating hearing loss,
ringing in the ear and the feeling of a plugged ear.
Migraine:
People who experience migraines may have episodes of vertigo or
other types of dizziness even when they’re not having a severe
headache. Such vertigo episodes can last minutes to hours and may
be associated with headache as well as light and noise sensitivity.
Other causes of dizziness:
 Neurological conditions
 Medications
 Anxiety disorders
 Low iron levels
 Low blood sugar
 Carbon monoxide poisoning.

BALANCE DISORDERS.

Balance disorder is a disturbance that causesindividual to feel

unsteady, for example when standing or walking. It may be
accompanied by feelings of giddiness, or wooziness, or having a
sensation of movement, spinning, or floating.
Balance is the result of several body systems working together:
the visual system (eyes), vestibular system (ears) and proprioception
(the body’s sense of where it Is in space) generation or loss of
function in any of these systems can lead to balance deficits.
 Everyone has a dizzy spell now and then, but the term
“dizziness” can mean different things to different people. For one
person, dizziness might mean a fleeting feeling of faintness, while for
another it could be an intense sensation of spinning (vertigo) that
lasts a long time.
Balance disorders can be caused by certain health conditions,
medications, or a problem in the inner ear or the brain. A balance
disorder can profoundly affect daily activities and cause
psychological and emotional hardship.
Peripheral vestibular dysfunction, which involves the
Vestibular end organs and/or the vestibular nerve, can Produce a
variety of signs and symptoms. A thorough Evaluation by a physician
is needed to identify the specific pathology behind the patient’s
complaints of vertigo or disequilibrium. Patient history is the main
key for Diagnosis, supported by a careful otoneurologic examination.
Determining whether vestibular rehabilitation is Appropriate and, if
it is, which approach should be used is based in part on the patient’s
diagnosis.
Signs and symptoms of balance problems include:
 Sense of motion or spinning (vertigo)
 Feeling of faintness or lightheadedness (presyncope)
 Loss of balance or unsteadiness
 Falling or feeling like you might fall
 Feeling a floating sensation or dizziness
 Vision changes, such as blurriness or confusion.
 Staggering when try to walk
 Confusion and disorientation.
 Loss of balance or unsteadiness
 Muscle weakness that causes a person to fall easily
 Pain when moving to that makes it difficult to maintain balance
  A spinal cord injury that makes it difficult or impossible to move
certain areas of the body
 Strange sensation when moving
 Feeling unsteady on the feet.

Other symptoms might include nausea and vomiting; diarrhea;

changes in heart rate and blood pressure and feelings of fear,
anxiety, or panic. Symptoms may come and go over short periods or
last for a long time and can lead to fatigue and depression.

Causes of balance disorders:

Causes of balance problems include medications, ear infection,
a head injury, or anything else that affects the inner ear or brain. Low
blood pressure can lead to dizziness when you stand up too quickly.
Problems that affect the skeletal or visual systems, such as arthritis
or eye muscle imbalance, can also cause balance disorders.
 Infection of ear
 Inner ear problems
 Head injury
 Poor blood circulation
 Certain medications
 Chemical imbalance in the brain
 Low blood pressure
 High blood pressure
 Neurological conditions
 Arthritis
 Ageing
 Traumatic brain injury
 Multiple sclerosis
 Hydrocephalus seizures
 Parkinson disease
  Cerebellar diseases.

CLASSIFICATION OF VESTIBULAR DISORDERS:

The vestibular can be classified into
o Peripheral disorders
o Central disorders .
PERIPHERAL BALANCE DISORDERS:
 Benign paroxysmal positional vertigo
 Vestibular hypofunction includes unilateral and bilateral
vestibular deficits
 Vestibular migrane
 Hyper ventilation syndrome
 Meiners diseases
 Superior Semicircular canal dehinscene
 Perilymph fistlula
 Vestibular neuritis
 Persistent postural perceptual dizziness
 Acoustic neuroma
 Labyrinthitis
 Vestibular neuronitis
 Mal de debarquement syndrome.
Here we discuss some of the important peripheral Vestibular
balance disorders,

BENIGN PAROXYSMAL POSITIONAL VERTIGO:

Benign paroxysmal positional vertigo (BPPV) is one of the most
common causes of vertigo — the sudden sensation that you’re
spinning or that the inside of your head is spinning.
 BPPV causes brief episodes of mild to intense dizziness. It is
usually triggered by specific changes in your head’s position. This
might occur when you tip your head up or down, when you lie down,
or when you turn over or sit up in bed.
Sometimes, a low-amplitude, secondary nystagmus,directed in the
opposite direction, may occur. If the Patient then quickly sits up, a
similar but usually milder Recurrence of these symptoms occurs, the
nystagmusBeing directed opposite to the initial nystagmus.
Further diagnostic criteria indicating a central positional
nystagmus are as follows: (1) the condition Does not subside with
maintenance of the head in the precipitating position, (2) the
nystagmus may change direction when different head positions are
assumed, and (3) The nystagmus may occur as downbeat nystagmus
only in the head-hanging position.
COMMON CAUSES OF BPPV:
Ear infection, meiners diseases, acoustic neuroma, multiple
slerosis, head trauma, migrane, sudden turning of head, post
labyrinthetomy quick bending of head, minor strokes.
COMMON CLASSIFICATION:

➢ Posterior canal BPPV

➢ Lateral canal BPPV
➢ Anterior canal BPPV
PATHOPHYSIOLOGY:
A vestibular labyrinth on each side of the body, CNS Receives
signals from both the right and left labyrinth and compares these
signals with one another when this discharges in both Vestibular
afferents are exactly balanced during motion the right and left
labyrinth are alternatively excited and inhibited leading to a left-
right difference in 8 nerve activity which is recognized as motion.

THEORIES OF BPPV:
CUPOLOLITHIASIS THEORY:
The classic explaination of the pathophysiology was first
described by schuknecht in 1969.
The Cupolithiasis theory suggests that the debris adhers to the
cupula, making it deserves than the surrounding endolymph and
thereby suspectible to the pull of gravity.
CANALITHIASIS THEORY:
Brandt and steddin emphasized a second theory, canalithiasis
which better explains the typical features of BPPV. It suggests that
the debris of a higher density than the endolymph is free floating in
the long arm of canal. This theory accords with the direction of
nystagmus and allows for a latency.
VESTIBULAR NEURITIS:
Vestibular neuritis is a disorder that affects the nerve of the inner
ear called the vestibulocochlear nerve. This nerve sends balance and
head position information from the inner ear to the brain. When this
nerve becomes swollen (inflamed), it disrupts the way the
information would normally be interpreted by the brain.
Vestibular neuritis can occur in people of all ages, but is rarely
reported in children.
The vestibulocochlear nerve sends balance and head position
information from the inner ear (see left box) to the brain. When the
nerve becomes swollen (right box), the brain can’t interpret the
information correctly. This results in a person experiencing such
symptoms as dizziness and vertigo.
SYMPTOMS OF VESTIBULAR NEURITIS:
Symptoms include:
 Sudden, severe vertigo (spinning/swaying sensation)
 Dizziness
 Balance difficulties
 Nausea, vomiting
 Concentration difficulties
Vestibular neuritis and labyrinthitis are closely related disorders.
Vestibular neuritis involves swelling of a branch of the
vestibulocochlear nerve (the vestibular portion) that affects balance.
CAUSES OF VESTIBULAR NEURITIS:
It is the most likely cause is a viral infection of the inner ear,
swelling around the vestibulocochlear nerve (caused by a virus), or a
viral infection that has occurred somewhere else in the body.
LABYRINTHITIS:
Labyrinthitis is a disorder that causes inflammation in the inner
ear. It can cause dizziness, nausea, vertigo, and loss of hearing.
Labyrinthitis is an inner ear disorder. The two vestibular nerves
in your inner ear send your brain information about your spatial
navigation and balance control. When one of these nerves becomes
inflamed, it creates a condition known as labyrinthitis.

Symptoms of labyrinthitis include:

 Dizziness
 Tinnitus, which is ringing in the ears
 Nausea
 Loss of balance
 Hearing or vision problems
Types of labyrinthitis:
There are several different types of labyrinthitis, which we cover
in more detail below.

Viral labyrinthitis
Most cases of labyrinthitis are due to viral infections, such as a cold
or the flu, spreading to the inner ear. Viral labyrinthitis typically
results in sudden vertigo, nausea, and vomiting. Sometimes, it also
leads to hearing loss.
Bacterial labyrinthitis
There are two main types of bacterial labyrinthitis:
Serous labyrinthitis
Suppurative labyrinthitis.
MEINER'S DISEASES:
Meniere’s disease is a disorder of the inner ear that can lead to
dizzy spells (vertigo) and hearing loss. In most cases, Meniere’s
disease affects only one ear.
Meiners disease can occur at any age, but it usually starts
between young and middle-aged adulthood. It’s considered a chronic
condition, but various treatments can help relieve symptoms and
minimize the long-term impact on your life.Vertigo, which gives a
person the sensation of spinning or the world spinning around them.
The four main symptoms are:
 Vertigo
 hearing loss.
 Tinnitus.
 Feeling pressure or a sense of fullness. This is usually in just one
ear.
Other symptoms include:
 Headaches.
 Belly (abdominal) pain.
 Nausea.
PERILYMPHATIC FISTULA:
A perilymphatic fistula refers to a tear or defect in the membranes
that separate your middle ear and inner ear. People with a
perilymphatic fistula may notice several symptoms, including a
feeling of fullness in their ear, hearing loss and vertigo. Treatments
include bed rest, blood patch injections or surgery.
Perilymphatic fistula symptoms may include:
 Sudden hearing loss.
 Hearing loss that comes and goes.
 A feeling of fullness in the ear.
 Dizziness.
 Vertigo.
 Motion sickness.
 Nausea.
 Memory loss.
 Balance problems.
VESTIBULAR PAROXYSMIA:
The main symptoms of vestibular paroxysmia (VP) are brief
attacks of spinning or non-spinning vertigo which lasts a fraction of a
second to a few minutes and occurs with or without ear symptoms
(tinnitus and hypo- or hyperacusis). Arteries or rarely veins in the
cerebellar pontine angle are the pathophysiological cause of a
segmental, pressure-induced dysfunction of the eighth nerve.
The syndrome of neurovascular cross-compression of the
eighth nerve was previously connected with so-called “disabling
positional vertigo” ,a very heterogeneous syndrome of vertigo with
symptoms of various durations (from seconds to days), various
characteristic features (rotatory or postural vertigo, light-headedness
or gait instability without vertigo), and varying accompanying
symptoms.
BILATERAL VESTIBULAR DISORDERS:
Bilateral vestibulopathy may occur secondary to meningitis,
labyrinthine infection, otosclerosis, Paget’s disease, Polyneuropathy,
bilateral tumors (acoustic neuromas in neurofibromatosis),
endolymphatic hydrops, bilateral sequential vestibular neuritis,
cerebral hemosiderosis,ototoxic drugs, inner-ear autoimmune
disease, or congenital malformations. Autoimmune conditions
affecting the inner ear are rare but distinct clinical entities,
characterized by a progressive, bilateral sensorineural hearing loss
often accompanied by a bilateral loss of vestibular function.
SUPERIOR SEMICIRCULAR CANAL DEHINSCENE SYNDROME:
Canal dehiscence refers to an opening (dehiscence) in the bone
that covers one of the semicircular canals of the inner ear. It most
commonly occurs in the superior semicircular canal of the ear. It can
result in symptoms that affect a person’s balance and hearing.
The true cause of canal dehiscence syndrome is unknown. The
dehiscence may, at least in part, be congenital (present from birth)
and may have occurred during the development of the inner ear. It
can also be caused from certain infections as well as head trauma.
HYPERVENTILATION SYNDROME:
Hyperventilation syndrome is a common disorder that is
characterized by repeated episodes of excessive ventilation in
response to anxiety or fear. Symptoms are manifold, ranging from
sensations of breathlessness, dizziness, paresthesias, chest pains,
generalized weakness, syncope, and several others. Although sudden
and extreme anxiety usually triggers discrete attacks, a pattern may
be chronic, recurrent and subtle. The resultant physical sensations
often dominate and obscure the underlying hyperventilation and
cause the over breathing to be overlooked.

CENTRAL BALANCE DISORDERS:

Not all vertigo results from peripheral vestibulopathy.
A comprehensive list follows,
 Migrane
 Neoplasms
Vestibular schwannomes
Brainstem neoplasms
Cerebellar neoplasms
 Cerebrovascular disorders
Vestibular insufficiency
Lateral medullary syndrome
Lateral pontomedullary syndrome
Cerebral infarction
Cerebral haemorrhage
 Craniovertebral junction disorders
Basilar infarction
Assimilation of the Atlas
Chiari malformations

 Multiple slerosis
 Cerebellar ataxia syndrome
 Focal seizure disorders
 Normal pressure hydrocephalus
 Pyschiatric dizziness
 Toxins and medications.
PATHOMECHANICS OF CENTRAL VESTIBULAR DISORDERS:
Central Vestibular disorders involve the Vestibular nuclear
complex and the cerebellum, as well as structures of the reticular
activating system, midbrain and higher centres of cortical function.
Integration and processing of input from the Vestibular,visual ,
and somatosensory system is affected in central Vestibular disorders.
INVESTIGATIONS.

The comon investigation of vestibular disorders are,

Good balance and clear vision rely on a close linkage between the
Vestibular organs and the eyes.
  Electronystagmography
 Rotation tests
 Vestibular evoked myogenic potential.
 Computerized dynamic posturography
 Hearing tests
 Pure tone audiometry
 Videonystagmography
 Speech audiometry tests
 Tympanometry
 Acoustic reflex testing
 Electrococleography
 Otoacoustic emissions
 Auditory brainstem response test

SCANS:
 Magnetic resonance imaging
 Computerized axial tomography
 Other tests
 Physical examination
 History of the patient
 Audiometry
 Neurological examination.
 TESTS FOR VESTIBULAR
DYSFUNCTION.

OBJECTIVE EVALUATION,
Examination of eye movements,
Oculomotor screen:
When conducting any vision screening or testing, it is important to
watch and ask the patient how must effort a task requires and the
degree of symptoms provoked. The basic oculomotor screen during a
vestibular assessment should include:
1. Fixation in primary and eccentric gaze
2. Smooth pursuit or tracking
3. Vestibulo-ocular reflex (VOR) cancellation
4. Saccades.
Oculomotor Testing:
Spontaneous Nystagmus,
Spontaneous nystagmus is tested in primary and eccentric gaze. It
occurs due to the unopposed tonic neural activity of the intact side
when there are lesions in the peripheral vestibular systems (acute) or
central vestibular pathways.
Primary gaze is tested as follows:
The patient looks forward and visually fixates on a target this
position is held for 10 seconds and the therapist looks for any
nystagmus.
The most common pathological type of nystagmus driven by the
CNS is gaze evoked nystagmus (GEN). It is tested as follows:
The patient is asked to fixate on a position 30 degrees to each
side, up and down (i.e. an eccentric position)
Each position is held for 10 seconds and the therapist looks for
nystagmus
GEN is only present with eccentric gaze, not in primary gaze.
HEAD IMPULSE TEST: (Examination of the VOR at High Acceleration):
 The head impulse test (HIT) is a widely accepted clinical tool used
to examine semicircular canal function.50-54 Cervical range of
motion (ROM) should be determined before performing the head
impulse test and the physical therapist should explain why the head
must be moved quickly. The head impulse test is performed by
having the patient first fixate on a near target (e.g., the clinician’s
nose). When testing the horizontal SCC, the head is flexed 30°.

HEAD SHAKING INDUCED NYSTAGMUS:

The head-shaking induced nystagmus (HSN) test is a useful aid
in the diagnosis of a unilateral peripheral vestibular defect. During
this test vision is occluded. The Patient is instructed to close his or
her eyes. He clinician flexes the head 30° before oscillating
horizontally for 20 cycles at a frequency of 2 repetitions per second
(2 Hz). On stopping the oscillation, the patient opens the eyes and
the clinician checks for nystagmus. In subjects with normal vestibular
function, nystagmus will not be present.
An asymmetry between the peripheral vestibular inputs to
central vestibular nuclei, however,may result in HS . Typically, a
person with a UVH will manifest a horizontal HS , with the quick
phases of the nystagmus directed toward the healthy ear and the
slow Phases directed toward the lesioned ear.60 ot all Patients with
a UVH will have HS .
Patients with a complete loss of vestibular function bilaterally
will not have HS because neither system is functioning. As a result,
there is no asymmetry between the tonic firing rates. The presence
of vertical nystagmus after either horizontal or vertical head shaking
suggests a central lesion.

DIX HALL PIKE TEST:

 The most commonly used test is Dix-Hallpike which assesses
involvement of the posterior canal (the most commonly affected
semicircular canal). The test involves turning the head 45 degrees to
the side being tested and then quickly moving from a seated to a
supine position with the head declined 30 degrees below the trunk.
The test must be performed quickly to ensure sufficient
displacement of the endolymp and otoconia to provoke the expected
symptoms. The test is considered positive for canalithiasis of the
posterior canal if vertigo is provoked and nystagmus is observed,
both of which should be of short-duration for canalithiasis. The
direction of the observed nystagmus should be consistent with the
canal being assessed.
For the posterior canal, nystagmus should be up-beating and
torsional in an ipsilateral direction (if testing the affected side. If the
left side is affected but the test Is performed with the head turned to
the right, the nystagmus would be up-beating and torsional to the
right).
HEAD IMPULSE TEST:
The patient will need to understand what will be their neck is
relaxed during the test. If the patient noted that the patient had
pain/ significant restrictions in cervical spine mobility, the test should
be performed with extreme caution or should be deferred.
Saccade ( to catch up) is a positive sign.
Peripheral dysfunction with corrective saccades.
HEAD SHAKE TEST:
Velocity storage integration dynamic balance of labyrinthis.
Eyes are closed and with 30° neck flexion ( horizontal SCC
position) . Therapists shakes their head side to side at 2 hz for 20
cycles. Stop and then they open their eyes for nystagmus.
SMOOTH PURSUIT TORSION TEST :
The smooth pursuit neck torsion test measures smooth pursuit eye
movement with the head / trunk in neutral and when the trunk and
neck are rotated relative to a stationary head.
Smooth pursuit neck torsion test is considered to be specific for
detecting eye movement disturbances due to altered cervical
sensory input.
MOTION SENSITIVE TESTING:
The motion sensitivity test (MST) measures motion-provoked
dizziness during 16 quick head or body position changes.
Certain head and body movements send abnormal vestibular
signals to the brain, which conflict with normal signals from the
intact visual and somatosensory systems
Sensory conflict is believed to produce the symptoms associated
with motion-induced dizziness.
BALANCE AND GAIT ASSESSMENT:
Static Balance Tests
The following tests can be used to assess static balance. It is
important to note, however, that vestibular patients may have
normal results in these tests.
Romberg test – the patient stands with his / her feet together and
arms crossed. The patient is asked to maintain this position with eyes
open and then eyes closed. It is usually stopped at around 30
seconds. Mild sway is present even in normal individual for few
seconds, immediately following mild initial sway, but a patient with
posterior column disease who depends upon the visual sensation
will sway maximally and may even fall.
 Sharpened Romberg – this test is similar to the Romberg, but this
version is performed in tandem standing with eyes open and closefal
Single leg stance – eyes open and closed.
VEERING TEST:
Procedure- instruct the patient to walk with his eyes closed.
Rationale- Veering in walking or a positive romberg test is indicative
of a unilateral Vestibular lesion.
PAST POINTING TEST:
Procedure:
With the patients eyes opened, instruct the patient to elevate his
extended arm over his head with the index finger extended. Next
instruct the patient to touch the the therapist extended index finger,
which is placed near the patient at the level of the hips. Repeat the
test with the patient eyes closed
Rationale:
If the patient has a vestibular lesion, the patients arm will dri,
and he will have difficulty placing his finger on the therapist with his
eyes closed.
REFLEX TEST:
CALORIC TESTING:
Compensatory mechanism may mask clinical evidence of
vestibular damage. Caloric testing provides useful supplementary
information and may reveal undetected vestibular dysfunction.

Method:
 Water at 30 degree Celsius irrigated into the external audiotory
meatus Nystagmus usually develops after 20 seconds delay and lost
for more than a minute. The test is repeated after 5 minutes with
water at 40 degree Celsius
Cold water effectively reduces the vestibular output from one side
creating an imbalance and producing eye drift towards the irrigated
ear. Rapid corrective movement results in nystagmus to the opposite
ear. Hot water (44 C) reverses the convection current increases the
vestibular output and changes the direction of nystagmus.
MANAGEMENT
 Treatment will depend on the underlying cause of the balance
disorder,and may include,
Treating any underlying causes. Depending on the cause, you may
need antibiotics or antifungal treatments. These can treat ear
infections that are causing your balance disorder.
Changes in lifestyle. You may be able to ease some symptoms
with changes in diet and activity. This includes quitting smoking or
avoiding nicotine.
Epley maneuver (Canalith repositioning maneuvers). These are a
specialized series of movements of your head and chest. The goal is
to reposition particles in your semicircular canals into a position
where they don’t trigger symptoms.
Surgery. When medicine and other therapies are unable to
control your symptoms, you may need surgery. The procedure
depends on the underlying cause of the disorder. The goal is to
stabilize and repair inner ear function.
Rehabilitation. If struggle with vestibular balance disorders, you
may need vestibular rehabilitation or balance retraining therapy. This
helps you move through your day safely.

PHARMACOLOGICAL MANAGEMENT .

Clincally , treatment options for patient with vertigo include

symptomatic , specific and prophylactic approaches. Symptomatic
treatment involves controlling the acute symptoms and autonomic
complaints.
Vestibular suppressants:
Vestibular suppressants are drugs that reduce the intensity of
vertigo and nystagmus evoked by a Vestibular imbalance.
Three major groups are anticholinergics , antihistamines,
benzodiazepenes.
Anticholinergics are Vestibular suppressants that inhibit firing in
Vestibular nucleus neurons as well as reduce the velocity of
Vestibular nystagmus in humans.
Benzodiazepenes namely diazepam , clonazepam , lorazepam,
alprazolam are used.
Antihistamines namely meclizine , dimenhydrinate, promethazine,
diphenhydramine are used.
Antiemitics, are dexamethasone, ondansetron, meclizine,
dimenthiazines, phenothiazines.

SURGICAL MANAGEMENT
Surgical procedures for peripheral vestibular disorders are either
corrective or destructive. The goal of corrective surgery is to repair or
stabilize inner ear function. The goal of destructive surgery is to stop
the production of sensory information or prevent its transmission
from the inner ear to the brain
Some of the common surgeries namely,
 Labyrinthetomy
 Vestibular nerve section
 Chemical labyrinthetomy
 Endolympatic sac decompression
 Oval or round window plugging
 Pneumatic equalization tubes
 Canal partitioning
 Microvascular decompression
 Stapedectomy
 Acoustic neuroma
 Ultrasound surgery.
 PHYSIOTHERAPY
MANAGEMENT.
VESTIBULAR
REHABILITATION.

The earliest Vestibular rehabilitation therapy called the cawthrone

and cookery exercises was developed by cawthrone and cooksey to
treat patients with labyrinth injury resulting from surgery or head
injury. The exercise for Vestibular rehabilitation can be categorised
into two types
Physical therapy for Vestibular hypofunction
Canalith repositioning for bppv.
Therefore, before an exercise program can be designed, a
comprehensive clinical examination is needed to identify problems
related to the Vestibular disorders. Depending on the Vestibular
related problems identified, three principles methods of exercise can
be prescribed ,
 Habituation exercises
 Gaze stabilization exercises
 Balance training exercises.
 Cawthrone and cooksey exercises.
Aims of Vestibular rehabilitation:
 Replace the otoconia in to the vestibule.
 Reduce the vertigo associated head motion.
 Improve balance.
 Educate the patient about self treatment strategies in the
advent of reoccuence.
 Return to daily activity involving head motion
Benefits of vestibular rehabilitation :
The benefits of physiotherapy treatment to someone with a
vestibular condition can be life changing. Not only will they gain a
greater understanding of their condition and develop coping
strategies, some people will experience an immediate and lasting
relief from their symptoms. Allowing them to resume normal
activities free of limitation. Some of the benefits experienced by
clients undergoing vestibular rehabilitation include;
Reduced dizziness and risk of falls.
 Improved Visual focus.
Improved balance.
Regain energy levels, improved exercise tolerance.
Return to normal activities of daily living.
Increased confidence, particularly in physical ability.

HABITUATION EXERCISES:
Habituation exercise is used to treat symptoms of dizziness that is
produced because of self-motion3 and/or produced because of
visual stimuli. 5, 6 Habituation exercise is indicated for patients who
report increased dizziness when they move around, especially when
they make quick head movements, or when they change positions
like when they bend over or look up to reach above their heads.
The goal of habituation exercise is to reduce the dizziness
through repeated exposure to specific movements or visual stimuli
that provokes patients’ dizziness. These exercises are designed to
mildly, or at the most, moderately provoke the patients’ symptoms
of dizziness. Over time, with good compliance and perseverance, the
dizziness intensity can reduce due to the brain learning to ignore the
abnormal signal.

GAZE STABILIZATION EXERCISES:

Gaze Stabilization exercises are used to improve control of eye
movements so vision can be clear during head movement.
These exercises are appropriate for patients who report
problems seeing clearly because their visual world appears to
bounce or jump around, such as when reading or when trying to
identify objects in the environment, especially when moving about.
There are two types of eye and head exercises used to promote gaze
stability. The choice of which exercise(s) to use depends on the type
of vestibular disorder and extent of the disorder.
One example is,

BALANCE TRAINING EXERCISES:

Balance Training exercises are used to improve steadiness so that
daily activities for self-care, work, and leisure can be performed
successfully. Exercises used to improve balance should be designed
to address each patient’s specific underlying balance problem(s).
Additionally, balance exercises should be designed to reduce
environmental barriers and fall risk.
For patients with Benign Paroxysmal Positional Vertigo (BPPV),
the exercise methods described above are not appropriate to resolve
this type of vestibular disorder. Through assessment, the type of
BPPV is identified, and depending on the type, different repositioning
maneuvers can be performed to help resolve the spinning that
occurs due to position changes.
EPLEY MANOEUVRE:
Epley manoeuvre is other wise called as canalith repositioning
treatment is used to treat posterior and anterior canal canalithiasis.

The manoeuvre is performed as follows:

 The patient is moved into DH on his / her affected side

 The therapist rotates the patient’s head through 90 degrees to
the opposite side; maintaining 30 degrees of extension
 The patient is rolled onto the unaffected side with his / her
head looking down
 Maintaining head rotation, the patient gently sits up at side of
bed
 Each position is held until the vertigo and nystagmus has
stopped and then for an additional 2 to 3 minutes
GANS MANOEUVRE:
The Gans manoeuvre is a modified Epley manoeuvre. It is performed
as follows (assuming the right side is affected:
 Patient is positioned in side lying test position – i.e. sitting.
 Patient turns head 45 degrees to the left
 Patient lies down quickly onto his / her right side (no pillow),
and holds this position for 2-3 minutes until the vertigo /
nystagmus resolves
 The patient then rolls over onto his / her left side, while
maintaining the same head position
 Wait 2-3 minutes as above
 The patient sits up to complete the manoeuvre.

There are two key treatments for horizontal canal canalithiasis:

Forced prolonged positioning (i.e. 8 to 12 hours) lying on the
unaffected side
Barbeque roll (also known as the Lempert roll)
BARBEQUE ROLL:
To perform this canalith repositioning treatment:

The patient is positioned in supine with his / her head elevated 20

degrees and turned toward the affected side
The therapist slowly rolls the patient’s head away from the affected
side in 90 degree increments until the head has moved through 360
degrees
Each position is maintained until the vertigo has stopped plus an
additional 15 seconds
 The patient should have no vertigo or nystagmus once they are
prone.
LIBERATORY (SEMONT) MANOEUVRE :
Semont Manouver is used to treat vertical canal Cupolithiasis.
To treat posterior canal BPPV using the liberatory (semont)
manoeuvre:

1) The patient sits with his / her legs over the side of the bed
2) The patient’s head is turned 45 degrees toward the
unaffected side
3) The therapist quickly moves the patient into side-lying on
the affected side
4) This position is held for 5 minutes
5) The patient is then quickly moved all the way back up and
then down to the opposite side-lying position, maintaining
his / her head position
6) This position is held for 5 minutes
In this second position, nystagmus and vertigo typically appear. If
they do not, the head is abruptly shaken once or twice to free the
debris.
The patient is slowly sat back up
To treat anterior canal BPPV with the liberatory (semont)
manoeuvre, the manoeuvre is similar, but the patient’s head is
turned to the affected side to begin..

1) Patient sits with legs over the side of the bed

2) Patient’s head is turned 45 degrees towards the affected
side
 3) The therapist quickly moves the patient into side-lying on
the affected side – essentially, the patient is lying on his /
her affected canal
4) This position is held for 5 minutes
5) The patient is then quickly moved all the way back up and
then down to the opposite side-lying position, maintaining
his / her head position
6) This position is held for 5 minutes
In this second position, nystagmus and vertigo typically appear. If
they do not, the patient’s head is abruptly shaken once or twice to
free the debris
The patient is slowly sat back up.

MODIFIED SEMONT MANOUVER:

The modified semont manoeuvre can be used to treat horizontal
canal cupulolithiasis. It is performed as follows:

1. The patient starts in sitting on a bed. Lie him / her quickly down
into side-lying on the affected side (i.e. the less symptomatic
side to the patient)
2. Immediately at this point, conduct a 45 degree rotation
downward
3. This position is held for 2 to 3 minutes
4. The patient is then quickly returned to the sitting position
BRANDT – DAROFF EXERCISE:
The Brandt – Daroff exercise is one of several exercises Intended
to speed up the compensation process and end the Symptoms of
vertigo. It is prescribed for people with Benign Paroxysmal Positional
Vertigo and sometimes for labyrinthitis.
AIM:
✓ To reduce dizziness
✓ To reduce the vertigo associated head motion
✓ To improve balance
✓ Return to daily activity involving head motion.

TIME EXERCISES DURATION:

The Brandt- Daroff exercises should be performed for two Or three
weeks and a suggest schedule is as follows.
✓ Morning 5 repetitions for 10 minutes
✓ Noon 5 repetitions for 10 minutes
✓ Evening 5 repetitions for 10 minutes.
To perform these exercise programme, patients are instructed to:

Turn their head 45 degrees away from the affected side and lie
quickly onto the affected side
 Hold this position until vertigo stops (+ 30 seconds)
 Then return to sitting position and hold for 30 seconds or
until the vertigo stops
 Repeat these steps on the opposite side
 Repeat this sequence 10-20 times, three times per day

CAWTHRONE AND COOKSEY EXERCISES:

 Some examples of Cawthorne-Cooksey balance disorder exercises
that help manage vertigo symptoms include:
In bed (if unable to sit)
1) Eye movements – at first slow, then quick:
2) Up and down
3) From side to side
4) Focusing on finger moving from 3 feet to 1 foot away from face
Sitting (if possible):
1) eye movements as above.
2) Head movements at first slow, then quick, later with eyes
closed
3) Bending forward and backward
4) Turning from side to side.
5) Shoulder shrugging and circling
6) Bending forward and picking up objects from the ground
Standing (might need some assistance):

1) Eye, head and shoulder movements as in the sitting protocol.

2) Changing from sitting to standing position with eyes open and
shut
3) Throwing a small ball from hand to hand (above eye level)
4) Throwing a ball from hand to hand under knee
5) Changing from sitting to standing and turning around in
between

Moving about (best in a class, as assistance may be needed)

1) Circle around center person who will throw a large ball
2) o whom it will be returned
3) Walk across room with eyes open and then closed
 4) Walk up and down slope with eyes open and then closed
5) Walk up and down steps with eyes open and then closed
Any game involving stooping and stretching and aiming such as
bowling and basketball
The goal is to increase the time you can perform these routines,
starting with 1-2 minutes for each. It may take a few days to get used
to the activities, and you may experience mild symptoms while
performing them. Don’t continue to do exercises .
BALANCE EXERCISES AND PROGRESSION :
Begin with:
Stand with feet shoulder width apart, arms across the chest.
Progress to:
Bring feet closer together, close eyes. Stand on sofa cushion pillow.
Purpose:
Enhance the use of vestibular signal for balance by decreasing base
of support. Eyes closed increases reliance on vestibular signals for
balance
Begin with:
Practice ankle sways (Anterior – Posterior, Medial – lateral)
Progress to:
Doing circle sways, close eyes.
Purpose:
Teaches the patient to use correct ankle strategy.
Begin with:
Attempt to walk with hell touching toe on firm surface.
Progress to:
Do the same exercise on carpet.
Purpose:
Enhance the use of vestibular signal for balance by decreasing base
of support. Doing the exercise on carpet decreases proprioception,
increasing difficulty.
Begin with:
Practice walking and turning around.
Progress to:
Making smaller turns. Closer eyes.

Purpose:
The turning stimulates and challenges the vestibular system.
Challenge balance stimulates both vestibular system
 METHODOLOGY

METHODOLOGY
Methodology is a science dealing with the principle of science ,
research and study.
PURPOSE OF STUDY :
To study the effectiveness of Vestibular rehabilitation for the
patients with dizziness and balance disorders.
STUDY SITTING:
Mahatma Gandhi Memorial Government hospital – trichy and
Government College of physiotherapy – Trichy.
STUDY DURATION: 10 to 14 Days.
STUDY SAMPLE: 10.
INCLUSION CRITERIA:
 Dizziness
 Balance disorders
  Giddiness
 Both sexes.
EXCLUSION CRITERIA:
 Fracture
 Acute infarction
 Pregnancy
 Menstruation
 Right after meal.

OUTCOME MEASURES: To reduce the dizziness and vertigo

associated head movements.
FUNCTIONAL DISABILITY SCALE:
0------ No disability – Negligible symptoms
1 ------No disability – Bother some symptoms
2------Mild disability – performing usual duties.
3------Moderate disability – Disrupts usual duties
4-----Recent severe disability – Medical leave
5 ------Established severe disability.

VISUAL VERTIGO ANALOGUE SCALE:

The Visual Vertigo Analogue Scale (VVAS) assesses visual vertigo.
Instead of the original scoring methods (positive VVAS > 1), we
propose categorizing patients as having No (0), Mild (0.1-40),
Moderate (40.01-70), or Severe (70.01-100) symptoms.
 PHYSIOTHERAPY
ASSESSMENT .

PHYSIOTHERAPY ASSESSMENT

SUBJECTIVE ASSESSMENT:

NAME
AGE
GENDER
ADDRESS
IP NO
DATE OF ASSESSMENT
HEIGHT
WEIGHT
 CHIEF COMPLAINTS ;
ASSOCIATED PROBLEMS ;
HISTORY OF THE PATIENT:
PRESENT HISTORY
PAST HISTORY
MEDICAL HISTORY
SURGICAL HISTORY
PERSONAL HISTORY
FAMILY HISTORY.
OBJECTIVE ASSESSMENT:
ON OBSERVATION:
BODY BUILT
POSTURE
GAIT
ON EXAMINATION:
VITAL SIGNS,
BLOOD PRESSURE
HEART RATE
PULSE RATE
RESPIRATORY RATE
TEMPERATURE
SENSORY ASSESSMENT:
CRANIAL NERVE EXAMINATION
Oculomotor for nystagmus
 Vestibulo cochlear nerve for rotation.
REFLEXES ;
Vestibulo ocular reflex
Vestibulo cochlear reflex
Vestibulo spinal reflex
Cervico ocular reflex.
SPECIAL TEST:
Dix hall pike test
Doll’ s head manoeuvre
Romberg test
Veering test
Head impluse test
CO ORDINATION EXAMINATION:
Non equilibrium and equilibrium tests.
Walking along a straight line.
TEST FOR VESTIBULAR APPARATUS:
Balance – sitting, standing, and listening reaction.
Posture- lying , sitting and Standing.
GAIT:
VISUAL VERTIGO ANALOGUE SCALE:
THE ACTIVITIES SPECIFIC BALANCE CONFIDENTIAL SCALE:
FUNCTIONAL BERG BALANCE GRADES:
GRADE BALANCE
NORMAL Patient is able to maintain balance without
 support.accepts maximal challenge and can shift
weight in all directs.
GOOD Patient is able to maintain without support .accepts
moderate challenge and can shift weight , although
limitations are evident.
FAIR Patient is able to maintain without support. Cannot
tolerate challenge, cannot maintain balance while
shifting weight.
POOR Patient requires support to maintain balance
ZERO Patient reqires maximal assitance to maintain balance.

BERG BALANCE SCALE:

The Berg Balance Scale (BBS) is used to objectively determine a
patient’s ability (or inability) to safely balance during a series of
predetermined tasks. It is a 14 item list with each item consisting of a
five-point ordinal scale ranging from 0 to 4, with 0 indicating the
lowest level of function and 4 the highest level of function and takes
approximately 20 minutes to complete. It does not include the
assessment of gait.
Your provider will ask you to perform 14 specific movements:

Move from a sitting to a standing position.

Stand up unsupported.
Sit unsupported.
Move from a standing to a sitting position.
Transfer from one chair to another.
Stand up with your eyes closed.
Stand with your feet together.
Reach forward with an outstretched arm.
Pick an object up off of the floor.
Turn and look behind you.
Turn around in a complete circle.
Place each foot alternately on a stool in front of you.
Stand unsupported with one food directly in front of the other.
Stand on one leg for as long as you can.

Berg balance scale scores are interpreted as such:

0 to 20: A person with a score in this range will likely need the
assistance of a wheelchair to move around safely.
21 to 40: A person with a score in this range will need some type of
walking assistance, such as a cane or a walker.
41 to 56: A person with a score in this range is considered
independent and should be able to move around safely without
assistance.
INVESTIGATION:
DIAGNOSIS:
PROBLEM LIST:
MANAGEMENT:
PHYSIOTHERAPY MANAGEMENT:
AIMS
MEANS
HOME ADVICE:

CASE STUDIES
 CASE STUDY- 1

OBJECTIVE ASSESSMENT:
Name : Chandra .
Age : 68 years
Gender : Female
Occupation : house wife
Address : attumandhai theru, puthur,
Trichy.
Date of assessment : 05/ 08/ 2022
IP no : 62726
Height : 160 cms
Weight :60 kg

Chief complaints :
 patients complaints of giddiness during wake up from
the bed.
Patient had a giddiness during walking and weight
lifting activities.

SUBJECTIVE ASSESSMENT:
Past medical history:
patient had suffering from cervical spondylosis for past 6
months , she also undergone medical management.

History of diabetic and hypertension.

Present medical history :
patient suffering from vertigo for 3 months . She has a
vertigo during walking.
Medical history:
patient had taken medications for diabetic and
hypertension.
Surgical history :
No relavant surgical history
Family history:
No relavant family history.

ON OBSERVATION :
Body built : mesomorphic.
Posture : Normal
 Gait : Normal.
ON EXAMINATION:

VITAL SIGNS,
Blood pressure – hypertension.
Respiratory rate -14 beats / minute.
Pulse rate – 75 beats / minute.
Temperature – normal.
Sensory – normal
Motor – normal.

VISUAL ANALOGUE SCALE FOR VERTIGO :

REFLEX TESTING :
Caloric stimulation – positive
Doll’ head maneuver – positive.

SPECIAL TEST :
Head shaking induced nystagmus – positive
Dix head pike test – positive
 Romberg test – positive
Veering test – positive .
DIAGNOSIS :
Vertigo.
PROBLEM LIST:
Imbalance
Nausea
Vomiting
Light headedness
PHYSIOTHERAPY MANAGEMENT:
AIMS :
To improve balance.
To get relief from light headedness
To get relief from giddiness.
MEANS :
Canalith repositioning maneuvre.
Semont Manouver
Balance exercise and progression.
Do’s :
Exercises in sitting position:
Shrugging and rotation of shoulder.
Bending forward and picking up object.
Turning head and trunk to the left and right.
Exercises in standing position:
 Changing from sitting to standing initally with eyes open
and then with the eyes shunt.
Throwing a small ball in an are from hand to hand and
following in with the eyes.
PROGNOSIS:
VISUAL ANALOGUE SCALE FOR VERTIGO:
 CASE STUDY -2
OBJECTIVE ASSESSMENT:
Name : Rajeshwari
Age : 75 years
Gender : Female
 Occupation : house wife
Address : 38 / 42 , lakshmigandha puram , thuraiyur ,
Trichy.
Date of assessment: 07 / 8 / 2022
IP no : 9689
Height : 155 cms
Weight :55 kg

Chief complaints :
patients complaints of giddiness during wake up from the bed.
Patient had a giddiness during walking and weight lifting
activities.
Patient had a problem in difficulty during walking.

SUBJECTIVE ASSESSMENT:

History:
Past medical history:
patient had suffering from cervical spondylosis for past
6 months , she also undergone medical management.
History of diabetic and hypertension.
Present medical history :
patient suffering from vertigo for 3 months . She has
a vertigo during walking.
 Medical history: patient had taken medications for diabetic and
hypertension.
Surgical history : No relavant surgical history
Family history: No relavant family history.
ON OBSERVATION :
Body built : mesomorphic.
Posture : Normal
Gait : Normal.
ON EXAMINATION:
VITAL SIGNS,
Blood pressure – hypertension.
Respiratory rate -14 beats / minute.
Pulse rate – 75 beats / minute.
Temperature – normal.
Sensory – normal
Motor – normal.
VISUAL ANALOGUE SCALE FOR VERTIGO :

REFLEX TESTING :
Caloric stimulation – positive
 Doll’ head maneuver – positive.
SPECIAL TEST :
Head impulse test – positive
Dix hall pike test – positive
Romberg test – positive
Veering test – positive .
Fukuda – untenberger ‘s test – positive
INVESTIGATIONS:
CT SCAN
MRI.
DIAGNOSIS :
Vertigo
Problem list:
Imbalance
Nausea
Vomiting
Light headedness
PHYSIOTHERAPY MANAGEMENT:

AIMS :
To improve balance.
To get relief from light headedness
To get relief from giddiness.
MEANS :
Canalith repositioning maneuvre.
Semont Manouver
Gans manouver
Brandt – daroff exercises
Balance exercise and progression.

Do’s :
Exercises in sitting position:
Shrugging and rotation of shoulder.
Bending forward and picking up object.
Turning head and trunk to the left and right.
Exercises in standing position:
Changing from sitting to standing initally with eyes open and
then with the eyes shunt.

Throwing a small ball in an are from hand to hand and following

in with the eyes.
HOME PROGRAM:
home eply manoever.

PROGNOSIS:
VISUAL ANALOGUE SCALE FOR VERTIGO

CASE STUDY – 3
SUBJECTIVE ASSESMENT:
Name : Muhaseensa
Age : 48 years
Gender : Female
 Occupation : house wife
Address : No 13 , steel thoppu , Trichy.
Date of assessment : 15/ 8 / 22
IP no : 6754
Height : 158 cms
Weight :64 kg

Chief complaints :
Patients complaints of difficulty in neck movements
Patient complaints of giddiness during walking and sitting
Patient had a giddiness during weight lifting activities.

SUBJECTIVE ASSESSMENT:
History:
Past history:
Patient had suffering from neck pain for past 15 days.
No known complaints of diabetic mellitus and hypertension.
History of occupational stress.
No history of trauma / injury.
Present history :
Patient suffering from vertigo for past 1 week . She has a
vertigo during walking.
Medical history:
patient had taken medications for neck pain.
 Surgical history :
No relavant surgical history
Family history:
No relavant family history.

ON OBSERVATION :
Body built : endomorphic.
Posture : Normal
Gait : Normal.
ON EXAMINATION:
VITAL SIGNS,
Blood pressure – Normal
Respiratory rate -Normal.
Pulse rate – Normal.
Temperature – normal.
Sensory – normal
Motor – normal.

VISUAL ANALOGUE SCALE FOR VERTIGO :

REFLEX TESTING :
Caloric stimulation – positive .
 Dolls head manoever – positive.
Special tests:
Head shaking induced nystagmus – positive
Dix hall pike test – postive
Romberg test – negative .

DIAGNOSIS:
Vertigo

Problem list :
Imbalance
Nausea
Vomiting
Light headedness
PHYSIOTHERAPY MANAGEMENT:
Aims :
To improve balance.
To get relief from light headedness
To get relief from giddiness
To get relief from vertigo.
Means:
Canalith repositioning maneuvre
Semont Maply maneuvre
Gans manouver
 Balance exercises.

Do’ s :
Exercises in sitting position;
Shrugging and rotation of shoulder
Bending forward and picking up object.
Turning head and trunk to the left and right.
Static neck exercises.
Exercises in standing position:
Changing from sitting to standing initally with eyes open and then
eyes shunt.
Throwing a small ball in are from hand to hand and following in
with the eyes shunt.
Don’ts :
Turning the head quickly.
Bending over or tipping the head and neck.

Prognosis:

CASE STUDY – 4
SUBJECTIVE ASSESSMENT:
Name : Manikandan .s
Age : 26 years.
Gender :Male
Occupation : It professionl
 Address : No 46 , perimilaguparai, opposite to
collector office, Trichy.
Date of assessment : 08/ 8 / 22
IP no : 2909
Height : 170cms
Weight :50 kg
Chief complaints :
Patients complaints of feeling of spinning or whirling during
head rotation movements and forward bending activities.
Patient complaints of giddiness during night time.
SUBJECTIVE ASSESSMENT:
History:
Past history: patient Had suffered from vertebro basilar for 1
year,he is taking a continuing medical treatment
No known complaints of diabetic mellitus and hypertension.
History of occupational stress.
No history of trauma / injury.

Present history : patient having the Symptoms of vertigo for

past 1 Year.
Medical history: medications are taken for vetigo
Surgical history : no relavant surgical history
Family history: no relavant family history.
ON OBSERVATION :
Body built : endomorphic.
 Posture : Normal
Gait : Normal.
ON EXAMINATION:
VITAL SIGNS,
Blood pressure – normal
Respiratory rate -normal.
Pulse rate – noamal.
Temperature – normal.
Sensory – normal
Motor – normal.

VISUAL ANALOGUE SCALE FOR VERTIGO :

Reflex testing ;
Caloric stimulation : positive.
Dolls head maneuver : positive
Special test :
Head shaking induced nystagmus – positive .
Dix hall pike test – positive
Romberg test - positive
 Veering test – positive
VBI TEST :
BARRE LEIOU SIGN.
HAUTAN ' S TEST.
DIAGNOSIS :
BPPV
PROBLEM LIST :
Imbalance
Nausea
Vomiting
Light headedness

Aims :
To improve balance.
To get relief from giddiness
To get patient confidence.
Means :
Eply Manouver.
Semont Manouver
Balance exercises.
Progression of balance exercises
Brantd daroff exercises.
PROGRESSION ;
 CASE STUDY – 5
Name : Jaya Lakshmi.
Age : 35 years.
Gender : Female
Occupation : house wife
Address : No 5 , Raja colony , k pudhur , Trichy.
Date of assessment: 05 / 07 / 2022
IP no : 9874.
Height : 150 cms
Weight : 56 kg
Chief complaints :
Patient had a history of dizziness for past 1 month.
Patient had a recurred episodes of vertigo for past 1 month.
Patient had a complaints of tittinus.
OBJECTIVE ASSESSMENT:
HISTORY:
PAST HISTORY:
Patient had a history of neck pain
Patient had a pain in the left ear for past 15 days.
PRESENT HISTORY:
Patient had a history of Dizziness for past 1 month.
Patient had a recurred episodes of vertigo.

ON OBSERVATION :
Body built : ectomorphic .
Posture : Normal.
Gait : Normal.
ON EXAMINATION:
Sensory : Normal
Motor :Normal
Cranial nerve Examination:
 Vestibulo cochlear nerve –
Weber test – positive .
Vital signs ;
Blood pressure – normal
Heart rate - normal.
Respiratory rate - normal
Pulse rate - normal.
VISUAL ANALOGUE SCALE FOR VERTIGO :

REFLEX TESTING :
Caloric stimulation : positive
Dolls head maneuver : positive
Special tests :
Dix hall pike test – positive
shake induced nystagmus test – positive
Romberg test – Negative
Video head impulse test - positive.
Hearing test- positive
Rotatory chair testing - positive.
 Videonystagmograpy – positive
Vestibular evoked myogenic potentials testing – positive.
DIAGNOSIS :
Meiners disease.
Problem list :
Tittinus
Hearing difficulty
Dizziness
Fearing of fullness or congestion in the ear.

PHYSIOTHERAPY MANAGEMENT:
Aims :
To gain patient confidence.
To regain the normal balance function
To get relief from light headedness
To get relief from giddiness
Means :
Canalith repositioning maneuvre
Semont Manouver
Habitituation exercises.
Balance and gaze stability exercises.
Brandt daroff exercises
Positive pressure therapy.
HOME MANAGEMENT:
DO’ S:
If the patient had an attack of vertigo, do the following,
Try to sit down and stay still
Don’t make any sudden movements, and avoid bright light , loud
noise, and other triggers. Watching tv and eve reading can also
harmful.
Fix the gaze on somethinh steady.
DONT’S :
Avoid smoking and alcohol
Avoid salty diet.
PROGNOSIS:

CASE STUDY – 6
SUBJECTIVE ASSESSMENT:
Name : Priya
Age : 36 years
Gender : Female
Occupation : Teacher
Address : no 56/ 3 , vekkaliamman Kovil street , uraiyur , Trichy
IP no : 2346
Height : 164 cms
Weight :55 kg
Chief complaints:
Giddiness during adl activities.
Giddiness during walking for prolonged time.
OBJECTIVE ASSESSMENT:
HISTORY:
Past history: No Relevant past history.
No history of trauma or injury.
NO history of diabetic mellitus and hypertension.
Present history:
Giddiness during adl activities.
ON OBSERVATION:
Body built – mesomorphic
Posture - Normal
Gait - normal
ON EXAMINATION:
Cranial nerve examination – normal
Sensory examination - normal
Motor - Normal.
Vital signs ,
Blood pressure – Normal
Heart rate – Normal
 Respiratory rate – normal
Pulse rate - normal.

Visual analogue scale for vertigo :

Reflex testing:
Caloric stimulation – positive
Dolls head maneuver – positive .
Special tests :
Dix hall pike test – Positive.
Head shake induced nystagmus test - positive.
Romberg test – positive
Veering test - positive.
DIAGNOSIS:
BPPV -Posterior semicircular canal.
PHYSIOTHERAPY MANAGEMENT:
AIMS :
To gain patient confidence.
To regain the normal adl activities
To relieve giddiness.
 To improve balance.
To enhancing normal adl activities.
MEANS :
Brandt daroff exercises.
General Balance erercises
Semont Manouver
Eply Manouver.
PROGNOSIS:

CASE STUDY – 7
SUBJECTIVE ASSESSMENT :
Name : Nanthini Bala.
Age :22 years.
Gender : Female
Occupation : student
Address : no 6 / 11 a, old Street , Sri rangam, trichy.
IP no : 1278
Date of assessment:01/09/2022
Height : 164 cms
Weight :54 kg
Chief complaints:
Giddiness during adl activities.
Giddiness during walking for prolonged time.
Patient complaints of giddiness during standing from sitting,
during alter the head positions and occasionally during eyes closed
situations.

HISTORY:
PAST MEDICAL HISTORY:
Patient had suffered from middle ear infection for past 4
months , and she undergoes a medical treatment.
No history of trauma or injury.
No history of diabetic mellitus and hypertension.

Present history:
Giddiness during adl activities.
ON OBSERVATION:
Body built – mesomorphic
Posture - Normal
Gait - normal
ON EXAMINATION:
Cranial nerve examination – normal
Sensory examination - normal
Motor - Normal.

Vital signs ,
Blood pressure – Normal
Heart rate – Normal
Respiratory rate – normal
Pulse rate - normal.
Visual analogue scale for vertigo :

Reflex testing:
Caloric stimulation – positive
Dolls head maneuver – positive .
Special tests :
Dix hall pike test – Positive.
Head shake induced nystagmus test - positive.
Romberg test – positive
 Veering test - positive.
DIAGNOSIS:
Vertigo.
PHYSIOTHERAPY MANAGEMENT:
AIMS :
To gain patient confidence.
To regain the normal adl activities
To relieve giddiness.
To improve balance.
To enhancing normal adl activities.

MEANS :
Brandt daroff exercises.
General Balance erercises
Semont Manouver
Eply Manouver.

PROGNOSIS:
 CASE STUDY – 8

Name : shanmugam.
Age : 60 years.
Gender : Male
Occupation: Retired teacher.
Address : No 32 , Gandhi nagar , sathiram , Trichy
IP no : 2346
Date of assessment : 05/09/2022
Height : 170 cms
Weight : 56 kg.

Chief complaints:
Patient had a feeling of giddiness and spinning for past 1 year.
Giddiness during adl activities.
Giddiness during walking for prolonged time.
Patient complaints of giddiness during standing from sitting,
during alter the head positions and occasionally during eyes closed
situations.
HISTORY:
Past medical history:
No history of trauma or injury
No history of diabetic mellitus and hypertension.
Present history:

Giddiness during adl activities.

Patient had a giddiness and spinning for past 1 year
ON OBSERVATION:
Body built – mesomorphic
Posture - Normal
Gait - normal
ON EXAMINATION:
 Cranial nerve examination – normal
Sensory examination - normal
Motor - Normal.
Vital signs ,
Blood pressure – Normal
Heart rate – Normal
Respiratory rate – normal
Pulse rate - normal.
Visual analogue scale for vertigo :

Reflex testing:
Caloric stimulation – positive
Dolls head maneuver – positive .
Special tests :
Dix hall pike test – Positive.
Head shake induced nystagmus test - positive.
Romberg test – positive
Veering test - positive.
DIAGNOSIS:
 Benign paroxysmal positional vertigo.

PHYSIOTHERAPY MANAGEMENT:
AIMS :
To gain patient confidence.
To regain the normal adl activities .
To relieve giddiness.
To improve balance.
MEANS :
Eply Manouver.
Brandt daroff exercises.
General Balance erercises
Semont Manouvere.
PROGNOSIS:

CASE STUDY – 9
SUBJECTIVE ASSESSMENT :
Name : Hari
Age : 22 years
Gender : Male
Occupation: student.
Address : No 46 , periyamilagurai , Trichy
IP no : 2367
Date of assessment: 09 / 06 / 2022
Height : 160 cms
Weight : 58 kg

Chief complaints:
Patient had a severe vertigo for past 2 weeks.
Patient had a complaints of nausea , and vomiting.
Patient complaints of giddiness during walking.
HISTORY:
Past medical history:
No history of trauma or injury
No history of diabetic mellitus and hypertension.
Present history:
Giddiness during adl activities and giddiness during walking.
Patient had a giddiness and spinning for past 1 year .
Patient had a nystagmus.
OBJECTIVE ASSESSMENT:
ON OBSERVATION:
Body built – Endomorphic.
Posture - Normal
Gait - normal
ON EXAMINATION:
Cranial nerve examination – normal
Sensory examination - normal
 Motor - Normal.
Vital signs ,
Blood pressure – Normal
Heart rate – Normal
Respiratory rate – normal
Pulse rate - normal.

Visual analogue scale for vertigo :

Reflex testing :
Caloric stimulation – positive .
Doll’ s head maneuver – positive .
Special test :
Head shaking induced nystagmus – positive .
Dix – hall pike test - positive.
Romberg test - Negative .
Veering test - positive.
Diagnosis:
VERTIGO.
PHYSIOTHERAPY MANAGEMENT:
AIMS :
 To gain patient confidence
To regain the normal adl activities .
To relieve giddiness.
To improve balance.
To enhancing normal adl activities.
MEANS :
Eply Manouver.
Brandt daroff exercises
General Balance erercise
Semont Manouvere.
Cawthrone cooksey habitutation exercises.
PROGNOSIS:

CASE STUDY – 10
SUBJECTIVE ASSESSMENT :
Name : Kavitha
Age : 50 years
Gender : Female
Occupation: House wife
Address : No 67 B , Rms colony , 2nd Street , karumandapam ,
Trichy
 IP no :3452
Date of assesment :15/09 /2022
Height : 146 cms
Weight : 60 kg
Chief complaints:
Patient complaints of difficulty in balance during walking.
Patient had a giddiness and feeling of dizzy during walking and
also had a feeling of fullness in the ear.
Patient also had a severe headache.
OBJECTIVE ASSESMENT :
HISTORY:
Past medical history:
No history of trauma or injury.
No history of diabetic mellitus and hypertension.
Present history:
Giddiness during adl activities and giddiness during walking.
Patient had a giddiness and spinning for past 1 year .
Patient had a nystagmus.
ON OBSERVATION:
Body built – Endomorphic.
Posture - Normal
Gait - normal
ON EXAMINATION:
Cranial nerve examination – normal
 Sensory examination - normal
Motor - Normal.
Vital signs ,
Blood pressure – Normal
Heart rate – Normal
Respiratory rate – normal
Pulse rate - normal.
Visual analogue scale for vertigo :

Reflex testing :
Caloric stimulation – positive .
Doll’ s head maneuver – positive .
Special test:
Head shaking induced nystagmus – positive .
Dix – hall pike test - positive.
Romberg test - positive .
Veering test - positive.
Diagnosis:
Benign paroxysmal positional vertigo.
PHYSIOTHERAPY MANAGEMENT:
AIMS :
To gain patient confidence.
To improve balance .
To get relief from light headedness.
Means ;
Canalith repositioning maneuvre
Eply Manouver
Brandt daroff exercises
Cawthrone cooksey exercises.
Prognosis:
CONCLUSION
 CONCLUSION.
In my study called , ‘’ EFFECTIVENESS OF VESTIBULAR
REHABITILATION FOR THE PATIENTS WITH DIZZINESS AND BALANCE
DIORDERS ‘’, I concluded that the vestibular rehabilitation therapy
was more effective for the patients.
After a detailed study and careful analysis , I applied vestibular
rehabilitation techniques like canalith repositioning techniques, eply
manoever , semont manoever ,balance exercises, and cawthrone
cooksey exercises for the patients with dizziness and balance
disorders patients with which I was able to restore the normal
balance position. It also enchanches the patient activities of daily
life.
BIBLIOGRAPHY
 BIBLIOGRAPHY
HUMAN ANATOMY – B. D CHAURSIA
THE MEDICAL PHYSIOLOGY – K. SEMBULINGAM
NEUROLOGY AND NEUROSURGERY ILLUSTRATED – KENNETH . W.
LINDSAY
PHYSICAL REHABILITATION – SUSAN B O’ SULLIVAN.
VESTIBULAR REHABILITATION – SUSAN J. HERDMAN

WEBSITES :
www.wikiepedia.com
www.physiopedia.com
www.webmed.com
www.balanced dizziness.org.
www.ncpi.nlm.nih.gov
www.healthline.com
THANK YOU