Vestibular Rehabilitation 3rd Edition

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Vestibular
Rehabilitation
THIRD EDITION
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Page ii
Steven L. Wolf, PT, PhD, FAPTA, Editor-in-Chief

Vestibular Rehabilitation, 3rd Edition
Susan J. Herdman, PT, PhD, FAPTA
Pharmacology in Rehabilitation, 4th Edition
Charles D. Ciccone, PT, PhD
Modalities for Therapeutic Intervention, 4th Edition
Susan L. Michlovitz, PT, PhD, CHT and Thomas P. Nolan, Jr., PT, MS, OCS
Fundamentals of Musculoskeletal Imaging, 2nd Edition
Lynn N. McKinnis, PT, OCS
Wound Healing: Alternatives in Management, 3rd Edition
Luther C. Kloth, PT, MS, CWS, FAPTA, and
Joseph M. McCulloch, PT, PhD, CWS, FAPTA
Evaluation and Treatment of the Shoulder:
An Integration of the Guide to Physical Therapist Practice
Brian J. Tovin, PT, MMSc, SCS, ATC, FAAOMPT and
Bruce H. Greenfield, PT, PhD, OCS
Cardiopulmonary Rehabilitation: Basic Theory and Application, 3rd Edition
Frances J. Brannon, PhD, Margaret W. Foley, RN, MN,
Julie Ann Starr, PT, MS, CCS, and Lauren M. Saul, MSN, CCRN
For more information on each title

in the Contemporary Perspectives in Rehabilitation series, go to
www.fadavis.com.
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Vestibular
Rehabilitation
THIRD EDITION

Professor, Departments of Rehabilitation
Medicine and Otolaryngology Head and Neck Surgery
Director, Division of Physical Therapy
Emory University
Atlanta, Georgia
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F. A. Davis Company
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Library of Congress Cataloging-in-Publication Data
Vestibular rehabilitation / [edited by] Susan J. Herdman. 3rd ed.
p. ; cm. (Contemporary perspectives in rehabilitation)
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1376-8
ISBN-10: 0-8036-1376-8
1. Vestibular apparatusDiseasesPatientsRehabilitation. I. Herdman, Susan.
[DNLM: 1. Vestibular Diseasesrehabilitation. WV 255 V5836 2007]
RF260.V4725 2007
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2007007436
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Dedication
I would like to dedicate this edition of

Vestibular Rehabilitation to my family.
I love you all very much.
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Foreword
Baseball has always been my passion. I played the sport
from the time I could walk all the way through college. I
always thought one could learn a lot about life from participating and from observing the game.teamwork,
responsibility, strategy and so on. In that context and for
reasons far transcending the purpose of this book, I
adopted the Boston Red Sox as my team. Through circumstances far more surreal than circumstantial, I was
interviewed by Weekend America, a National Public
Radio show the day after the Red Sox miraculous comeback against the New York Yankees to win the American
League title in 2004. The interview was taped on Thursday, October 21 two days before the first game of the
World Series in which my team defeated the St. Louis
Cardinals in four consecutive games, and aired immediately before the first game. During the interview, Bill
Radke asked if the Red Sox could win the Series (a
thought that any self-respecting Sox fan would never
contemplate after 86 barren years filled with countless
frustrations) and win or lose, if I thought the team players would all be back the following year to start their own
dynasty. To the latter question I responded that I doubted
the possibility since in contemporary sports the notion of
team loyalties and perpetuation of excellence amongst a
cohesive unit was easily supplicated by the lure of more
lucrative promises from rival baseball clubs.
So what does this stream of consciousness have to
do with the third edition of Vestibular Rehabilitation?
These thoughts about this radio interview crept into my
mind as I was reviewing Susan Herdmans third edition.
Here is a text already filled with contributions from clinicians and researchers acknowledged as superstars in
this field. Each of these individuals is already quite busy
and well in demand for other academic and intellectual
opportunities. Yet rather than abandoning the team, Dr.
Herdman has strengthened it further and moreover has
revised the line up to field an even stronger team that
will have even greater appeal to the fans. Hence at a
time when star quality seeks autonomy at the sacrifice of
team congruity, the exact opposite has occurred for
Vestibular Rehabilitation, Third Edition.
Dr. Herdman has painstakingly adhered to the principles of the Contemporary Perspectives in Rehabilitation Series by assuring that each contributor has updated
references and has, when appropriate, challenged the
readers critical thinking skills. The text is written for
any specialist in vestibular rehabilitation or any student
or clinician aspiring to become one. While already established as the gold standard for the assessment and management of patients with vestibular disorders, this third
edition takes off from where the second edition has left.
There are four new chapters and several others have been
revamped considerably. The four new additions to this
already comprehensive text include: a chapter (12) by
Ronald Tusa on Migraine, Mnires Disease and Motion
Sickness that represents a considerable expansion from
his chapter on migraine in the second edition and distinguishes these three problem areas and their medical management; a chapter (13) by Timothy Hain and Janet
Helminski on Mal de Dbarquement Disorder, a problem
that has received increasing attention since the second
edition of this book and now includes guidelines for
treatment and indications that physical therapy may be
inappropriate in the treatment of this disorder; a chapter
(18) on Compensatory Strategies for the Treatment of
Vestibulo-Ocular Hypofunction by Michael Schubert that
offers new information on compensatory mechanisms
used by patients undergoing vestibular rehabilitation; and
a chapter (26) by Ronald Tusa on Non-vestibular Dizziness and Imbalance that uniquely addresses lesions not
directly implicated in the central vestibular pathways,
including disuse disequilibrium, spino-cerebellar ataxia,
leukoaraiosis, and normal pressure hydrocephalus. In fact
the last 5 chapters of the third edition are grouped to
emphasize assessment and management of disorders
either within or external to the central vestibular pathways or in the treatment of non-vestibular dizziness.
Moreover in addition to adding several new contributors including Janet Helminski, Sharon Polensek,
Michael Schubert, Greg Marchetti, and Robert Landel,
many chapters have undergone substantial revision.
Ronald Tusa has converted what had been one presentavii
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FOREWORD
tion on quantification of vestibular function tests and

clinical examination into two exciting chapters presented
from the physicians perspective on History and Clinical Examination (7) and Vestibular Function Tests (8).
The chapter (24) by Helen Cohen on disability now
approaches the concept in a diagnosis specific manner.
Perhaps the most dominating impression created
from this unique team is deriving a realization that contributions from vestibular neurorehabilitation therapists
and specialty physicians blend almost seamlessly into a
continuum of fact pointed toward a comprehensive
understanding of the assessment and management of
patients with vestibular disorders. In fact, one gets the
impression that the content of this book could have

easily been extracted from dialogue amongst these interdisciplinary specialists at a symposium or workshop.
While students new to this topic might not appreciate the
value of such a constellation of knowledgeable professionals, those clinicians familiar with many of these
authors and their contributions to vestibular rehabilitation
will recognize that within these hard covers lie content
the sum of whose parts far exceeds the whole.
Steven L. Wolf, Ph.D., PT, FAPTA, FAHA

Series Editor
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Preface
The 3rd edition of Vestibular Rehabilitation! I never
expected that the little black book published in 1994
would have multiple editions, much less that we would
(or even could) provide a CD with the book to augment
the written word with videos of patients. These videos
have been chosen to provide the reader with examples of
both normal and abnormal clinical tests, with visual
examples of some of the exercises used in the treatment
of BPPV and of vestibular hypofunction, and with examples of non-vestibular oculomotor and gait signs that
should help with differential diagnosis. As I reviewed a
multitude of video clips of patients we made over the past
20 years, I found that I remembered these people and
their individual personalities and problems. What a wonderful experience this has been and how thankful I am for
everything they taught me. If I had only one person to
thank, it would be the accumulation of all these people.
Once again, we have extended the material presented to include several new chapters and have augmented
the material presented in all the chapters to reflect
changes in our understanding of management of vestibular disorders. The new chapters include management of
persons with mal de dbarquement syndrome, and persons with dizziness that is unrelated to the vestibular sys-
tem such as disuse disequilibrium and central disorders.

The third new chapter presents new information about
the mechanisms that underlie compensation for vestibular hypofunction. In addition to these new chapters, there
are a number of new topics presented within different
chapters such as differential diagnosis in BPPV to identify disorders that mimic BPPV, differentiation among
Mnires, migraine, and motion sensitivity, and the role
of chemical labyrinthectomy in the management of
episodic vertigo.
Another shift you will find in the book, as well as in
many clinical studies, is an increasing use of functional
measures, rather than impairment measures, to assess
outcome of rehabilitation. Of great value is the International Classification of Functioning, Disability and
Health (ICF) scheme (World Health Organization 2001.
http://www.cdc.gov.hchs/about/otheract/ic99/icfhome.
htm). The ICF provides a framework for the description
of health-related states and includes both positive experiences and negative consequences of disease. It consists
of three domains that can be used to describe the effect of
different disorders or diseases on a persons health, with
a number of environmental and personal contextual factors that may affect each of those domains (Table below).
HEALTH CONDITION DISORDER OR DISEASE
Normal Function and Structure

Versus
Impairment (body level)
Activities
Versus
Limitations (individual level)
Participation
Versus
Restriction (societal level)
Contextual Factors
e.g.
Environmental Factors
Natural environment
Support and relationships
Attitude of family
Attitude of society
Services, systems, policies
Products and technology
e.g.
Personal Factors
Gender, age
Co-morbidities
Social background
Education and profession
Past experience
Coping style
ix
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PREFACE
Because it provides a more comprehensive depiction of the health of an individual, the ICF model shifts
the emphasis away from impairment and disability to a
more balanced perspective.
Finally, we have tried, as in the other editions of
Vestibular Rehabilitation, to provide you with an update
on evidence that supports our practice. There is an
increasing body of research that support different exercise approaches as appropriate and successful tools in the
management of patients with vestibular dysfunction. The
number of blinded, randomized clinical trials is growing
and they provide compelling evidence that we are effectively improving outcome in these patients. Some studies
offer guidance in how certain treatment can be modified
to simplify treatment for the patient. Still other studies
explore the extent of recovery that can be achieved. Some

studies offer insight into new methods for identifying the
nature of the vestibular dysfunction such as involvement
of the utricle and saccule. I expect that in the next 5 to 10
years there will be another great leap in our knowledge
and we will have several additional rehabilitation
approaches. Researchers are exploring the use of techniques such as virtual reality, sensory substitution
devices, vestibular implants, and methods to induce hair
cells regeneration. These techniques are not ready yet but
the next edition of this book may be filled with wonderful new ways to help people with vestibular disorders.

Editor
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Contributors
Annamarie Asher, PT
Clinical Education Coordinator
Physical Therapy Division
Physical Medicine and Rehabilitation
Department
University of Michigan Health System
Ann Arbor, Michigan
Thomas Brandt, MD, FRCP
Department of Neurology
Klinikum Grosshadern
University of Munich
Munich, Germany
Richard A. Clendaniel, PT, PhD
Assistant Professor
Doctor of Physical Therapy Program
Department of Community and Family
Medicine
Duke University Medical Center
Durham, North Carolina
Helen Cohen, EdD, OTA, FAOTA
Associate Professor
Department of Otorhinolaryngology
Baylor College of Medicine
Houston, Texas
Ian S. Curthoys, PhD
Professor of Vestibular Function
School of Psychology
University of Sydney
Sydney, Australia
Marianne Dieterich, MD
Johannes Gutenberg University of
Mainz
Mainz, Germany
Michael Fetter, MD
Department of Neurology II
Klinikum Karlsbad-Langensteinbach
Karlsbad, Germany
Timothy C. Hain, MD
Associate Professor
Department of Physical Therapy and
Movement Sciences
Northwestern University
Chicago, Illinois
G. Michael Halmagyi, MD
Royal Prince Alfred Hospital
Camperdown, Australia
Janet O. Helminski, PT, PhD
Associate Professor
Physical Therapy Program
Midwestern University
Downers Grove, Illinois
Fay B. Horak, PT, PhD
Senior Scientist and Research Faculty
Neuroscience Graduate Program
R.S. Dow Neurological Sciences Institute
Oregon Health and Science University
Portland, Oregon
Emily A. Keshner, PT, EdD
Professor and Chair
Department of Physical Therapy
Temple University
Philadelphia, Pennsylvania
Robert Landel, PT, DPT, OCS
Associate Professor
Department of Biokinesiology and
Physical Therapy
University Southern California
Los Angeles, California
R. John Leigh, MD
Professor
Case Western Reserve University
Director
Ocular Motility Laboratory
Cleveland VA Medical Center
Cleveland, Ohio
Gregory F. Marchetti, PT, PhD
Assistant Professor
Duquesne University
Pittsburgh, Pennsylvania
Douglas E. Mattox, MD
Professor and Chair
Department of Otolaryngology-Head
Neck Surgery
Emory University School of Medicine
Atlanta, Georgia
Sharon Polensek, MD, PhD
Assistant Professor
Neurologist
Dizziness and Balance Center
Center for Rehabilitation Medicine
Atlanta, Georgia
Rose Marie Rine, PT, PhD
Associate Professor
University of North Florida
Jacksonville, Florida
Michael C. Schubert, PT, PhD
Assistant Professor
Department of OtolaryngologyHead and Neck Surgery
Johns Hopkins School of Medicine
Baltimore, Maryland
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CONTRIBUTORS
Neil T. Shepard, PhD

Professor of Audiology
Department of Special Education and
Communications Disorders
University of Nebraska Lincoln
Lincoln, Nebraska
Anne Shumway-Cook, PT, PhD,
FAPTA
Professor
Division of Physical Therapy
Department of Rehabilitation Medicine
University of Washington
Physical Therapist
Seattle, Washington
Ronald J. Tusa, MD, PhD, NCS, ATC

Professor
Departments of Neurology and
Otolaryngology Head and Neck
Surgery
Director
Dizziness and Balance Center
Atlanta, Georgia
Susan L. Whitney, PT, PhD, NCS, ATC
Associate Professor
Departments of Physical Therapy and
Otolaryngology
University of Pittsburgh
Pittsburgh, Pennsylvania
David S. Zee, MD
Professor
Johns Hopkins University
Baltimore, Maryland
**Series Editor**
Steven L. Wolf, PhD, PT, FAPTA,
FAHA
Professor, Medicine
Professor, Rehabilitation Medicine
Atlanta, Georgia
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Reviewers
Cheryl D. Ford-Smith, MS, PT, NCS
Assistant Professor
Virginia Commonwealth University
Richmond, Virginia
James Megna, PT, NCS
Coordinator
Balance and Vestibular Rehabilitation Clinic
Southside Hospital
Bay Shore, New York
Gail F. Metzger, BS, MS, OTR/L

Senior Occupational Therapist &
Assistant Professor
Department of Occupational Therapy
Alvernia College
Reading, Pennsylvania
Roberta A. Newton, PT, PhD
Professor & Associate Director
Physical Therapy Department
Temple University
Philadelphia, Pennsylvania
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Acknowledgments
I would like to express my gratitude to the wonderful colleagues I have worked with in the clinic. Over my years
as a physical therapist, they have honed my skills, challenged my assumptions, contributed to my research
and made me a better clinician. So my thanks go to Ron
Tusa, Courtney Hall, Lisa Gillig, Tim Hain, John Leigh,
David Zee, Doug Mattox, Rick Clendaniel, and Michael
Schubert.
I also want to thank the authors of this edition of
Vestibular Rehabilitation. They have contributed their
considerable knowledge and perspectives so we can all
learn how best to help the dizzy patient. As a result,
many more clinicians will become familiar with the problems and management of vestibular disorders and many,
many more patients will receive appropriate treatment.
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Contents in Brief
SECTION ONE
Fundamentals
CHAPTER
CHAPTER
1 Anatomy and Physiology of the Normal

Vestibular System
2
2 Vestibular Adaptation
CHAPTER
CHAPTER
19
3 Role of the Vestibular System in

Postural Control
32
4 Postural Abnormalities in
Vestibular Disorders
54
CHAPTER
5 Vestibular Compensation: Clinical

Changes in Vestibular Function
with Time after Unilateral
Vestibular Loss
76
6 Vestibular System Disorders
CHAPTER
7 History and Clinical

Examination
108
Ronald J. Tusa, MD, PhD
xvi
12 Migraine, Mnires and Motion

Sensitivity
188
CHAPTER
98
13 Therapy for Mal de

Dbarquement Syndrome
202
Timothy C. Hain, MD
SECTION TWO
CHAPTER
11 Pharmacological and Optical

Methods of Treatment for Vestibular
Disorders and Nystagmus
178
R. John Leigh, MD
Michael Fetter, MD
Medical Assessment and

Vestibular Function Tests
162
Medical and Surgical

177
Management
Ian S. Curthoys, PhD and

CHAPTER
10 Auditory Examination
SECTION THREE

CHAPTER
144

CHAPTER
9 Otolith Function Tests

G. Michael Halmagyi, MD and
David S. Zee, MD
CHAPTER
125
Timothy C. Hain, MD
CHAPTER
8 Vestibular Function Tests
CHAPTER
107
14 Surgical Management of Vestibular

Disorders
205
CHAPTER
15 Psychological Problems and

the Dizzy Patient
214
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CONTENTS IN BRIEF
SECTION FOUR
CHAPTER
Rehabilitation Assessment and

227
Management
CHAPTER
CHAPTER

CHAPTER
24 Disability in Vestibular
Disorders
398
Helen S. Cohen, OTR, EdD, FAOTA
17 Physical Therapy Management of

Benign Positional Vertigo
233
CHAPTER

Appendix 17A-Differential
Diagnosis: Mimicking BPPV
23 Management of the Elderly Person

with Vestibular Hypofunction
376
16 Physical Therapy Diagnosis for

228
25 Assessment and Management

of Disorders Affecting Central
Vestibular Pathways
409
261

CHAPTER
CHAPTER
18 Compensatory Strategies
for Vestibulo-Ocular
Hypofunction
265
CHAPTER
CHAPTER

Appendix 19A Evaluation

Form
300
Appendix 19B Dizziness Handicap
Inventory
307
CHAPTER
20 Interventions for the Patient

CHAPTER
309

CHAPTER
22 Management of the Pediatric Patient

360
28 Non-vestibular Dizziness and

Imbalance: Suggestions for
Patients with Migraine and
Mal de Dbarquement
458
Annamarie Asher, PT
CHAPTER
21 Assessment and Interventions

for the Patient with Complete
Vestibular Loss
338

of the Patient with Traumatic
Brain Injury and Vestibular
Dysfunction
444
Anne Shumway-Cook, PT, PhD, FAPTA

CHAPTER

Imbalance: From Disuse
Disequilibrium to Central
Degenerative Disorders
433
19 Physical Therapy Assessment of

Vestibular Hypofunction
272
xvii
29 Non-vestibular Diagnosis
and Imbalance: Cervicogenic
Dizziness
467
Appendix A Questionnaire for

History and Examination
485
Index
493
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Contents
SECTION ONE
Fundamentals
CHAPTER
1 Anatomy and Physiology of the

Normal Vestibular System
2
Timothy C. Hain, MD
Purpose of the Vestibular System

2
The Peripheral Sensory Apparatus
3
Bony Labyrinth
3
Membranous Labyrinth
3
Hair Cells
4
Vascular Supply
4
Physiology of the Periphery
5
Semicircular Canals
6
Otoliths
7
The Vestibular Nerve
7
Central Processing of Vestibular Input
8
Vestibular Nucleus
9
Vascular Supply
9
Cerebellum
10
Neural Integrator
10
Motor Output of the Vestibular
System Neurons
10
Output for the Vestibulo-ocular Reflex
10
Output for the Vestibulospinal Reflex
10
Vestibular Reflexes
11
The Vestibulo-ocular Reflex
11
The Vestibulospinal Reflex
12
The Vestibulocollic Reflex
12
Cervical Reflexes
12
The Cervico-ocular Reflex
12
The Cervicospinal Reflex
12
The Cervicocollic Reflex
12
Visual Reflexes
13
Somatosensory Reflexes
13
Neurophysiology of Benign Paroxysmal Positional
13
Vertigo
Higher-Level Vestibular Processing
14
xviii
Velocity Storage
14
Estimation: Going Beyond Reflexes
Higher-Level Problems of the
Vestibular System
16
Compensation for Overload
16
Sensor Ambiguity
16
Motion Sickness
16
Repair
17
Summary
18
CHAPTER
2 Vestibular Adaptation
15
19
David S. Zee, MD
Recalibration, Substitution,
and Alternative Strategies
19
Compensation after Unilateral
Labyrinthectomy
20
Bilateral Vestibular Loss
23
Experimental Results in Nonhuman
Primates
23
Studies of Vestibulo-ocular Reflex Adaptation
in Normal Subjects
24
Imagination and Effort of Spatial
00
Localization in Vestibular Adaptation
25
Context Specificity
26
Neurophysiologic Substrate
of Vestibulo-ocular Reflex Adaptation
26
Summary
27
CHAPTER
3 Role of the Vestibular System in

Postural Control
32
Sensing and Perceiving Position and Motion

Orienting the Body to Vertical
34
Postural Alignment
34
Weighting Sensory Information
36
Controlling Center of Body Mass
40
Role in Automatic Postural Responses
41
Stabilizing the Head and Trunk
46
Summary
47
33
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CONTENTS
CHAPTER
4 Postural Abnormalities in
54
Examining the Vestibulospinal System

55
Advantages and Limitations of Clinical Tests
Dynamic Posturography
55
Tests of Quiet Stance
58
Stabilometry
58
Tiltboards
59
Stepping Tests
59
Virtual Reality Environments
59
Postural Reactions in Peripheral Vestibular
Disorders
59
Deficient Labyrinthine Inputs
60
Indicators of Vestibulospinal
Deficiency
61
Indications of Vestibulospinal
Distortion
63
Postural Reactions in Central Vestibular
Lesions
63
Postural Dysfunction with Disorder of
Other Sensory-Motor Centers
64
Mechanisms for Recovery of Postural Stability
Sensory Substitution
66
Compensatory Processes
67
Summary
70
CHAPTER
55
Angular versus Linear Acceleration

92
Cerebellum
92
Neural Network Models of Vestibular Function
and Compensation
92
Summary
93
Acknowledgments
93
CHAPTER
6 Vestibular System Disorders
98
Michael Fetter, MD
Benign Paroxysmal Positional Vertigo

98
Vestibular Neuritis
98
Mnires Disease and Endolymphatic
Hydrops
100
Perilymphatic Fistula
102
Vestibular Paroxysmia
(Disabling Positional Vertigo)
103
Bilateral Vestibular Disorders
103
Summary
104
SECTION TWO
66
5 Vestibular Compensation: Clinical

Changes in Vestibular Function
with Time after Unilateral
Vestibular Loss
76
Ian S. Curthoys, PhD and
Overview
77
Causes
77
The uVD Syndrome
79
Static Symptoms
79
Dynamic Symptoms
81
Sensory Components
84
Clinical Evidence Concerning Factors Affecting
the uVD Syndrome and Vestibular
Compensation
84
Decompensation
87
Psychological Factors
87
Medication
88
Plasticity of the Vestibulo-Ocular Reflex
89
Rehabilitation
89
Neural Evidence Concerning Recovery after Unilateral
89
Vestibular Deafferentation
Medical Assessment and

CHAPTER
107
7 History and Clinical

Examination
108
History
108
Elements that Help with the Diagnosis
108
Elements that Lead to Goals for Management,
Including Physical Therapy
112
Physical Examination
113
Spontaneous Nystagmus
113
Skew Eye Deviation
116
Vestibular-Ocular Reflex
116
Maneuver-Induced Vertigo and Eye
Movements
118
Visual Tracking
120
Stance and Gait
122
CHAPTER
8 Vestibular Function Tests

Tests that Specifically Assess Labyrinth or

Vestibular Nerve
125
Caloric Test
125
Rotary Chair Testing
127
Quantified Dynamic Visual Acuity
131
Strengths of Test
132
Weaknesses of Test
132
125
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CONTENTS
Vestibular Evoked Myogenic Potential Test

132
Subjective Visual Vertical Test
133
Tests That Do Not Specifically Assess Labyrinth or
Vestibular Nerve
134
Visual Tracking
134
Computerized Dynamic Posturography
134
Summary 142
CHAPTER
9 Otolith Function Tests
144
174
Other Causes of Hearing Loss
Summary
175
SECTION THREE
Medical and Surgical

177
Management
CHAPTER
G. Michael Halmagyi, MD and

Otolith Structure
144
Otolith Function
146
Primary Otolithic Afferents
146
Central Projections
146
Function of Otolithic Input
147
Subjective Visual Horizontal or Vertical Testing of
Otolith Function
147
Peripheral Vestibular Lesions
147
Central Vestibular Lesions and Settings of the
Subjective Visual Vertical
149
Clinical Significance
149
Vestibular Evoked Myogenic Potential Testing of
Otolith Function
150
Physiological Background
150
Method
151
Clinical Applications
152
Comment
159
Summary
159
Acknowledgments
159
CHAPTER
10 Auditory Examination
162
History and Physical Examination

162
Audiological Evaluation and Management
163
Evaluative Procedures
163
Audiological Management
169
Medical Testing in the Evaluation of Hearing
Loss
170
Laboratory Testing
170
Radiological Imaging
170
Clinical Presentations of Auditory Impairment
170
Sudden Sensorineural Hearing Loss
170
Hearing Loss from Infectious Disease
171
Pharmacological Toxicity
171
Surgical Management of Hearing Loss
172
Cochlear Implants
172
Cerebellopontine Angle Tumors
174
Superior Semicircular Canal Dehiscence
174
175
11 Pharmacological and Optical

Methods of Treatment for Vestibular
178
R. John Leigh, MD
Vertigo
178
Pathophysiology of Vertigo
178
Neuropharmacology of Vertigo and
Nystagmus
180
Treatment of Vertigo
180
Oscillopsia
182
Pathogenesis
182
Treatment of Oscillopsia
183
Nystagmus and its Visual Consequences
Pathogenesis
183
Treatments
183
Summary
186
Acknowledgments
186
CHAPTER
183
12 Migraine, Mnires and Motion

Sensitivity
188
Incidence of Migraine
188
Symptoms of Migraine
188
Case Example
188
Symptoms during Vestibular Migraine Aura
189
Classification and Criteria for Diagnosis
189
Migraine
189
Disorders Associated with Migraine
192
Pathophysiology of Migraine
192
Dopamine D2 Receptor
192
Calcium Channel Receptor (CACNA1A)
193
Noradrenergic System
193
Serotonin 5HT1 Receptor and the Headache
Phase
193
Management
193
Treatment of Vestibular Migraine
193
Prophylactic Medical Therapy
194
Abortive Medical Therapy
196
Migraine versus Mnires Disease
197
Summary
200
Patient Information
200
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CHAPTER
13 Therapy for Mal de

Dbarquement Syndrome
Management
221
Medications
222
Summary
226
202
Timothy C. Hain, MD
SECTION FOUR
Cause of the Syndrome: Persistent Adaptation to

Swaying Environments?
202
Treatment
203
Summary
204
CHAPTER
Rehabilitation Assessment and

227
Management
CHAPTER
14 Surgical Management of Vestibular

Disorders
205
Acoustic Neuromas
(Vestibular Schwannomas)
205
Surgical Approaches
206
Middle Cranial Fossa
206
Translabyrinthine Approach
206
Suboccipital Craniectomy
207
Complications
208
Stereotactic Radiosurgery
208
Mnires Disease
208
Surgical Management of Mnires Disease
Chemical Labyrinthectomy
209
Post-Traumatic Vertigo
211
211
211
Vascular Loops
212
Summary
213
CHAPTER
15 Psychological Problems and

the Dizzy Patient
214
Psychological Disorders and Their

Prevalence
214
Dizziness in Patients with Psychological
Disorders
214
Psychological Problems in Patients with
Dizziness
215
Assessment
216
Scales
216
Clinical Examination
218
Examination for Psychogenic Stance and
Gait Disorders
218
219
Psychological Disorders
219
Anxiety
219
Mood Disorders
219
Somatoform Disorders
220
Factitious and Malingering Disorders
221
16 Physical Therapy Diagnosis for

228
Physical Therapy Diagnosis and the International

Classification of Functioning, Disability,
and Health Model of Diasablement
228
History
229
229
Diagnostic Flowchart
230
Identification of Modifiers
231
Summary
232
CHAPTER
209
17 Physical Therapy Management of

Benign Positional Vertigo
233
Characteristics and History

233
Mechanism
233
Semicircular Canal Involvement
234
Diagnosis
235
Dix-Hallpike Test
236
Side-Lying Test
237
Roll Test
237
Test Series
237
Treatment
238
Treatment of the Most Common Form of BPPV:
Posterior Canal Canalithiasis
238
Treatment of Posterior Canal BPPV:
Cupulolithiasis
245
Variations in SCC Involvement
248
Algorithm for Treatment of BPPV
251
Evidence-Based Practice
251
Quality of Available Evidence to Use Repositioning
Maneuvers to Treat BPPV
251
Quality of Available Evidence to Use
the Liberatory Maneuver to Treat BPPV
252
Brandt-Daroff Habituation Exercises
to Treat BPPV
253
Managing Persistent Imbalance in Patients
with BPPV
254
xxi
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Contraindications to the Assessment and

Treatment of BPPV
255
Unraveling Complicated Cases
256
Summary
259
APPENDIX
17A Differential Diagnosis:

Mimicking BPPV
261
Central Positional Vertigo with Nystagmus

261
Episodic Signs and Symptoms (Benign)
261
Persistent Signs and Symptoms
(Pathological)
261
Central Positional Nystagmus without
Vertigo
261
CPN Present Only When Patient Is Supine
(Benign)
261
CPN Present When Patient Is Supine and When
Sitting (Pathological)
262
Peripheral Positional Vertigo with Nystagmus Other
Than BPPV
262
Pressure-Induced Disorders
262
Positional Dizziness without Nystagmus
263
Orthostatic Hypotension
263
Head Extension Dizziness and Extreme Rotation
Dizziness
263
Cervical Range of Motion

274
Physical Deconditioning
274
Activities versus Limitation
274
Participation versus Restriction
275
Physical Therapy Evaluation
275
History
276
278
Oculomotor and Vestibulo-Ocular Testing
278
Balance Assessment
284
Gait Evaluation
289
Red Flags
293
Transition from Assessment to Treatment
294
Is There a Documented Vestibular Deficit?
294
What Type of Vestibular Problem Does this Patient
Have?
294
Not All Dizzy Patients Have a Vestibular
Lesion
294
Assess and Reassess
295
Quantify the Assessment
295
Determining Whether There Has Been
Improvement
295
Summary
295
Acknowledgments
295
APPENDIX
APPENDIX
CHAPTER
18 Compensatory Strategies
Hypofunction
265
CHAPTER
19 Physical Therapy Assessment of

272
Normal Structure and Function versus

Impairment
272
Vestibulo-Ocular Function and Dysfunction
Perception of Head Movement and Position
Postural Instability
274
Evaluation Form
300
19B Dizziness Handicap

Inventory
307
20 Interventions for the Patient
309

Normal Vestibulo-Ocular Reflex

265
Abnormal Vestibulo-Ocular Reflex
265
Compensatory Strategies
265
Saccadic Modifications
267
Cervico-Ocular Reflex
267
Effects of Prediction
268
Enhanced Smooth Pursuit
270
Summary
270
CHAPTER
19A
272
274
Mechanisms of Recovery
309
Cellular Recovery
309
Reestablishment of Tonic Firing Rate
309
Recovery of the Dynamic Component
310
Vestibular Adaptation
310
Substitution
311
Habituation
312
Evidence that Exercise Facilitates Recovery
312
Goals of Treatment
313
Treatment Approaches
313
Adaptation Exercises
314
Substitution Exercises
315
Expectations for Recovery
317
Factors Affecting Outcome
317
Treatment
320
General Considerations
320
Problem-Oriented Approach
321
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CONTENTS
Problem: Visual Blurring and Dizziness When

Performing Tasks that Require Visual Tracking
or Gaze Stabilization
321
Problem: Exacerbation of Symptoms
323
Problem: Static and Dynamic Postural
Instability
323
Problem: Progression of Balance and
Gait Exercises
326
Problem: Physical Deconditioning
326
Problem: Return to Driving
327
Summary
328
Acknowledgment
329
CHAPTER
21 Assessment and Interventions

for the Patient with Complete
Vestibular Loss
338

Primary Complaints
338
Balance
338
Oscillopsia
339
Sense of Disequilibrium or Dizziness

339
339
Assessment
339
History
339
343
Gaze Stability
343
Postural Stability
344
345
Evidence that Exercise Facilitates Recovery
345
Treatment
346
Progression of Exercises
346
Guidelines to Treatment and Prognosis
347
Future Directions
351
Summary
358
Acknowledgment
358
CHAPTER
22 Management of the Pediatric Patient

360
360
23 Management of the Elderly Person

376
Normal Changes of Aging

376
Vestibular Function
376
Visual Deficits
378
Somatosensory Changes
378
Musculoskeletal Deficits
381
Postural Hypotension
382
Cerebellar Atrophy
382
Fear of Falling
382
Attention
382
Depression
382
Risk of Falling in Older Adults with Vestibular
Disorders
383
Questionnaires for Balance
Assessment
383
Dizziness Assessment
387
Typical Balance Tests
390
Home Assessment
390
Duration of Treatment 390
What to Do Once the Risk Factor
Has Been Identified
390
Summary
394
CHAPTER
24 Disability in Vestibular
Disorders
398
Evaluating Disablement
398
Chronic Vestibulopathy
400
Bilateral Vestibular Impairment
400
Acoustic Neuroma
402
Mnires Disease
404
Acknowledgments
406
CHAPTER
Incidence of Vestibular Deficits in Children

Development of Postural and Oculomotor
Control as Related to Vestibular System
Function
363
Evaluation of Children with
Vestibular System Dysfunction
365
Treatment of Vestibular Dysfunction
370
Peripheral Disorders
370
Central Vestibular and Postural
Control Deficits
370
CHAPTER
xxiii
399

of Disorders Affecting Central
Vestibular Pathways
409
Clinical Classification of Central

409
Vestibular Disorders in (Frontal)
Roll Plane
410
Etiology
415
Natural Course and Management
415
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Thalamic and Cortical Astasia Associated

with Subjective Visual Vertical Tilts
417
Torsional Nystagmus
417
Vestibular Disorders in (Sagittal) Pitch Plane
Downbeat Nystagmus
418
Upbeat Nystagmus
(Upbeat Nystagmus Syndrome)
419
Summary
423
Vestibular Disorders in (Horizontal)
Yaw Plane
423
Vestibular Cortex: Locations, Functions,
and Disorders
424
Multimodal Sensorimotor Vestibular Cortex
Function and Dysfunction
424
Spatial Hemineglect: a Cortical
Vestibular Syndrome?
426
Vestibular Epilepsy
426
Paroxysmal Central Vertigo
427
Summary
428
Acknowledgment
428
CHAPTER

Imbalance: From Disuse
Disequilibrium to Central
Degenerative Disorders
433
Disuse Disequilibrium and Fear of Fall

433
Description
433
Useful Outcome Tests
434
Management
434
Leukoaraiosis and Normal-Pressure
Hydrocephalus
434
Description
434
Useful Outcome Scores
436
Management
436
Progressive Supranuclear Palsy,
Parkinsons Disease, Large-Fiber Peripheral
Neuropathy, and Spinocerebellar
Ataxia
437
Description
437
438
Management
438
CHAPTER

of the Patient with Traumatic
Brain Injury and Vestibular
Dysfunction
444
417
Vestibular Pathology
444
Concussion
445
Fractures
446
Central Vestibular Lesions
446
Vestibular Rehabilitation
446
Vertigo
447
Eye-Head Coordination
447
Postural Control Underlying
Stability
448
Assessment
448
Impairments Limiting Postural
Stability
452
Time Course for Recovery
453
Summary
456
CHAPTER

Imbalance: Suggestions for
Patients with Migraine and
Mal de Dbarquement
458
Annamarie Asher, PT
Definition of Non-vestibular Dizziness

Mal de Dbarquement
459
Migraine-Associated Dizziness
460
Primary Anxiety and Panic
462
Methodological Considerations for
Assessment and Treatment
Development
464
CHAPTER
29 Non-vestibular Diagnosis
and Imbalance:
Cervicogenic Dizziness
458
467

Proposed Etiologies
468
Posterior Cervical Sympathetic
Syndrome
468
Vertebrobasilar Insufficiency
Altered Proprioceptive Signals
Examination
475
Management
476
Summary 477
468
468
Appendix A Questionnaire for History

and Examination 485
Index
493
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ONE
Fundamentals
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1
Anatomy and Physiology
of the Normal Vestibular
System
Timothy C. Hain, MD
Purpose of the Vestibular System

The human vestibular system is made up of three components: a peripheral sensory apparatus, a central processor,
and a mechanism for motor output (Fig. 1.1). The peripheral apparatus consists of a set of motion sensors that send
information to the central nervous systemspecifically,
the vestibular nucleus complex and the cerebellum
about head angular velocity and linear acceleration. The
central nervous system processes these signals and combines them with other sensory information to estimate
head and body orientation. The output of the central

vestibular system goes to the ocular muscles and spinal
cord to serve three important reflexes, the vestibuloocular reflex (VOR), the vestibulocollic reflex (VCR),
and the vestibulospinal reflex (VSR). The VOR generates
eye movements that enable clear vision while the head is
in motion. The VCR acts on the neck musculature to
stabilize the head. The VSR generates compensatory
body movement in order to maintain head and postural
stability and thereby prevent falls. The performance of the
VOR, VCR and VSR is monitored by the central nervous
Figure 1.1 Block diagram illustrating the organization of the vestibular system.
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Chapter 1 ANATOMY AND PHYSIOLOGY OF THE NORMAL VESTIBULAR SYSTEM
system, is readjusted as necessary by the cerebellum, and

is supplemented by slower but more capable higher cortical processes.
From a rehabilitation perspective, it is crucial to realize that because orientation in space is a critical function,
multiple fail-safe mechanisms are closely integrated into
vestibular responses. The capability for repair and adaptation is remarkable! Two years after removal of half of
the peripheral vestibular system, such as by a unilateral
vestibular nerve section, finding clinical evidence of
vestibular dysfunction is often quite difficult. The ability
of central mechanisms to use vision, proprioception, auditory input, tactile input, or knowledge about an impending movement allows vestibular responses to be based on
a richly textured, multimodal sensory array.
With these general philosophical considerations
kept in mind, the purpose of this chapter is to describe the
anatomy and the physiologic responses of the vestibular
system, with particular attention to aspects relevant to
rehabilitation. We proceed from the peripheral structures
to central structures and conclude with a discussion of
higher-level problems in vestibular physiology that are
relevant to rehabilitation.
The Peripheral Sensory Apparatus

Figure 1.2 illustrates the peripheral vestibular system
in relation to the ear. The peripheral vestibular system
Figure 1.2 Anatomy of the peripheral

vestibular system in relation to the ear.
(Illustration adapted from http://www.
dizziness-and-balance.com/disorders/
hearing/sensorineural.htm, with permission.)
consists of the membranous and bony labyrinths as

well as the motion sensors of the vestibular system,
the hair cells. The peripheral vestibular system lies within the inner ear. Bordered laterally by the air-filled middle ear and medially by temporal bone, it is posterior to
the cochlea.1
Bony Labyrinth
The bony labyrinth consists of three semicircular
canals (SCCs), the cochlea, and a central chamber called
the vestibule (Fig. 1.3). 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 puncture) can also affect inner
ear function. [2]
Membranous Labyrinth
The membranous labyrinth is suspended within the bony
labyrinth by perilymphatic fluid and supportive connective tissue. It contains five sensory organs: the membranous portions of the three SCCs and the two otolith
organs, the utricle and saccule. Note that one end of each
SCC is widened in diameter to form an ampulla. This
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Section ONE FUNDAMENTALS
Bone
Membrane
Cochlea
Vestibule
Ampulla
Cupula
Figure 1.3 The membranous and bony labyrinths. The inset illustrates the perilymphatic and
endolymphatic fluid compartments. (Adapted from an illustration by Mary Dersch; originally adapted
from Pender, 1992.2)
widening is relevant to the understanding of a common

vestibular condition, benign paroxysmal positional vertigo (see later).
The membranous labyrinth is filled with endolymphatic fluid (see Fig. 1.3). In contrast to perilymph, the
endolymph resembles intracellular fluid in electrolyte
composition (high K:Na ratio). Under normal circumstances, there is no direct communication between the
endolymph and perilymph compartments.
Hair Cells
Specialized hair cells contained in each ampulla and
otolith organ are biological sensors that convert displacement due to head motion into neural firing (Fig. 1.4). The
hair cells of the ampullae rest on a tuft of blood vessels,
nerve fibers, and supporting tissue called the crista
ampullaris. The hair cells of the saccule and utricle, the
maculae, are located on the medial wall of the saccule
and the floor of the utricle. Each hair cell is innervated
by an afferent neuron located in the vestibular (Scarpas)
ganglion, which is located close to the ampulla. When
hairs are bent toward or away from the longest process
of the hair cell, firing rate increases or decreases in
the vestibular nerve (see Fig. 1.4A). A flexible, diaphrag-
matic membrane called the cupula overlies each crista

and completely seals the ampulla from the adjacent vestibule. Associated with angular head motion, endolymphatic pressure differentials across the cupula cause the
cupula to bend back and forth, stimulating the hair cells
(Fig. 1.4B). 3
The otolithic membranes are structures that are
similar to the cupulae but they are also weighted. They
contain calcium carbonate (limestone) crystals called
otoconia and have substantially more mass than the
cupulae (Fig. 1.5). The mass of the otolithic membrane
causes the maculae to be sensitive to gravity and linear
acceleration. In contrast, the cupulae normally have the
same density as the surrounding endolymphatic fluid and
are insensitive to gravity. 4
Vascular Supply
The labyrinthine artery supplies the peripheral vestibular system (Fig. 1.6; see also Fig. 1.11). The labyrinthine
artery has a variable origin. Most often it is a branch
of the anterior-inferior cerebellar artery (AICA), but
occasionally it is a direct branch of the basilar artery.
Upon entering the inner ear, the labyrinthine artery
divides into the anterior vestibular artery and the com-
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Figure 1.4 Effects of head rotation

on the canals. (A) The direction from
which hair cells are deflected determines
whether or not hair-cell discharge frequency increases or decreases. (B) Cross
section of the membranous labyrinth
illustrating endolymphatic flow and cupular deflection in response to head
motion. (From Bach-Y-Rita et al, 1971.3)
mon cochlear artery. The anterior vestibular artery supplies the vestibular nerve, most of the utricle, and the
ampullae of the lateral and anterior SCCs. The common
cochlear artery divides into a main branch, the main
cochlear artery, and the vestibulocochlear artery. The
main cochlear artery supplies the cochlea. The vestibulocochlear artery supplies part of the cochlea, the ampulla
of the posterior semicircular canal, and the inferior part
of the saccule.5
The labyrinth has no collateral anastomotic network
and is highly susceptible to ischemia. Only 15 seconds of
selective blood flow cessation is needed to abolish auditory nerve excitability.6
Figure 1.5 The otolithic macula and its overlying membrane.

(From Baloh et al, 1990.4)
Physiology of the Periphery

The hair cells of the canals and otoliths convert the
mechanical energy generated by head motion into neural
discharges directed to specific areas of the brainstem and
the cerebellum. By virtue of their orientation, the canals
and otolith organs are able to respond selectively to head
motion in particular directions. By virtue of differences
in their fluid mechanics, the canals respond to angular
velocity, and the otoliths to linear acceleration.
Semicircular Canals
The SCCs provide sensory input about head velocity,
which enables the VOR to generate an eye movement that
matches the velocity of the head movement. The desired
result is that the eye remains still in space during head
motion, enabling clear vision. Neural firing in the
vestibular nerve is proportional to head velocity over
the range of frequencies in which the head commonly
moves (0.57 Hz). In engineering terms, the canals are
rate sensors.
A second important dynamic characteristic of the
canals has to do with their response to prolonged rotation
at constant velocity. Instead of producing a signal proportional to velocity, as a perfect rate sensor should, the
canals respond reasonably well only in the first second or
so, because output decays exponentially with a time constant of about 7 seconds. This behavior is due to a springlike action of the cupula that tends to restore it to its
resting position.7
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Anterior Inferior
Cerebellar Artery
Basilar
Artery
Anterior
Vestibular
Artery
Arteries of
the Canals
Labyrinthine Artery
Common
Cochlear
Artery
Main
Cochlear
Artery
Cochlear Ramus
Vestibulocochlear Artery
Posterior Vestibular Artery
Three important spatial arrangements characterize

the alignment of the SCCs loops. First, each canal plane
within each labyrinth is perpendicular to the other canal
planes, analogous to the spatial relationship between two
walls and the floor of a rectangular room (Fig. 1.7).
Second, paired planes of the SCCs between the labyrinths
conform very closely to each other. The six individual
SCCs become the following three coplanar pairs: (1) right
and left lateral, (2) left anterior and right posterior, and
(3) left posterior and right anterior. Third, the planes of
the canals are close to the planes of the extraocular muscles, thus allowing relatively simple connections between
sensory neurons (related to individual canals), and motor
output neurons (related to individual ocular muscles).
The coplanar pairing of canals is associated with a
push-pull change in the quantity of SCC output. When
angular head motion occurs within their shared plane, the
endolymph of the coplanar pair is displaced in opposite
directions with respect to their ampullae, and neural
firing increases in one vestibular nerve and decreases
on the other side. For the lateral canals, displacement of
the cupula towards the ampulla (ampullopetal flow) is
excitatory.
There are three advantages to the push-pull arrangement of coplanar pairing. First, pairing provides sensory
redundancy. If disease or surgical intervention affects
the SCC input from one member of a pair (e.g., as in
vestibular neuritis, or canal plugging for benign paroxysmal positional vertigo), the central nervous system will
Figure 1.6 The arterial supply of the

labyrinth. (Redrawn from Schuknecht,
1993.5)
still receive vestibular information about head velocity

within that plane from the contralateral member of the
coplanar pair.
Second, such a pairing allows the brain to ignore
changes in neural firing that occur on both sides simultaneously, such as might occur due to changes in body temperature or chemistry. These changes are not related to
Figure 1.7 The spatial arrangement of the semicircular

canals. The canals on each side are mutually perpendicular, are
paired with conjugate canals on the opposite side of the head,
and also are closely aligned with the optimal pulling directions
of the extraocular muscles.
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head motion and are common-mode noise. The engineering term for this desirable characteristic is commonmode rejection. Third, as discussed in a later section, a
push-pull configuration assists in compensation for sensory overload.
Otoliths
The otoliths register forces related to linear acceleration
(Fig. 1.8). They respond to both linear head motion and
static tilt with respect to the gravitational axis. The function of the otoliths is illustrated by the situation of a passenger in a commercial jet. During flight at a constant
velocity, he has no sense that he is traveling at 300 miles
per hour. However, in the process of taking off and ascending to cruising altitude, he senses the change in velocity
(acceleration) as well as the tilt of the plane on ascent. The
otoliths therefore differ from the SCCs in two basic ways:
They respond to linear motion instead of angular motion,
and to acceleration rather than to velocity.7
The otoliths have a simpler task to perform than the
canals. Unlike the canals, which must convert head velocity into displacement to properly activate the hair cells of
the cristae, the otoliths need no special hydrodynamic

system. Exquisite sensitivity to gravity and linear acceleration is obtained by incorporation of the mass of the
otoconia into the otolithic membrane (see Fig. 1.5). Force
is equal to mass multiplied by acceleration, so with incorporation of a large mass, a given acceleration produces
enough shearing force to make the otoliths extremely sensitive (shearing force refers to force that is directed perpendicularly to the processes of the hair cells).
Like the canals, the otoliths are arranged to enable
them to respond to motion in all three dimensions
(Fig. 1.9). However, unlike the canals, which have one
sensory organ per axis of angular motion, the otoliths
have only two sensory organs for three axes of linear
motion. In an upright individual, the saccule is vertical
(parasagittal), whereas the utricle is horizontally oriented
(near the plane of the lateral SCCs). In this posture, the
saccule can sense linear acceleration in its plane, which
includes the acceleration oriented along the occipitocaudal axis as well as linear motion along the anterior-posterior axis. The utricle senses acceleration in its plane,
which includes lateral accelerations along the interaural
axis as well as anterior-posterior motion.8
The earths gravitational field is a linear acceleration
field, so in a person on the earth, the otoliths register tilt.
For example, as the head is tilted laterally (which is also
called roll; see Fig. 1.8), shear force is exerted upon the
utricle, causing excitation, but shear force is lessened
upon the saccule. Similar changes occur when the head is
tilted forwards or backwards (called pitch). Because linear acceleration can come from two sourcesearths
gravitational field as well as linear motionthere is a
sensor ambiguity problem. We discuss strategies that the
central nervous system might use to solve this problem
later, in the section on higher-level vestibular processing.
In the otoliths, as in the canals, there is redundancy,
with similar sensors on both sides of the head. Push-pull
processing for the otoliths is also incorporated into the
geometry of each of the otolithic membranes. Within
each otolithic macula, a curving zone, the striola, separates the direction of hair-cell polarization on each side.
Consequently, head tilt increases afferent discharge from
one part of a macula while reducing the afferent discharge from another portion of the same macula. This
extra level of redundancy in comparison with the SCCs
probably makes the otoliths less vulnerable to unilateral
vestibular lesions.
The Vestibular Nerve

Figure 1.8 The otoliths register linear acceleration and
static tilt.
Vestibular nerve fibers are the afferent projections from

the bipolar neurons of Scarpas (vestibular) ganglion. The
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Figure 1.9 Geometry of the otoliths. (From

Barber and Stockwell, 1976.) [8]
vestibular nerve transmits afferent signals from the

labyrinths along its course through the internal auditory
canal (IAC). In addition to the vestibular nerve, the IAC
contains the cochlear nerve (hearing), the facial nerve,
the nervus intermedius (a branch of the facial nerve,
which carries sensation), and the labyrinthine artery. The
IAC travels through the petrous portion of the temporal
bone to open into the posterior fossa at the level of the
pons. The vestibular nerve enters the brainstem at the
pontomedullary junction. Because the vestibular nerve is
interposed between the labyrinth and the brainstem, some
authorities consider this nerve a peripheral structure,
whereas others consider it a central structure. We consider it a peripheral structure.
There are two patterns of firing in vestibular afferent
neurons. Regular afferents usually have a tonic rate and
little variability in interspike intervals. Irregular afferents
often show no firing at rest and, when stimulated by head
motion, develop highly variable interspike intervals.9
Regular afferents appear to be the most important type
for the VOR, because in experimental animals irregular
afferents can be ablated without much change in the
VOR. However, irregular afferents may be important for
the VSR and in coordinating responses between the
otoliths and canals.
Regular afferents of the monkey have tonic firing
rates of about 90 spikes per second and a sensitivity
to head velocity of about 0.5 spike per degree per
second.10,11 We can speculate about what happens immediately after a sudden change in head velocity. Humans
can easily move their heads at velocities exceeding 300
degrees per second (deg/sec). As noted previously, the
SCCS are connected in a push-pull arrangement, so that

one side is always being inhibited while the other is being
excited. Given the sensitivity and tonic rate noted previously, the vestibular nerve, which is being inhibited,
should be driven to a firing rate of 0 spikes per second,
for head velocities of only 180 deg/sec! In other words,
head velocities greater than 180 deg/sec may be unquantifiable by half of the vestibular system. This cutoff
behavior has been advanced as the explanation for
Ewalds second law, which says that responses to rotations that excite a canal are greater than those to rotations
that inhibit a canal.12,13 Cutoff behavior explains why a
patient with unilateral vestibular loss avoids head motion
toward the side of the lesion. More is said about this issue
in the later discussion of how the central nervous system
may compensate for overload.
Central Processing
of Vestibular Input
There are two main targets for vestibular input from primary afferents: the vestibular nuclear complex and the
cerebellum (see Fig. 1.1). The vestibular nuclear complex
is the primary processor of vestibular input and implements direct, fast connections between incoming afferent
information and motor output neurons. The cerebellum is
the adaptive processor; it monitors vestibular performance and readjusts central vestibular processing if necessary. At both locations, vestibular sensory input is
processed in association with somatosensory and visual
sensory input.
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Vestibular Nucleus
The vestibular nuclear complex consists of four major
nuclei (superior, medial, lateral, and descending) and at
least seven minor nuclei (Fig. 1.10). This large structure, located primarily within the pons, also extends caudally into the medulla. The superior and medial
vestibular nuclei are relays for the VOR. The medial
vestibular nucleus is also involved in VSRs and coordinates head and eye movements that occur together. The
lateral vestibular nucleus is the principal nucleus for
the VSR. The descending nucleus is connected to all of
the other nuclei and the cerebellum but has no primary
outflow of its own. The vestibular nuclei between the two
sides of the brainstem are laced together via a system of
commissures that are mutually inhibitory. The commissures allow information to be shared between the two
sides of the brainstem and implement the push-pull pairing of canals discussed earlier.14
In the vestibular nuclear complex, processing of the

vestibular sensory input occurs concurrently with the
processing of extravestibular sensory information (proprioceptive, visual, tactile, and auditory). Extensive connections between the vestibular nuclear complex,
cerebellum, ocular motor nuclei, and brainstem reticular
activating systems are required to formulate appropriate
efferent signals to the VOR and VSR effector organs, the
extraocular and skeletal muscles.
Vascular Supply
The vertebral-basilar arterial system supplies blood to the
peripheral and central vestibular system (Fig. 1.11). The
BRAINSTEM
4
PCA
SCA
SCA
5
7
8
9
10
AICA
12
11
PICA
PICA
Figure 1.10 The vestibular nuclear complex. This section

shows the brainstem with the cerebellum removed. DVN
descending vestibular nucleus; LVN lateral vestibular nucleus; NPH nucleus prepositus hypoglossi; III oculomotor
nucleus (inferior oblique muscle and medial, superior, and inferior rectus muscles); IV trochlear nucleus (superior oblique
muscle); VI abducens nucleus (lateral rectus muscle). The
medial vestibular nucleus (not labeled) lies between the NPH
and the DVN. (From Brodal, 1981.14)
Vertebral Arteries
Figure 1.11 The vertebral-basilar system. AICA anterior
inferior cerebellar artery; PCA posterior cerebellar artery;
PICA posterior inferior cerebellar artery; SCA superior
cerebellar artery. Numerals indicate individual cranial nerve roots
(all nerves are paired, but for clarity, both sides are not always
labeled here). ( Northwestern University, with permission.)
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posterior-inferior cerebellar arteries (PICAs) branch off

the vertebral arteries. The two PICAs are the most important arteries for the central vestibular system. They supply the surface of the inferior portions of the cerebellar
hemispheres as well as the dorsolateral medulla, which
includes the inferior aspects of the vestibular nuclear
complex. The basilar artery is the principal artery of the
pons. The basilar artery supplies central vestibular structures via perforator branches, which penetrate the medial
pons, short circumferential branches, which supply the
anterolateral aspect of the pons, and long circumferential
branches, which supply the dorsolateral pons. The AICA
is an important branch of the basilar artery because it is
the sole blood supply for the peripheral vestibular system
via the labyrinthine artery. The AICA also supplies blood
to the ventrolateral cerebellum and the lateral tegmentum
of the lower two-thirds of the pons. Recognizable clinical
syndromes with vestibular components may appear after
occlusions of the basilar artery, labyrinthine artery,
AICA, and PICA.
Cerebellum
The cerebellum, a major recipient of outflow from the
vestibular nucleus complex, is also a major source of
input itself. Although the cerebellum is not required for
vestibular reflexes, vestibular reflexes become uncalibrated and ineffective when this structure is removed.
Originally, the vestibulocerebellum was defined as the
portions of the cerebellum receiving direct input from the
primary vestibular afferents. We now understand that
most parts of the cerebellar vermis (midline) respond to
vestibular stimulation. The cerebellar projections to the
vestibular nuclear complex have an inhibitory influence
on the vestibular nuclear complex.
The cerebellar flocculus adjusts and maintains the
gain of the VOR.15 Lesions of the flocculus reduce the
ability of experimental animals to adapt to disorders that
reduce or increase the gain of the VOR. Patients with
cerebellar degenerations or the Arnold-Chiari malformation typically have floccular disorders.
The cerebellar nodulus adjusts the duration of VOR
responses and is also involved with processing of otolith
input. Patients with lesions of the cerebellar nodulus,
such as those with medulloblastoma, show gait ataxia and
often have nystagmus, which is strongly affected by the
position of the head with respect to the gravitational axis.
Lesions of the anterior-superior vermis of the cerebellum affect the VSR and cause a profound gait ataxia
with truncal instability. Patients with such lesions are
unable to use sensory input from their lower extremities
to stabilize their posture. The lesions are commonly related to excessive alcohol intake and thiamine deficiency.
Neural Integrator
Thus far we have discussed processing of velocity signals
from the canals and acceleration signals from the
otoliths. These signals are not suitable for driving the
ocular motor neurons, which need a neural signal encoding eye position. The transformation of velocity to position is accomplished by a brainstem structure called the
neural integrator. The nucleus prepositus hypoglossi,
located just below the medial vestibular nucleus, appears
to provide this function for the horizontal oculomotor
system.15 Although a similar structure must exist for the
vestibulospinal system, the location of the VSR neural
integrator is currently unknown. Clinically, poor function
of the oculomotor neural integrator causes gaze-evoked
nystagmus.
Motor Output of the

Vestibular System Neurons
Output for the Vestibulo-ocular Reflex
The output neurons of the VOR are the motor neurons of
the ocular motor nuclei, which drive the extraocular muscles. The extraocular muscles are arranged in pairs, which
are oriented in planes very close to those of the 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 the same plane as head motion.
Two white matter tracts carry output from the
vestibular nuclear complex to the ocular motor nuclei.
The ascending tract of Deiters carries output from the
vestibular nucleus to the ipsilateral abducens nucleus
(lateral rectus) during the horizontal VOR. All other
VOR-related output to the ocular motor nuclei is transmitted by the medial longitudinal fasciculus (MLF) (Fig.
1.12). Because the median longitudinal fasciculus is
often injured in multiple sclerosis, this connection may
account for central vestibular symptoms in patients with
this disorder.14
Output for the Vestibulospinal Reflex

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 compli-
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11
majority of its input from the otoliths and the cerebellum

(see Fig. 1.12). This pathway generates antigravity postural motor activity or protective extension, primarily in
the lower extremities, in response to the head position
changes that occur with respect to gravity. The medial
vestibulospinal tract originates from the contralateral
medial, superior, and descending vestibular nuclei (see
Fig. 1.12) and mediates ongoing postural changes or head
righting in response to SCC sensory input (angular head
motion). The medial vestibulospinal tract descends only
through the cervical spinal cord in the medial longitudinal fasciculus and activates cervical axial musculature.
The reticulospinal tract receives sensory input from
all of the vestibular nuclei as well as from all of the other
sensory and motor systems involved with maintaining
balance. This projection has both crossed and uncrossed
components and is very highly collateralized. As a result,
the reticulospinal tract through the entire extent of the
spinal cord is poorly defined, but it is probably involved
in most balance reflex motor actions, including postural
adjustments made to extravestibular sensory input (auditory, visual, and tactile stimuli).
Figure 1.12 The vestibulo-ocular reflex (VOR) and vestibulospinal reflex (VSR) arcs. S, L, M, and D indicate the superior,
lateral, medial, and descending vestibular nuclei, respectively.
The lateral vestibulospinal and medial vestibulospinal tracts are
shown as heavy lines and light lines, beginning in the lateral
vestibular nucleus and medial vestibular nucleus, respectively.
(From Brodal, 1981.14)
cated than that for the VOR. The VSR has a much more
difficult task than the VOR, because multiple strategies
involving entirely different motor synergies can be used
to prevent falls. For example, when one is shoved from
behind, ones center of gravity might become displaced
anteriorly. In order to restore balance, one might (1)
plantar-flex 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 (see the
frame of reference problem discussed later in the section
on higher-level problems in vestibular processing).
The VSR must also use otolith input, reflecting linear motion, to a greater extent than the VOR. Although the
eyes can only rotate and thus can do little to compensate
for linear motion, the body can both rotate and translate.
Three major white matter pathways connect the
vestibular nucleus to the anterior horn cells of the spinal
cord. The lateral vestibulospinal tract originates from the
ipsilateral lateral vestibular nucleus, which receives the
Vestibular Reflexes
The sensory, central, and motor output components of the
vestibular system have been described. We now discuss
their integration into the VOR, VSR, and VCR. Additionally, we include brief descriptions of cervical, visual,
and somatosensory reflexes. Although not directly mediated by the vestibular apparatus, these reflexes have a
close interaction with vestibular reflexes.
The Vestibulo-ocular Reflex

The VOR normally acts to maintain stable vision during head motion. This reflex has two components. The
angular VOR, mediated by the SCCs, 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 when near targets are being viewed and
the head is being moved at relatively high frequencies.
An example of how the horizontal canal VOR is orchestrated follows:
1. When the head turns to the right, endolymphatic flow deflects the cupulae to the left
(see Fig. 1.4B).
2. The discharge rate from hair cells in the right
crista increases in proportion to the velocity
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3.
4.
5.
6.
of the head motion, whereas the discharge rate

from hair cells in the left lateral crista decreases
(see Fig. 1.4A).
These changes in firing rate are transmitted
along the vestibular nerve and influence the
discharge of the neurons of the medial and
superior vestibular nuclei and cerebellum.
Excitatory impulses are transmitted via white
matter tracts in the brainstem to the oculomotor
nuclei, which activate the right (ipsilateral)
medial rectus and the left (contralateral) lateral
rectus. Inhibitory impulses are also transmitted
to their antagonists.
Simultaneously, contraction of the left lateral
rectus and right medial rectus muscles and
relaxation of the left medial rectus and right lateral rectus muscles occur, resulting in lateral
compensatory eye movements toward the left.
If the eye velocity is not adequate for the given
head velocity and retina image motion is more
than 2 deg/sec, the cerebellar projection to the
vestibular nuclei will modify the firing rate of
the neurons within the vestibular nuclei to
reduce the error.
The Vestibulospinal Reflex

The purpose of the VSR is to stabilize the body. The VSR
actually consists of an assemblage of several reflexes
named according to the timing (dynamic vs. static or
tonic) and sensory input (canal vs. otolith); these reflexes are discussed in more detail in Chapter 2. As an example of a VSR, let us examine the sequence of events
involved in generating a labyrinthine reflex, as follows:
1. When the head is tilted to one side, both the
canals and the otoliths are stimulated. Endolymphatic flow deflects the cupula, and shear force
deflects hair cells within the otoliths.
2. The vestibular nerve and vestibular nucleus are
activated.
3. Impulses are transmitted via the lateral and
medial vestibulospinal tracts to the spinal cord.
4. 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 sensed by the
motion sensors.
The Vestibulocollic Reflex

The VCR acts on the neck musculature to stabilize the
head. The reflex head movement produced counters the
movement sensed by the otolithic or SCC organs. The

precise pathways mediating this reflex have yet to be
detailed.
Cervical Reflexes
The Cervico-ocular Reflex
The cervico-ocular reflex (COR) interacts with the VOR.
The COR consists of eye movements driven by neck proprioceptors that can supplement the VOR under certain
circumstances. Normally, the gain of the COR is very
low.16 The COR is facilitated when the vestibular apparatus is injured.17,18 It is rare, however, for the COR to have
any clinical significance.
The Cervicospinal Reflex

The cervicospinal reflex (CSR) is defined as changes in
limb position driven by neck afferent activity. Analogous
to the COR, which supplements the VOR under certain
circumstances, the CSR can supplement the VSR by
altering motor tone in the body. Like the VSR, the CSR
consists of an assemblage of several reflexes. Two pathways are thought to mediate these reflex signals: an excitatory pathway from the lateral vestibular nucleus and an
inhibitory pathway from the medial part of the medullary
reticular formation.
When the body is rotated with head stable, neurons
of the excitatory vestibulospinal system increase their
rate of firing on the side to which the chin is pointed. At
the same time, neurons thought to be in the inhibitory
reticulospinal system show a reduced rate of firing. This
activity leads to extension of the limb on the side to
which the chin is pointed and flexion of the limb on the
contralateral side. Vestibular receptors influence both of
these systems by modulating the firing of medullary neurons in a pattern opposite to that elicited by neck receptors. With their interaction, the effects on the body of
vestibular and neck inputs tend to cancel one another
when the head moves freely on the body, so that posture
remains stable.19
The Cervicocollic Reflex

The cervicocollic reflex (CCR) is a cervical reflex that stabilizes the head on the body. The afferent sensory changes
caused by changes in neck position create opposition to
that stretch by way of reflexive contractions of appropriate neck muscles. The reflex is thought to be primarily
a monosynaptic one.16 The extent to which the CCR
contributes to head stabilization in normal humans is cur-
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rently uncertain, but it seems likely that the CCR is useful

primarily to stabilize head movement in the vertical plane,
and it may also be facilitated after labyrinthine loss.
Visual Reflexes
The visual system is a capable and sophisticated sensory
system that influences vestibular central circuitry and
drives visual after-responses (i.e., 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 above about 0.5 Hz than vestibular responses. Visual tracking responses may be facilitated after vestibular loss.
Somatosensory Reflexes
Somatosensory mechanisms appear to be involved in
postural stability as well. Bles and associates documented somatosensory-induced nystagmus (stepping-around
nystagmus).20 Interestingly, the subjects in their study
with bilateral vestibular loss developed a more pronounced nystagmus than normal subjects. This finding
implies that subjects with bilateral vestibular loss use
somatosensory information to a greater extent than normal subjects.
13
Neurophysiology of Benign
Paroxysmal Positional Vertigo
Although most vestibular disorders can be described in
terms of imbalance between the ears or loss of function,
benign paroxysmal positional vertigo (BPPV) has an
entirely different mechanism. BPPV is caused by movement of detached otoconia within the inner ear (canalithiasis) or otoconia adherent to the cupula (cupulolithiasis)
(Fig. 1.13). Great progress has now been made in our
understanding of BPPV.
Figure 1.14, from Squires and colleagues,21 illustrates the fluid mechanics of BPPV. In this disorder, vertigo and nystagmus begin after a characteristic latency of
about 5 seconds. The delay in onset of symptoms is
caused by movement of detached otoconia through the
ampulla, because pressure caused by moving otoconia is
negligible until otoconia enter the narrow duct of the
SCC. Figure 1.14 also shows that particle-wall interactions can account for variability in duration and latency
of BPPV.21
Other results from fluid mechanics have direct bearing on our understanding of treatment maneuvers for
BPPV. Under the influence of a full 1 g of gravity, typical otoconia move at a rate of 0.2 mm/sec, or only about
1% of the circumference of the canal each second. It follows that inertial effects of treatment maneuvers can
DIRECTION OF VIEW
STRAIGHT LATERAL
POSTERIOR
SEMI-CIRCULAR CANAL
DARK CELLS
UTRICLE
SACCULE
COCHLEA
CUPULA
DISPLACED OTOCONIA
Figure 1.13 Physiology of benign

paroxysmal positional vertigo. Otoconia
become displaced from the utricle and
relocate to the bottom of the posterior
semicircular canal, which is the lowest
part of the inner ear. ( Northwestern
University, with permission.)
OTOCONIA
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a)
bc = 0.68 mm
b)
1
Cupular Pressure Pc
(mPa)
0.5
C
0
0
10
15
20
25
Cupular Volume Displacement Vc
30
20
10
(pL)
C
0
10
15
20
25
Nystagmus
2
(/sec)
C
bd = 0.16 mm
10
15
20
25
Time(s)
Figure 1.14 Fluid mechanics of benign paroxysmal positional vertigo. (A) Trajectories of three
otoconia after a sudden change of head position that makes the posterior canal vertical. Otoconia
begin close to the cupula, fall through the ampulla with radius bc, and then enter the duct with radius
bd. (B) Simulated pressure, displacement, and nystagmus due to otoconia falling with the trajectories
of A. (From Squires et al, 2004.) 21
cause negligible movement of otoconia and that, practically, sudden jerks of the head or maneuvers that incorporate eccentric moments (such as the Semont maneuver)
are unlikely to have a substantial additional effect in
comparison with maneuvers that rely on gravity to
accomplish canalith repositioning.22
Higher-Level Vestibular Processing

In this section we identify some of the more sophisticated aspects of central vestibular processing, which are not
reflexes but rather require much more processing, are
generally much more accurate, and often are at least partially under conscious control. Because these mechanisms are more modifiable than vestibular reflexes, they
are especially relevant to rehabilitation. Most of these
mechanisms process multiple sensory inputs.
Velocity Storage
How good does the VOR have to be? In order to keep the
eye still in space while the head is moving, the velocity
of the eyes should be exactly opposite to that of head
movement. When this happens, the ratio of eye move-
ment to head movement velocity, called the gain, equals

1.0. In order to maintain normal vision, retinal image
motion must be less than 2 deg/sec. In other words, for a
head velocity of 100 deg/sec, which is easily produced by
an ordinary head movement, the gain of the VOR must be
98% accurate, because any greater error would cause
vision to be obscured.
The normal VOR can deliver this high standard of
performance only for brief head movements. In other
words, the VOR is compensatory for high-frequency
head motion but not for low-frequency head motion.
This fact can be most easily seen if one considers the
response of the SCCs to a sustained head movement,
which has a constant velocity. The canals respond by producing an exponentially decaying change in neural firing
in the vestibular nerve. The time constant of the exponential is about 7 seconds; in other words, the firing rate
decays to 32% of the initial amount in 7 seconds. Ideally,
the time constant should be infinite, which would be
associated with no response decline. Apparently, a time
constant of 7 seconds is not long enough, because the
central nervous system goes to the trouble to perseverate the response, replacing the peripheral time constant of 7 seconds with a central time constant of about
20 seconds.
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The perseveration is provided via a brainstem structure called the velocity storage mechanism.23
The velocity storage mechanism is used as a repository for information about head velocity derived from
several kinds of motion sensors. During rotation in the
light, the vestibular nucleus is supplied with retinal slip
information. Retinal slip is the difference between eye
velocity and head velocity. Retinal slip can drive the
velocity storage mechanism and keep vestibular-related
responses going even after vestibular afferent information
decays. The vestibular system also uses somatosensory
and otolithic information to drive the velocity storage
mechanism.24 The example discussed here shows how the
vestibular system resolves multiple, partially redundant
sensory inputs.
reasonable estimate of orientation in space, even without

any recent sensory input, is needed. In engineering terms,
we are discussing an estimator.
Navigating the space shuttle involves similar problems. The shuttle has dozens of sensors and motors.
Some sensors respond quickly, and some slowly. They
may differ in accuracy, scaling, coordinate frame, timing,
and noise characteristics. No single sensor can provide a
complete picture of the shuttles state. A mechanism is
needed to integrate sensor output and to develop an internal estimate of the state of the system (i.e., position,
velocity, acceleration) in order to keep the shuttle on the
desired course and heading.
The engineering solution to this problem developed
out of work performed by Kalman and is often called a
Kalman filter. It is also commonly called an optimal
estimator or an internal model. The essentials of the
Kalman filter are shown in Figure 1.15. There is considerable evidence that mechanisms similar to Kalman filters are used for human sensorimotor processing.25
The Kalman filter is far more powerful than a simple
reflex. Several key concepts must be considered before
one can understand how it is superior. First, internal models of sensors and motor output are used to develop an
estimate of the current sensory and motor state. These
internal models are adjusted according to experience and
Estimation: Going Beyond Reflexes

Reflexes are by definition simple sensory processors that
rapidly convert sensory input into motor outflow. What
happens when sensory input is not available (such as
when the eyes are closed) or inaccurate (such as when a
person with positional vertigo tilts the head), or noisy
(such as when a sensor has been damaged)? A mechanism that combines sensory inputs, weights them according to their relevance and reliability, and provides a
Feedforward path
Forward Model
of Dynamics
Predicted
Next State
Current State
Estimate
Model of
Sensory
Output
+
+
Next State
Estimate
Kalman Gain
Predicted
Sensory
Feedback
Sensory
Error
-
Gain
Motor
Command
Feedback path
15
1
2
Time(s)
Actual Sensory
Feedback
Figure 1.15 Block diagram showing a Kalman filter such as may be used by the body for sensorimotor integration. Sensory inflow and motor outflow are used to estimate the current state. (From
Wolpert and Miall, 1997.) [25]
State
Correction
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must track changes in bodily function. It seems likely that

vestibular rehabilitation affects internal models.
Second, sensory input is not used to directly compute body state, but rather, the difference between sensory input and predicted sensory input is used to correct the
current estimate of body state. This design allows the
Kalman filter to easily combine multiple sensor inputs
from eyes, ears, and somatosensors. The Kalman filter
continues to work even in the absence of a sensory input,
because it uses its estimate when the sensor is missing.
Both of these highly desirable features make the Kalman
filter far superior to a simple assemblage of reflexes.
The Kalman gain weights the extent to which a sensory input affects the ongoing state estimate. This
weighting provides a method of adjusting for the salience
and reliability of sensory streams. It seems highly likely
that vestibular rehabilitation adjusts the Kalman gain.
Overall, this sort of mechanism is clearly far superior to vestibular reflexes: Although not as fast, it can be
far more accurate, it functions even in the absence of sensory input, and it is modifiable by experience and rehabilitation.
Higher-Level Problems
of the Vestibular System
Compensation for Overload
Humans can easily move their heads at velocities exceeding 300 deg/sec. Consider, for example, driving a car.
When one hears a horn to the side, ones head may rapidly rotate to visualize the problem and, potentially, avoid
an impending collision. Similarly, during certain sports
(e.g., racquetball), head velocity and acceleration reach
high levels. One must be able to see during these sorts of
activities, but the vestibular nerve is not well suited to
transmission of high-velocity signals. The reason is the
cutoff behavior discussed in the earlier section on motor
output of the vestibular system. High-velocity head movement may cause the nerve on the inhibited side to be driven to a firing rate of 0.
In this instance, the vestibular system must depend
on the excited side, which is arranged in push-pull configuration with the inhibited side. Whereas the inhibited
side can be driven only to 0 spikes per second, the side
being excited can be driven to much higher levels. Thus,
the push-pull arrangement takes care of part of the overload problem. Note, however, that in patients with unilateral vestibular loss, this mechanism is not available to deal
with the overload problem, and they are commonly disturbed by rapid head motion toward the side of the lesion.
Sensor Ambiguity
Sensory input from the otoliths is intrinsically ambiguous, because the same pattern of otolith activation can be
produced by either a linear acceleration or a tilt. In other
words, in the absence of other information, we have no
method of deciding whether we are being whisked off
along an axis or whether the whole room just tilted.
Canal information may not be that useful in resolving the
ambiguity, because one might be rotating and tilting at
the same time. These sorts of problems are graphically
demonstrated in subway cars and airplanes, which can
both tilt and/or translate briskly.
Outside of moving vehicles, vision and tactile sensation can be used to decide what is happening, perhaps
through the use of a Kalman filter as discussed previously. As long as one does not have to make a quick decision,
these senses may be perfectly adequate. However, visual
input takes 80 msec to get to the vestibular nucleus and
tactile input must be considered in the context of joint
position and of the intrinsic neural transmission delays
between the point of contact and the vestibular nuclear
complex.
Another strategy that the brain can use to separate
tilt from linear acceleration is filtering. In most instances,
tilts are prolonged but linear accelerations are brief.
Neural filters that pass low or high frequencies can be
used to tell one from the other.
Nevertheless, in humans, evolution apparently has
decided that the ambiguity problem is not worth solving.
Otolith-ocular reflexes appropriate to compensate for linear acceleration or tilt do exist in darkness but are
extremely weak in normal humans.26 Stronger otolithocular reflexes are generally seen only in the light, when
vision is available to solve the ambiguity problem.
Sensory ambiguity becomes most problematic for
patients who have multiple sensory deficits, because they
cannot use other senses to formulate appropriate vestibulospinal responses.
Motion Sickness
The phenomenon of motion sickness illustrates how the
brain routinely processes multiple channels of sensory
information simultaneously. The motion sickness syndrome consists of dizziness, nausea or emesis, and
malaise after motion. It is thought to be caused by a conflict between movement information in related sensory
channels, such as visual-vestibular conflict or conflict
between an actual and an anticipated sensory input. For
example, motion sickness is often triggered by reading a
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book while riding in a car. In this instance, the vestibular

and proprioceptive systems signal movement, but the
visual system signals relative stability.
The vestibular apparatus provides partially redundant information, allowing for the possibility of intralabyrinthine conflict. Space motion sickness is thought to
be caused by intralabyrinthine conflict. About 50% of
space shuttle astronauts experience motion sickness during the initial 24 to 72 hours of orbital flight. It is currently thought that space motion sickness is due to a
disturbance in otolith-tilt translation.27 The otoliths normally function in the context of a gravitational field, so
that at any moment the total force acting on the otoliths is
the vector sum of the force due to gravity and that due to
linear acceleration of the head. The central nervous system expects linear acceleration to be mainly related to tilt,
because linear acceleration due to gravity is usually much
greater than that due to acceleration of the head. When
one is outside earths gravitational field, like astronauts in
outer space, the only source of otolith stimulation is linear
acceleration of the head. In susceptible individuals, the
central nervous system continues to interpret linear acceleration as being primarily related to tilt, which is now
untrue, causing the motion sickness syndrome.27,28
Structures that appear to be essential for the production of motion sickness are (1) intact labyrinth and central vestibular connections, (2) cerebellar nodulus and
uvula that coordinate labyrinthine stimuli, (3) the
chemoreceptive trigger zone located in the area postrema,
and (4) the medullary vomiting center.29 Why some people are more prone to motion sickness than others is not
completely understood.
Repair
Thus far, we have described some of the problems posed
by the limitations of the vestibular sensory apparatus and
the constraints of physics. In normal individuals, these
problems can be satisfactorily resolved by relying on
redundancy of sensory input and central signal processing. In addition to these intrinsic problems, there are
extrinsic problems related to ongoing changes in sensory
apparatus, central processing capabilities, and motor output channels. Because being able to see while ones head
is moving and avoiding falls are so important to survival,
the repair facility of the vestibular system must be
regarded as an integral part of its physiology; for this reason, it is our final topic.
Adaptive plasticity for peripheral vestibular lesions
is dealt with elsewhere in this volume. Suffice it to say
here that repair is amazingly competent, even enabling
17
the vestibular system to adapt to peculiar sensory situations requiring a reversal of the VOR.30 Adjustments of
internal models and weighting of sensory inputs (e.g.,
Kalman gain) are probably at least as important as readjustment of reflexes, because internal models provide
many important features that reflexes cannot provide
(such as functioning in the absence of sensory input).
Although most people are capable of abstract
thought and can generalize from one context to another,
there is a high degree of context dependency to the repair
of peripheral vestibular lesions. In other words, adaptations learned within one sensory context may not work
within another. For example, a patient who can stabilize
gaze on a target with the head upright may not be able to
do so when making the same head movements from a
supine posture. Experimentally, in the cat, VOR gain
adaptations can be produced that depend on the orientation of the head.31 Similarly, when the VOR of cats
is trained with the use of head movements of low frequency, no training effect is seen at high frequencies.32
Another type of context dependency relates to the
VSRs and has to do with the difference in reference
frames between the head and body. Because the head can
move on the body, information about how the head is
moving may be rotated with respect to the body. For
example, consider the situation in which the head is
turned 90 degrees to the right. In this situation, the coronal plane of the head is aligned with the sagittal plane of
the body, and motor synergies intended to prevent a fall
for a given vestibular input must also be rotated by 90
degrees. For example, patients with vestibular impairment who undergo gait training in which all procedures
are performed only in a particular head posture (such as
upright) may show little improvement in natural situations in which the head assumes other postures, such as
looking down at the feet. Little is understood about the
physiology of context dependency.
Repair of central lesions is much more limited than
that available for peripheral lesions; this is the Achilles
heel of the vestibular apparatus. Symptoms due to central lesions last much longer than symptoms due to
peripheral vestibular problems. The reason for this vulnerability is not difficult to understand. To use a commonplace analogy, if your television breaks down you
can take it to the repair shop and get it fixed. If, however,
your television is broken and the repair shop is out of
business, you have a much bigger problem. The cerebellum fulfills the role of the repair shop for the vestibular
system. When there are cerebellar lesions or lesions in
the pathways to and from the cerebellum, symptoms of
vestibular dysfunction can be profound and permanent.
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Clinicians use this reasoning when they attempt to separate peripheral from central vestibular lesions. A spontaneous nystagmus that persists over several weeks is
generally due to a central lesion; a peripheral nystagmus
can be repaired by an intact brainstem and cerebellum.
Summary
The vestibular system is an old and sophisticated human
control system. Accurate processing of sensory input
about rapid head and postural motion is difficult as well
as critical to survival. Not surprisingly, the body uses
multiple, partially redundant sensory inputs and motor
outputs in combination with central state estimators and
competent central repair. The system as a whole can withstand and adapt to major amounts of peripheral vestibular
dysfunction. The weakness of the vestibular system is a
relative inability to repair central vestibular dysfunction.
References
1. Hain, TC: http://www.dizziness-and-balance.com, version
of 12/3/2006.
2. Pender, D., Practical Otology. 1992, Philadelphia: JB
Lippincott.
3. Bach-Y-Rita, P., C. Collins, and J. Hyde, eds. The control
of eye movements. 1971, Academic Press: New York.
4. Baloh, R. and V. Honrubia, Clinical Neurophysiology of
the Vestibular System. 1990, Philadelphia: F.A.Davis.
5. Schuknecht, H., Pathology of the Ear. 1993, Philadelphia,
PA: Lea and Ferbiger.
6. Perlman, H.B., R. Kimura, and C. Fernandez,
Experiments on temporary obstruction of the internal auditory artery. Laryngoscope, 1959. 69(6):
p. 591613.
7. Wilson, V. and M. Jones, Mammalian Vestibular Physiology. 1979, New York: Plenum.
8. Barber, H. and C. Stockwell, Manual of Electronystagmography. 1976, St. Louis: C.V. Mosby.
9. Goldberg, J.M. and C. Fernandez, Physiology of peripheral neurons innervating semicircular canals of the squirrel monkey. I. Resting discharge and response to constant
angular accelerations. J Neurophysiol, 1971. 34(4): p.
63560.
10. Fernandez, C. and J.M. Goldberg, Physiology of peripheral neurons innervating semicircular canals of the
squirrel monkey. II. Response to sinusoidal stimulation
and dynamics of peripheral vestibular system. J
Neurophysiol, 1971. 34(4): p. 66175.
11. Miles, F.A. and D.J. Braitman, Long-term adaptive
changes in primate vestibuloocular reflex. II. Electrophysiological observations on semicircular canal primary
afferents. J Neurophysiol, 1980. 43(5): p. 142636.
12. Baloh, R.W., V. Honrubia, and H.R. Konrad, Ewalds
second law re-evaluated. Acta Oto-Laryngologica, 1977.
83(56): p. 4759.
13. Ewald, R., Physiologische Untersuchungen ueber das
Endorgan des Nervus Octavus. 1892, Wiesbaden:
Bergman.
14. Brodal, A., Neurological Anatomy in Relation to Clinical

Medicine. 3 ed. 1981, Oxford Press: New York.
15. Cannon, S.C. and D.A. Robinson, Loss of the neural integrator of the oculomotor system from brain stem lesions
in monkey. J Neurophysiol, 1987. 57(5): p. 1383409.
16. Peterson, B., Cervicocollic and Cervicoocular Reflexes, in
Control of Head Movement, B. Peterson and F.
Richmond, Editors. 1988, Oxford Press: New York. p.
9099.
17. Kasai, T. and D.S. Zee, Eye-head coordination in
labyrinthine-defective human beings. Brain Research,
1978. 144(1): p. 12341.
18. Botros, G., The tonic oculomotor function of the cervical
joint and muscle receptors. Adv Otorhinolaryngol, 1979.
25: p. 21420.
19. Pompeiano, O., The Tonic Neck Reflex: Supraspinal
Control, in Control of Head Movement, B. Peterson
and F. Richmond, Editors. 1988, Oxford: New York.
p. 108119.
20. Bles, W., J.M. de Jong, and G. de Wit, Somatosensory
compensation for loss of labyrinthine function. Acta
Otolaryngol, 1984. 97(34): p. 21321.
21. Squires, T.M., et al., A mathematical model for top-shelf
vertigo: the role of sedimenting otoconia in BPPV. J
Biomech, 2004. 37(8): p. 113746.
22. Hain, T.C., T.M. Squires, and H.A. Stone, Clinical implications of a mathematical model of benign paroxysmal
positional vertigo. Ann N Y Acad Sci, 2005. 1039: p.
38494.
23. Raphan, T., V. Matsuo, and B. Cohen, Velocity storage in
the vestibulo-ocular reflex arc (VOR). Exp Brain Res,
1979. 35(2): p. 22948.
24. Hain, T.C., A model of the nystagmus induced by off
vertical axis rotation. Biological Cybernetics, 1986.
54(45): p. 33750.
25. Wolpert, D.M. and R.C. Miall, Forward Models for
Physiological Motor Control. Neural Netw, 1996. 9(8):
p. 12651279.
26. Israel, I. and A. Berthoz, Contribution of the otoliths to
the calculation of linear displacement. J Neurophysiol,
1989. 62(1): p. 24763.
27. Parker, D.E., et al., Otolith tilt-translation reinterpretation
following prolonged weightlessness: implications for
preflight training. Aviat Space Environ Med, 1985. 56(6):
p. 6016.
28. Oman, C.M., et al., M.I.T./Canadian vestibular experiments on the Spacelab-1 mission: 4. Space motion sickness: symptoms, stimuli, and predictability. Exp Brain
Res, 1986. 64(2): p. 31634.
29. Harm, D., Physiology of motion sickness symptoms, in
Motion and Space Sickness, G. Crampton, Editor. 1990,
CRC Press: Boca Ratan.
30. Gonshor, A. and G. Melvill-Jones, Extreme vestibuloocular adaptation induced by prolonged optical reversal of
vision. J. Physiol (Lond), 1976. 256: p. 381.
31. Baker, J., C. Wickland, and B. Peterson, Dependence of
cat vestibulo-ocular reflex direction adaptation on animal
orientation during adaptation and rotation in darkness.
Brain Res, 1987. 408(12): p. 33943.
32. Godaux, E., J. Halleux, and C. Gobert, Adaptive change
of the vestibulo-ocular reflex in the cat: the effects of a
long-term frequency-selective procedure. Exp Brain Res,
1983. 49(1): p. 2834.
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CHAPTER
David S. Zee, MD
A robust and versatile capability for adaptive control of

vestibular motor behavior is essential if an organism is to
maintain optimal visual function and stable balance
throughout life. Changes associated with normal development and aging, as well as with disease and trauma,
demand mechanisms both to detect errors in performance
and to correct them. An understanding of such mechanisms is crucial in the design and evaluation of programs
of physical therapy that are used to rehabilitate patients
with vestibular disorders. The purpose of this chapter is to
review information about adaptive mechanisms that bears
on the management of patients with disorders of the
vestibular system. By necessity, this discussion emphasizes studies of the vestibulo-ocular reflex (VOR), because more is known about its adaptive control. When
possible, however, vestibulospinal (VSR), vestibulocollic
(VCR), and cervico-ocular (COR) reflexes are also discussed.
Recalibration, Substitution,
and Alternative Strategies
Adaptive control of vestibular reflexes must be regarded
in the larger context of overall compensation for vestibular deficits. Restoring adequate motor behavior by readjusting the input-output relationships (e.g., gain, timing,
or direction) of the VOR or VSR may be impossible,
especially when deficits are large. Other mechanisms of
compensation must then be invoked (Box 2-1). Examples

are as follows:
Substitution of another sensory input to drive
the same motor response (e.g., substitution of a
spared otolith-driven response in the absence of
canal-driven responses, or the substitution of the
COR for an absent angular VOR)
Substitution of an alternative motor response in
lieu of the usual compensatory motor response
(e.g., use of saccades instead of slow phases to
help stabilize gaze during head motion)
The use of strategies based on prediction or
anticipation of intended motor behavior (e.g.,
preprogramming compensatory slow phases in
anticipation of a combined eye-head movement
toward a new target)
Furthermore, there is considerable variability
among subjects as to which particular mechanisms are primarily used for compensation.1
This heterogeneity dictates a need for quantitative evaluation of vestibular function in patients
before and during rehabilitation. Any plan of
therapy must focus on what is likely to work
best and what is working best. The promotion
of different goals may require a different therapeutic emphasis, and different therapeutic programs may potentially work at cross purposes.
Therefore, it is essential to plan the program of
19
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Box 2-1
The Error Signals that Drive

Vestibulo-ocular Reflex Adaptation
COMPENSATORY MECHANISMS
What might be the error signals that drive VOR adaptation? Image motion or slip on the retina, when associated with head movements, is the obvious candidate; the
raison dtre of the VOR is to keep images stable on the
retina during head movements. My colleagues and I
investigated the role of vision, and especially of visual
information mediated by geniculostriate pathways, on
both the acquisition and the maintenance of adaptation to
UL in monkeys.6,7 VOR function was recorded in three
groups of animals. One group had undergone bilateral
occipital lobectomy many months before the labyrinthectomy. These cortically blind animals were allowed normal light exposure after UL. The other animals had
experienced no prior lesions and were divided into two
groups: those that were kept in complete darkness for 4
days after UL and those that were allowed normal exposure to light after the UL.
Adaptation: changing the gain, phase, or direction

of the vestibular response Substitution of
Other sensory input mechanisms (e.g.,
cervico-ocular reflex for absent VOR,
otolith-ocular response for absent canalocular response)
Alternative motor responses (e.g., saccades
or pursuit)
Strategies based on prediction or anticipation
therapy on the basis of (1) what is most likely to

succeed in the context of the type and the degree
of deficit and (2) the patients inherent potential
for compensation.2 To illustrate these points, I
first discuss two archetypal paradigms requiring
vestibular compensation: unilateral loss and
bilateral loss of labyrinthine function.
Compensation after
Unilateral Labyrinthectomy
Unilateral labyrinthectomy (UL) has been used as an
experimental model to study motor learning and compensation for more than 100 years. Yet, until recently, little has been known about the error signals that drive the
compensatory process, the precise mechanismsboth
physiological and molecularthat underlie recovery
from both static and dynamic disturbances created by the
loss of labyrinthine input from one side, and the additional strategies that are available to assist in the overall
goal of gaze and postural stability during movement.35
Let us use the VOR as an example. UL creates two
general types of deficits for which a correction is
required: static imbalance, related to the differences in the
levels of tonic discharge within the vestibular nuclei, and
dynamic disturbances, related to the loss of one half of
the afferent input that normally contributes, in a push-pull
fashion, to the generation of compensatory responses during head movement. Spontaneous nystagmus with the
head still and sustained torsion (ocular counter-roll) with
the head still are examples of the static type of disturbances that occur from an imbalance in inputs from the
semicircular canal and from the otoliths, respectively.
Decreased amplitude (gain), abnormally directed slow
phases (i.e., misalignment between the axes of rotation of
the eye and head), and a left-right asymmetry of eye rotation during yaw axis head rotation are examples of the
dynamic type of disturbance.
Restoration of Static Vestibuloocular Reflex Balance after

Unilateral Labyrinthectomy
The results from this experiment were clear-cut. Restoration of static balance, as reflected in the disappearance of
spontaneous nystagmus, proceeded independently of
whether or not the animals had undergone a prior occipital lobectomy and whether or not they were kept in the
dark after UL. Furthermore, a bilateral occipital lobectomy performed nearly a year after the labyrinthectomy,
when compensation to UL had taken place, did not result
in the reappearance of spontaneous nystagmus. Thus,
both the acquisition and the maintenance of static balance
in semicircular canalmediated VORs after UL are independent of visual inputs. Another example of restoration of static imbalance after UL is the elimination of
cyclotorsion [ocular counter-roll] that follows UL.8 This
bias arises from imbalance in otolith-ocular reflexes.
Whether this readjustment also requires visual inputs is
not known.
Restoration of Dynamic
Vestibulo-ocular Reflex Function
after Unilateral Labyrinthectomy
On the other hand, the restoration of dynamic performance after UL depended critically on visual experience in
these experiments.6,7 There was no increase in the amplitude (gain) of the VOR until exposure to light. Similar
results occur in monkeys after unilateral plugging of a
lateral semicircular canal, which causes a nearly 50%
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Chapter 2 VESTIBULAR ADAPTATION
decrease in VOR gain.9 Presumably, the critical stimulus

for recalibration of dynamic VOR responses is not light
per se but, rather, the presence of motion of images on the
retina during head movements. A similar dependence on
vision has been shown for recovery of balance in cats
after vestibular neurectomy.10
Furthermore, my colleagues and I found that the
compensatory changes in the gain of the VOR that
occurred after UL were lost, over the course of several
weeks, after a bilateral occipital lobectomy.6,7 The occipital lobectomy itself was unlikely to have been responsible for the decrease in the gain of the VOR, because only
small alterations in the gain and in the symmetry of the
VOR are produced by occipital lobectomy in animals that
have not undergone any prior vestibular lesions.
Taken together, these findings suggest that adaptation of VOR gain is a dynamic process that requires visual experience for its acquisition and depends on the
posterior cerebral hemispheres for its maintenance.
Presumably, the contribution of the occipital lobes is that
they transmit information about image slip on the retina
during head movements to more caudal structures, which
in turn use this error information to readjust the dynamic
performance of the VOR. The nucleus of the optic tract
(NOT) in the pretectal region of the midbrain is one such
structure shown to be important in VOR adaptation. The
NOT receives visual information from the cerebral cortex
as well as directly from the retina. It has a strong projection to the inferior olive and to other brainstem nuclei that
also project to the cerebellum. Lesions in the NOT interfere with compensation to UL11 and VOR adaptation in
general.12
The NOT does more, however, than simply relay
visual information for adaptive changes in the VOR,
because lesions in the NOT also lead to change in the
baseline VOR gain. Whether the NOT is also important
for maintaining long-term adaptive changes is not known,
but presumably it is. The cerebellum must be constantly
apprised of the need for adaptive recalibration, and visual inputs are critical. Even in a patient who can see in
the usual sense, lesions in the brainstem interfere with the
transmission of visual information to the cerebellum, so
the VOR can still become uncalibrated.
Other studies have shown that recovery after unilateral labyrinthine lesions is less complete when stimuli
are composed of high accelerations or high frequencies.5
Different strategies are needed, especially preprogramming of movements similar to those movements shown
by patients who have lost labyrinthine function bilaterally. Indeed, a major implication of much recent research
on recovery from unilateral vestibular loss is how important the saccade contribution really is. These issues are
discussed later along with saccade strategies.
21
Restoration of Spontaneous Activity

in the Deafferentiated Nuclei
One might ask why visual experience is necessary for
recalibration of dynamic VOR function but not for
restoration of static balance. Without motion of images
on the retina during head movements, adaptive mechanisms do not have a reliable error signal that they can use
to recalibrate the dynamic VOR. With respect to static
imbalance, however, deafferentation of the vestibular
nucleus might (1) initiate alterations in the intrinsic properties of the vestibular neurons themselves, (2) lead to
denervation hypersensitivity to remaining sensory inputs,
or (3) stimulate sprouting of extralabyrinthine afferents.3,13,14 Each process might result in a rise in the level
of the spontaneous activity of neurons on the lesioned
side. One should recall that restoring vestibulospinal balance also depends on rebalancing of the vestibular nuclei
and that many neurons within the vestibular nuclei have
axons that bifurcate and project both rostrally, to the ocular motor nuclei, and caudally, to the spinal cord.15
Vestibulospinal compensation would not be expected to
rely solely on visual inputs to provide the necessary error
signals for central readjustment of balance.16 Proprioceptive and somatosensory cues are probably more important and could provide the requisite error signals leading
to the static rebalancing of the vestibular nuclei that
would affect both vestibulo-ocular and vestibulospinal
responses.
A Critical Period for Vestibuloocular Reflex Adaptation

Another finding, potentially of important clinical relevance, emerged from our study in labyrinthectomized
monkeys. Monkeys that had been kept in the dark for 4
days after UL and then allowed normal visual experience
generally showed a recovery of dynamic VOR performance at about the same rate, and to the same level, as monkeys allowed visual experience immediately after UL.
There was, however, one important exception: For highvelocity rotations directed to the lesioned side, recovery
was markedly delayed in the monkeys initially deprived
of vision, although the final level reached was close to
that of monkeys that had not been deprived of vision
immediately after UL. This finding suggests that there
may be a critical period during which, if error signals
are not provided to the adaptive mechanism and recalibration does not get under way, the rate and, perhaps, the
ultimate extent of recovery may decrease. Restoration of
postural control after UL also appears to be subject to a
critical period.17 If animals are immobilized for a period
of seven days after UL, their recovery of locomotor func-
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tion, even after normal activity is reinstituted, is delayed

and limited.
The obvious implication of these findings is that
when patients incur enduring vestibular damage, they
should be encouraged to move about in the light and
to try to engage their VORs and VSRs as much as possible. In this way, they will generate and experience the
sensorimotor mismatches that make the central nervous
system aware of a need for adaptive readjustment of
its motor reflexes. As a further caveat, heavy sedation,
immobilization, and restriction of activity of patients
with a recent loss of vestibular function should be discouraged. Such practices may potentially retard or even
limit the ultimate level of compensation after a vestibular
lesion.
In the same vein, physical exercise promotes recovery of balance function in monkeys that have undergone
either unilateral or bilateral experimental vestibular ablations.18 Although carefully controlled studies of the
effects of different types of activity on vestibular compensation are sparse in human beings, physical therapy
most likely also promotes recovery in patients. Most evidence is based on evaluations of balance,1926 but there is
some evidence that vestibulo-ocular function, too, may
improve with physical therapy.26,27
Substitution of Saccades for Inadequate

Compensatory Slow Phases
Although we usually think of the main function of the
VOR as stabilizing images on the retina, getting the
image near the fovea and keeping it relatively close there,
by whatever strategy, can be the optimal strategy for preserving vision during head motion. This is especially true
when the brain is confronted with trying to compensate
for a severe loss of function, either bilateral or unilateral.
Because of the inherent limitations with respect to maximum frequency, velocity, and acceleration, the ability of
subjects with just one labyrinth to generate slow phases
of the correct magnitude when the head is rotated toward
the side of the lesion may be limited (Ewalds second
law).2830 Patients may learn to generate catch-up saccades (elicited, automatically, even in complete darkness)
in the same direction as their inadequate compensatory
slow phases. A number of factors influence which saccade strategies are invoked. Perhaps most important are
whether the movements are active or passive and the
ability to predict and invoke the gaze stabilizing strategy
that is best suited for the upcoming pattern of head
motion.3134 The severity of deficit, whether it was
acquired suddenly or gradually, and the duration of the
deficit are likely key factors as well.
Recovery Nystagmus
and Related Phenomena
A practical clinical implication of these ideas about
recovery from unilateral labyrinthine lesions relates to
the phenomenon of recovery nystagmus. As indicated
previously, the static imbalance created by a unilateral
peripheral lesion leads to a spontaneous nystagmus that is
compensated by a rebalancing of the level of activity between the vestibular nuclei. If peripheral function should
suddenly recover, central adaptation becomes inappropriate, and a nystagmus would appear with slow phases
directed away from the paretic side. Recovery nystagmus
may confuse the clinician or therapist, who may think
that the reappearance of symptoms and of a spontaneous
nystagmus are due to a loss of function on the previously healthy side rather than to a recovery of function on the
previously diseased side. In either case, a spontaneous
nystagmus ensues that must be eliminated, adaptively, by
a further readjustment of levels of activity within the
vestibular nuclei.
An analogous circumstancealthough rather than
recovery, there is further damage after compensation
occurs if the other labyrinth is destroyed after recovery
from an initial unilateral labyrinthine lesion. In this case,
a deficit occurs as if the original damaged labyrinth were
intact. This Bechterews phenomenon reflects the rebalancing of central vestibular tone after the first lesion. The
second lesion then creates a new imbalance.35,36 These
clinical examples illustrate the importance of taking into
account the actions of adaptive mechanisms in interpretations of patterns of nystagmus that do not seem to
reflect the effects of the sudden onset of a new lesion.
A similar mechanism may account for some
instances in which nystagmus is provoked by hyperventilation.37 In these cases, the induced alkalosis alters the
amount of calcium available for generating action potentials along the vestibular nerve and, so, may lead to a restoration of function on partially demyelinated fibers (for
example, due to multiple sclerosis, chronic microvascular
compression, petrous bone tumors such as cholesteatoma,
or cerebellopontine angle tumors such as acoustic neuroma). Hyperventilation, however, may also produce nystagmus in patients with a perilymphatic fistula, by an
alteriation in intracranial pressure that is then transmitted
to the labyrinth. Other mechanisms for hyperventilationinduced nystagmus are possible, including alterations in
compensatory mechanisms.38,39
There may even be a dynamic equivalent of recovery nystagmus. After sustained head shaking, patients
who have a unilateral peripheral vestibular loss often
demonstrate a transient eye nystagmus with slow phases
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directed toward the impaired ear, so-called head-shaking

nystagmus.40 The initial phase of head-shaking nystagmus
may be followed by a reversal phase in which nystagmus
is directed opposite to the initial phase. The primary phase
of head-shaking nystagmus is related to a dynamic asymmetry in the VOR such that excitation (rotation toward the
intact side) elicits a larger response than inhibition (rotation toward the impaired side). Head-shaking nystagmus
is another manifestation of Ewalds second law. The secondary phase is often attributed to short-term (with a time
constant of about 1 minute) vestibular adaptation, probably reflecting adaptive processes in both the peripheral
nerve and central structures.
If recovery occurs peripherally, however, any prior
central VOR gain adaptation (which would increase the
dynamic response during rotation toward the impaired
side) could lead to a head-shakinginduced nystagmus
with the slow phases of the primary phase directed away
from the impaired ear. Thus, one can appreciate the
pivotal role that adaptation plays in determining the particular pattern and direction of any spontaneous or
induced nystagmus that may appear during the process of
recovery.
Bilateral Vestibular Loss

An even more challenging problem for the central nervous system is to compensate for a complete bilateral loss
of labyrinthine function (BL). In the case of a truly
complete loss, there is no labyrinthine-driven VOR to
recalibrate, so alternative mechanisms, such as sensory
substitution, motor substitution, and predictive and anticipatory strategies, must be invoked.
Whether or not labyrinthine function is completely
absent helps determine what type of program of physical
therapy should be prescribed. Because the response of
the VOR to high frequencies of head rotation is usually
spared until the labyrinthine function loss is complete,
caloric responses (which primarily simulate a lowfrequency rotational stimulus) may be absent even when
the patient has a relatively functional VOR. One should
recall that response to the high-frequency components of
head rotation requires the fast-acting labyrinthine-driven
VOR; visual stabilizing reflexes are adequate only to
ensure stabilization for the low-frequency components of
head rotation. Accordingly, the results of a rotational test
can help determine the level of preservation of labyrinthine function.41 Such information may help the therapist
decide whether to prescribe a program of rehabilitation
that stresses recalibration of a deficient but present VOR
or a program that emphasizes sensory substitution and
alternative strategies.
23
Experimental Results
in Nonhuman Primates
Dichgans and colleagues42 first described compensatory
mechanisms of eye-head coordination in monkeys that
had undergone bilateral labyrinthine destruction. These
researchers identified the following three major adaptive
strategies used to improve gaze stability during head
movements: (1) potentiation of the COR (neck-eye loop),
as reflected in slow-phase eye movements elicited in
response to body-on-head (head stable in space) rotation,
(2) preprogramming of compensatory slow phases in
anticipation of intended head motion, and (3) a decrease
in the saccadic amplituderetinal error relationship, selectively during combined eye-head movements, to prevent
gaze overshoot. With respect to the last phenomenon, saccades made with head movements would normally cause
gaze to overshoot the target if there were no functioning
VOR to compensate for the contribution of the movement
of the head to the change in gaze. Dichgans and colleagues42 also showed that saccades were programmed to
be smaller when an accompanying head movement was
also anticipated. When the head was persistently immobilized, however, saccades were programmed to be their
usual size.
Additional Strategies in Human

Patients with Bilateral Loss of
Labyrinthine Dysfunction
The compensatory mechanisms described for monkeys
without labyrinthine function have also been identified in
human beings who have a complete BL.4347 How much
one or another mechanism is adopted, however, varies
from patient to patient. In addition, several other strategies have been identified in humans that are also quite
idiosyncratic from patient to patient (Box 22).4851
These strategies are as follows:
1. Substitution of small saccades in the direction
opposite to head rotation, in order to augment
inadequate compensatory slow phases.
2. Enhanced visual following reflexes.
3. Predictive strategies to improve gaze stability
during tracking of targets jumping periodically
or during self-paced tracking between two stationary targets.
4. Effort of spatial localization, as judged by a
much better compensatory response to head
rotation when the patient imagines the location of stationary targets, as opposed to the
response while the patient performs mental
arithmetic.
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Box 2-2
COMPENSATORY MECHANISMS
AFTER BILATERAL VESTIBULAR
DEFICITS
Potentiation of cervico-ocular reflex
Central preprogramming of slow phases
or saccades
Decreased saccade amplitude
Enhanced visual following
Effort of spatial localization
Suppression of perception of oscillopsia
As a corollary to these last two mechanisms, responses during active (self-generated) head rotations
occur at a shorter latency, and usually with a larger gain,
than those during passive head rotations.33,34,52 Even
somatosensory cues from the feet can be used to augment
inadequate compensatory slow phases of the eyesproducing so-called stepping-around nystagmus.53 Finally,
perceptual mechanismssuppression of oscillopsia (illusory movement of the environment) in spite of persistent
retinal image motionmay also be part of the compensatory response to vestibular loss.54,55
Another example of potentiation of a reflex that is
normally vestigial in human beings can be shown in the
ocular motor response to static lateral tilt of the head.
This presumably otolith-mediated reflex is composed of
a static torsion of the eyes opposite to the direction of lateral head tiltso-called ocular counter-rolling. In
labyrinthine-defective human beings, but not in normal
subjects, ocular counter-rolling can be produced by lateral tilt of the trunk with respect to the (stationary, upright)
head.56 This response probably reflects a potentiation of
a static COR in lieu of the missing otolith signals.
Patients with BL also show a greater sensitivity to visually induced tilt. With the loss of the inertial frame of reference normally provided by the dominating labyrinthine
inputs, visual inputs become more potent stimuli to
vestibular reflexes.
A new reliance on visual inputs is a necessary and
useful adaptation to labyrinthine loss, although it may
become a liability if visual inputs should become incongruent with the actual motion or position of the head. For
example, when one is reading a newspaper in a moving
elevator or escalator, visual inputs (from the motion of
the image of the newspaper on the retina) provide misleading information about the position or the movement
of the head that, if relied upon (as may occur in patients

with BL), would lead to an inappropriate (or lack of)
compensatory response and, possibly, a fall.
Studies of Vestibulo-ocular Reflex

Adaptation in Normal Subjects
Adaptive control of the VOR has been investigated in
normal subjects through artificial creation of motion of
images on the retina, by optical or other means, during
head rotation. For example, in the pioneering experiments by Gonshor and Melvill Jones57,58 subjects wore
right-left reversing prisms, which required and led to a
reversal in the direction of the slow phase of nystagmus
with respect to the direction of head motion. Likewise,
magnifying and minifying spectacle lenses (used to correct for farsightedness and nearsightedness, respectively)
require and produce adaptive increases and decreases,
respectively, in VOR gain. A practical consequence of
this phenomenon is that normal subjects wearing a spectacle correction undergo an adaptive change in VOR gain
to meet the needs of the new visual circumstances created by their optical correction. Such gain changes must be
considered in the evaluation of the results of vestibular
function tests in individuals who habitually wear spectacles.59 Furthermore, if a patient does show a change in
VOR gain in response to wearing spectacles, one can
infer that the patient has at least some capability to undergo adaptive VOR recalibration.
VOR adaptation can also be studied via prolonged
rotation of subjects during artificial manipulation of the
visual surround. One can use an optokinetic drum that
surrounds the subject and rotate it either in phasein the
same direction as chair rotationto produce a decrease in
VOR gain, or out of phaseopposite the direction of
chair rotationto produce an increase in VOR gain. If the
amplitude of drum rotation is exactly equal to that of the
chair, the required VOR gain would be 0.0 for in-phase
viewing (so-called x0 viewing) and 2.0 for out-of-phase
viewing (so-called x2 viewing). The usual duration for
VOR training in these types of paradigms is an hour or
two, although VOR adaptation can probably be detected
within minutes of the onset of the change in the relationship between the visual and vestibular stimuli.60
A potentially important practical application of
vestibular rehabilitation comes from a recent novel finding related to consolidation in a short-term learning
paradigm used to stimulate adaptation of saccade amplitude. Frequent but short (a minute or so) rest periods during about 20 or 30 minutes of training were found to
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considerably enhance the rate and degree of adaptation.61

Potentially, then, a similar strategy might be attempted
with vestibular rehabilitation exercises.
Imagination and Effort of Spatial

Localization in Vestibular Adaptation
Finally, we note that ones imagination can be a potent
substitute for the real stimulus to VOR adaptation
motion of images on the retina during head rotation.
Melvill Jones and colleagues62 have shown that the VOR
of normal subjects can be adaptively modified (as measured in darkness and tested under the same mental set)
with just a few hours of imagining a visual stimulus moving in such a way that it would normally create slip of
images on the retina if it were actually visible. Indeed,
simply imagining body rotation can lead to compensatory slow-phase eye movements.63 Along these lines,
Eggers and associates64 have shown that just paying
attention to, without even looking at, the new location of
a target after a head rotation (i.e., using a position rather
than a retinal image motion error) leads to adaptive modification of the VOR.
Thus, what are usually called psychological factorsmotivation, attention, effort, and interestmay
actually play a more specific role in promoting adaptive
recovery than originally believed. The habit of a professional athletesdownhill skiers or ice skaters, for exampleof going through their routes or routines in their
minds as they prepare for actual events is probably an
example of using this cognitive capability to create an
internal model of the external environment (and the sensory consequences of moving within it) in which to
rehearse and improve motor performance.
Similar types of paradigms, in which the motion of
the visual surround is artificially manipulated with
respect to the motion of the head, have been used to
induce an alteration in the phase (timing) of the angular or
translational VOR65,66 or a change in the direction of the
VOR, so-called cross-axis plasticity.6769 In the latter paradigm, the visual surround is rotated around an axis
orthogonal to that of rotation of the head. This cross-axis
plasticity accords with electrophysiological evidence that
secondary neurons in the vestibular nucleus receive inputs
from one, two, or all three pairs of semicircular canals.70
Similar considerations account for the recovery in
VOR function when just one single semicircular canal is
plugged. The spatial tuning of information from an intact
canal (as a function of the plane of rotation) is readjusted
centrally so that it can provide a better signal of rotation
in a plane close to that of the plugged canal. Furthermore,
25
during cross-axis training, neurons in the vestibular

nuclei that are normally maximally sensitive to pitch axis
(vertical) stimulation increase their sensitivity to yaw axis
(horizontal) rotation,71 providing a neurophysiological
substrate for the change in direction of the VOR. The torsional VOR undergoes similar adaptive adjustments, as
do the vertical and horizontal VOR, although the mechanisms may be somewhat distinct.7275
A clinical consequence of a disturbance of crossaxis VOR plasticity is the occurrence of perverted nystagmusnystagmus in which the slow phases are in the
wrong direction relative to that of the stimulus. A strong
vertical nystagmus induced during either caloric stimulation or vibration of the mastoid bone is such an example,
and it usually occurs with central vestibular lesions.
The linear (translational) VOR, and other otolithocular reflexes, are also under adaptive control.66,76,77 In
the absence of canal-driven responses, otolith-ocular
responses to a changing gravity vector (which can occur
when rotation is around an axis tilted away from the vertical) are potentiated, leading to improved stabilization of
gaze during off-axis rotation of the head.78 The vestibular
responses to translation, and their potential for rehabilitation in vestibular patients, have been largely neglected in
clinical practice.
These short-term adaptation experiments probably
test only one particular type of vestibular adaptation,
because the learned response is not sustained in the
absence of continued stimulation. There is also a longterm adaptive process, taking days to weeks rather than
just minutes to hours, that gradually supervenes and leads
to a more enduring, resilient adaptive change. Thus, one
must be cautious when extrapolating results from these
short-term experiments to the long-term problems of
patients adapting to chronic vestibular deficits.
Adaptive capabilities have been investigated in
elderly subjects79; at higher frequencies (above about
0.75 Hz), the ability of these subjects to increase VOR
gain adaptively is significantly diminished. Because the
angular VOR is most needed to compensate for the highfrequency components of head rotation, a loss of adaptive
capability in elderly patients could account for the more
devastating and persistent symptoms in such patients after
a vestibular loss. Furthermore, with aging, patients with
deficient vestibular responses lose some ability to substitute corrective saccades for hypometric slow phases.80,81
Potentiation of the cervico-ocular reflex (COR) can
be well demonstrated in patients with bilateral loss of
labyrinthine function.44,45,47 Even normal individuals can
be shown to undergo modification of the COR in shortterm VOR adaptation paradigms.54,82 The role of the
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COR in compensation for unilateral vestibular loss is not

clear, although in an occasional patient the reflex may be
potentiated and may even be subject to improvement with
vestibular exercises.83
circumstances in which the patient usually becomes

symptomatic?
Context Specificity
Neurophysiologic Substrate of
Vestibulo-ocular Reflex Adaptation
One finding that may have important clinical implications

is the demonstration that VOR gain adaptation is contextspecific.69 Baker and associates84 showed that cats can be
trained to adaptively change the gain of their canalinduced (rotational) VOR in one way when the head is
oriented with respect to gravity in one particular position
(e.g., right ear down), and in another way when the head
is oriented in the opposite position with respect to gravity
(e.g., left ear down). Thus, even though the pattern of
canal activation is the same, the pattern of static otolith
inputs determines or gates different central responses to
an identical input from the semicircular canals.
VOR adaptation in humans also depends on the static orientation of the head in which the training of the
canal-induced VOR took place.85,86 Similar results have
been shown for the translational VOR.87 Shelhamer and
coworkers88 have also shown that adaptation of the gain of
the VOR can be made to depend on the position of the eye
in the orbit in which the training took place. In their paradigm, the horizontal VOR gain was trained to depend on
the vertical position of the eye in the orbit. Such a capability would be particularly useful for individuals who
wear a bifocal spectacle correction (although clearly, context-specific adaptation of the VOR did not evolve to meet
the needs of the spectacle-wearing human, because glasses are a relatively new arrival to the human experience).
When viewing through the lower part of the lenses, which
have the stronger prescription needed to overcome the
effects of presbyopia, subjects require a higher VOR gain
during head rotation than when viewing through the top
part of the spectacles.
Potentially, then, simply putting ones glasses on (or
perhaps just the frames, or putting on the glasses in complete darkness) might be enough of a cue to generate a
different vestibular response. Just such an effect of spectacles has been shown for another type of ocular motor
adaptation in which the eyes are required to rotate by different amounts when the two eyes have different spectacle corrections.89
Thus, context specificity of vestibular learning,
which potentially can be derived from a variety of cues,
both vestibular and non-vestibular, must be considered in
the design of programs of physical therapy: Will the particular training paradigm that is being used to promote
vestibular compensation transfer to the more natural
Where might the structures be that elaborate various types

of vestibular plasticity within the central nervous system?
First, one should remember that one must distinguish
between static and dynamic VOR adaptation. The cerebellum, especially the flocculus, seems to play an important role in the acquisition of adaptive changes in VOR
gain.9096 The flocculus also plays a role in recovery of
function after unilateral labyrinthine loss. Although
restoration of relatively small degrees of imbalance
between the vestibular nuclei can probably take place
independently of the flocculus,97 large amounts of spontaneous nystagmus and the recovery of amplitude and symmetry of gain during head movement probably require the
flocculus.98101 Some of this effect may occur through the
vestibular commissural pathway, which likely mediates
some aspects of recovery of static balance and dynamic
function.102 Furthermore, potentiation of the COR as an
adaptive strategy during head rotation is lost in patients
with bilateral vestibular loss who also have cerebellar
atrophy, implying a role for the cerebellum in this aspect
of vestibular adaptation.45
The exact sites and specific mechanisms underlying these types of vestibular learning are still unsettled;
evidence exists for multiple mechanisms and both a
cerebellar cortex and a brainstem (vestibular nuclei)
locus.94,95,101,103106 The VOR pathway has been parsed
into linear and nonlinear (velocity-dependent) components, and depending on the pattern of head motion during learning, one or both are engaged.107,108 There may
be differences in mechanisms that underlie adaptive
increases versus decreases in the amplitude of the VOR
and context-specific versus generalized VOR adaptation.95 Long-term, more hard-wired changes in the
VOR may take place in the vestibular nuclei themselves94
but again, are subject to higher-level control, which can
gate particular responses according to prevailing circumstances and needs. As emphasized earlier, there certainly
are multiple mechanisms and multiple time frames even
for something as simple and fundamental as adaptation
of the gain of the VOR.
Many neurotransmitters and neuropeptides have
been implicated in the process of vestibular adaptation.3,109118 In the vestibulocerebellum, nitric oxide,
NMDA receptors, acetylcholine, and catecholamines
appear to be important.3 Long-term depression (LTD) has
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been implicated in the cerebellar contribution to VOR

adaptation, and long-term potentiation (LTP) may also be
important.104,119122 Specific transmitters may relate to
the direction (increase versus decrease) or the frequency
spectra (high versus low) of a particular adaptive response.123,124 The exact role of these processes and of
specific neurotransmitters in vestibular compensation has
not yet been settled. The challenge remains as to how to
apply the results of the many studies of vestibular compensation in experimental animals to human patients with
vestibular disturbances.125
Still unclear are the substrates for the variety of
strategies and cognitive influences (e.g., context and
imagination, and effort of spatial localization) that are
incorporated as part of the compensatory response to
vestibular damage. A possible anatomical substrate for
such higher-level influences may reside in the extensive
reciprocal connections between the vestibular nuclei and
the cerebral cortex.126 Indeed, a number of areas in the
cerebral hemispheres are activated with vestibular stimulation.127131 On the other hand, it has been shown that
when a rabbit is exposed to sustained sinusoidal oscillation of the head, some climbing fibers in the nodulus of
the rabbit discharge in a sinusoidal fashion after the animal stops rotating.132 This finding is compatible with the
idea that the cerebellum can learn patterns of vestibular
stimulation and generate them even after the actual stimulus has ceased.
Summary
This discussion has emphasized that consideration and
knowledge of the adaptive capabilities of the brain are
essential to the diagnosis and management of patients
with vestibular disorders. The proper interpretation of the
symptoms and signs shown by patients with vestibular
dysfunction, the design of an optimal plan of physical
therapy to promote recovery from vestibular dysfunction,
and an objective analysis of any salutary effects of physical therapy cannot be accomplished unless constant
attention is paid to the actions of the variety of compensatory mechanisms that are used to cope with abnormal
vestibular function. Furthermore, the discussion has
reemphasized that compensation is far more than a simple
readjustment of low-level, largely subconscious reflexes.
The roles of anticipation and prediction, altered motor
strategies, sensory substitution, and cognitive factors
related to mental set, psychological effort, imagination,
and context are all important in the adaptive process and
must be considered in the planning of physical therapy.2
We are only now beginning to identify the wide repertoire of compensatory mechanisms available. Indeed, the
27
remarkable adaptive capabilities of the vestibular system

may lend itself to a successful response to a vestibular
prosthesis, much like the success story of the cochlear
prosthesis.133 The challenge now is for us to learn to marshal these adaptive mechanisms to best promote recovery
in our patients.
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3
Role of the Vestibular
System in Postural
Control
One of the most important tasks of the human postural

control system is that of balancing the body over the
small base of support provided by the feet. As a sensor
of gravity, the vestibular system is one of the nervous
systems most important tools to control posture. The
vestibular system is both a sensory system and a motor
system. As a sensory system, the vestibular system provides the central nervous system (CNS) with information
about the position and motion of the head and the direction of gravity. The CNS uses this information, together
with information from other sensory systems, to construct a picture (sometimes called a model or schema
or an internal representation or map) of the position
and movement of the entire body and the surrounding
environment. In addition to providing sensory information, the vestibular system also contributes directly to
motor control. The CNS uses descending motor pathways, which receive vestibular and other types of information, to control static head and body positions and to
coordinate postural movements.
Because the vestibular system is both a sensory system and a motor system, it plays many different roles in
postural control. This chapter explores the four most
important roles (Fig. 3.1). First is a discussion of the role
of the vestibular system in the sensation and perception
of position and motion. Second, its role in orienting the
head and body to vertical, including the static alignment
of the head and body and the selection of appropriate sensory cues for postural orientation in different sensory
32
environments, is dealt with. These first two roles are primarily sensory in nature; the vestibular system provides
the sensory information about head motion and position
and the direction of gravity that the CNS needs to carry
out these functions. Third is a discussion of the role of the
vestibular system in controlling the position of the bodys
center of mass, for both static positions and dynamic
movements. Fourth is a description of the vestibular systems role in stabilizing the head during postural movements. These latter two roles involve motor aspects of the
vestibular system.
Figure 3.1 Four important roles of the vestibular system in

postural control interact with other sensory and motor systems
to accomplish tasks like maintaining equilibrium and body alignment on an unstable surface.
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Chapter 3 ROLE OF THE VESTIBULAR SYSTEM IN POSTURAL CONTROL
Sensing and Perceiving

Position and Motion
The vestibular system provides information about the
movement of the head and its position with respect to
gravity and other inertial forces (like those generated by
moving vehicles). Therefore, this system contributes
important information to the sensation and perception of
the motion and position of the body as a whole. The
vestibular system consists of two types of motion sensors, the semicircular canals (SCCs) and the otoliths. The
SCCs sense rotational movement of the head. Rotational
movements in the sagittal and frontal plane are detected
by the vertical (anterior and posterior) SCCs. The horizontal canals are sensitive to motions in the horizontal
plane. The largest head motions during quiet stance
and walking or running occur in the sagittal (anteriorposterior) plane. Frontal plane (side-to-side) and horizontal plane (as if to shake the head no) movements
also occur, but they are smaller.1 Information from all
three sets of SCCs contributes directly to the perception
of self-motion.
In contrast to the SCCs, which sense rotational
motion, the otoliths sense linear accelerations. Vertical
linear accelerations of the head, like the head translations
generated during deep knee bends, are sensed by the saccular otoliths. Horizontal linear accelerations, like the
translations of the head generated during walking forward, are sensed by the utricular otoliths. The otolith
organs also provide information about the direction of
gravity. Gravity, which is also a linear acceleration, produces an otolith signal that changes systematically as the
head is tilted. The CNS uses this signal to determine head
alignment with respect to gravitational vertical.
As important as good vestibular function is for
determining the position and motion of the body, vestibular information by itself is not enough. First, the vestibular system can provide information only about head
movements and not about the position or movement of
any of the other body segments. Second, vestibular information about head movements can be ambiguous. A signal from the vertical canals indicating anterior head
rotation can be produced by the head flexing on the neck
or by the body flexing at the waist, but the vestibular system alone cannot distinguish between the two. In addition to these problems, the vestibular system is not
equally sensitive to the entire range of possible head
movements. The SCCs are most sensitive to faster head
movements, such as those that occur at heel strike during
gait or as a result of a sudden trip or slip.25 The canals
respond poorly to slower head movements, such as the
slow drifting movements that occur during quiet stance.
33
The otolith organs can signal tilts with respect to gravity

and slow, drifting movements, but only when these
movements are linear, rather than rotational.69
In order to clarify the ambiguities inherent in
vestibular information and to get good sensory information about the entire range of possible head and body
movements, the CNS relies on information from all available sensory systems. Each sensory system contributes a
different kind of important information about body position and motion to the CNS, and each sensory system is
most sensitive to particular types of motion.1015 The
visual system signals the position and movement of the
head with respect to surrounding objects. The visual system can provide the CNS with the information necessary
to determine whether a signal from the otoliths corresponds to a tilt with respect to gravity or a linear translation of the head. The visual system also provides
information about the direction of vertical, because walls
and door frames are typically aligned vertically, parallel
to gravity. The visual system provides good information
about slow movements or static tilts of the head with
respect to the visual environment.12,16,17
In contrast to vision, the somatosensory system provides information about the position and motion of the
body with respect to its support surface and about the
position and motion of body segments with respect to one
another. For example, somatosensory information can
help the CNS distinguish whether a head rotation signal
from the vertical canals is due to motion of the head on
the neck or due to flexion of the body at the waist. The
somatosensory system can also provide information
about how body segments are aligned with respect to
each other and the support surface, through sending
information about muscle stretch and joint position at the
ankle or more proximal joints. The somatosensory system is particularly sensitive to fast movements, like those
generated by sudden perturbations of joint positions.18
The contribution of each sensory system to the sensation of self-motion has been demonstrated experimentally through stimulation of the individual sensory
systems. Electrical stimulation of the vestibular nerve by
means of current passed through electrodes placed on the
skin over the mastoid bone produces sensations of selfmotion or tilt in humans by mimicking the vestibular signals that would be generated by an actual head
movement.19,20 Similar results can be achieved by presenting subjects with large moving visual scenes (Fig.
3.2).12,17,2123 When the head is moved, the image of the
entire visual scene moves in the opposite direction. When
subjects watch a large moving visual scene, their CNSs
often misinterpret the visual stimulus, and the observers
feel self-motion in the opposite direction. Vibrating ten-
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Figure 3.2 Visual information can be used to determine how

the body is moving. In this and all subsequent stick figures, the
asterisk corresponds to the position of the bodys center of
mass, which is located about 2 cm in front of the spinal column
at the level of the pelvis (A). As the body sways forward (B),
visual objects placed in front of the subject loom toward the
subject. If visual objects are moved toward a stationary subject
(C), the subject can experience an illusion of forward sway
(dotted arrow), especially in cases of vestibular loss.
dons in the neck and legs, which stimulate somatosensory motion detectors, can also give rise to sensations of
body motion.10,24,25
The perception of self-motion and orientation
depends on more than sensory cues alone, however. What
the subject predicts and knows about the sensory environment or what the subject has experienced in the past
(sometimes called the subjects central set) can contribute powerfully to how sensory signals are interpreted.26 For example, imagine two cars stopped next to each
other at a traffic light. If one car moves forward slightly,
the driver of the second car may step on the brake, mistakenly believing that his car has rolled backward. This
illusion is very powerful, because cars often do roll backward when stopped, as most drivers know. The central
set of the driver is to expect the car to move, and so the
driver accepts the visual motion cue, despite the fact that
both his vestibular system and somatosensory system
indicate that he has not moved. This phenomenon has also
been demonstrated in the laboratory. Subjects seated in a
stationary chair who observe a large moving visual scene
may perceive either chair motion or visual scene motion,
depending on whether they are asked to concentrate on
visual or somatosensory cues.27 This observation is particularly interesting because these illusions of motion
occur despite the fact that in either case the vestibular system is signaling lack of motion.
Given the vestibular systems important role in the
sensation of self-motion, it is not surprising that patients
with vestibular disorders often have abnormal percep-
tions of self-motion. Patients may report that they feel

themselves spinning or rocking or that the room appears
to spin around them. These sensations may be associated
with particular head positions, depending on the disorder.
Patients may adopt leaning postures while insisting that
they feel themselves aligned vertically, indicating that
self-motion perception and automatic postural responses
may be independent of each other to some extent.
Patients with profound losses of vestibular function have
difficulty determining how they are moving in environments that lack good visual and somatosensory orientation cues, such as while walking at night on a sandy
beach or while swimming in muddy water.
In summary, the vestibular system, along with other
sensory systems, provides the CNS with the information
about body motion and position with respect to vertical,
which is critical for sensing and perceiving self-motion.
No sensory system alone provides all the necessary
information for sensing motion of the whole body; each
sensory system contributes different and necessary information. The next section explores how sensory information is used by the CNS to align the body to vertical and
how the CNS selects sensory information for body orientation in different environments.
Orienting the Body to Vertical

Keeping the body properly aligned parallel to gravity and
directly over the feet is one of the most important goals of
the postural control system. The vestibular system, which
can detect the direction of gravity, plays a very important
role in maintaining the orientation of the whole body to
vertical. Because the term orientation also includes the
alignment of body segments other than the head with
respect to one another and with respect to vertical, other
sensory systems contribute to body orientation as well.
This section discusses the role of the vestibular system in
the orientation of the head and body to vertical and how
the nervous system selects appropriate sensory information for orientation in different sensory environments.
Postural Alignment
Spinal radiographs and fluoroscopy have revealed that
most vertebrates hold the vertical spine parallel to gravitational vertical.28 The vestibular system, which signals
the direction of gravity, plays an important, but not exclusive, role in the alignment of head and trunk in animals.
A unilateral vestibular lesion in animals results in head
and body tilts toward the lesioned side.2830 The amount
of asymmetrical posturing gradually diminishes over
time, and the return to normal postural alignment has
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been considered a sign of vestibular compensation.31 In

humans, the vestibular system also plays an important
role in the alignment of the head and body with respect to
gravity, although the effect of unilateral vestibular lesions
on postural alignment is more variable and more shortlived than in lower species.29,30,32 Humans with sudden
loss of vestibular function on one side can also show lateral flexion of the head to the side of the loss during the
acute phase of the lesion.31,32 However, within 6 months
to 1 year of total unilateral vestibular loss in humans, postural alignment and control can be indistinguishable from
that of normals.33 Bilateral loss of vestibular function
may be associated with a forward head position.34 Altered
postural alignment, sometimes associated with excessive
muscle tension and pain, especially in the neck, is a familiar problem for patients with vestibular dysfunction.35
In addition to head tilts, the entire body seems to
shift, temporarily, to the side of vestibular loss. Patients
with unilateral vestibular lesions shift their weight to the
side of the lesion and then regain normal weight distribution over the course of several weeks.36 Fukuda37 developed a stepping-in-place test to document the asymmetry
and gradual compensation that follow unilateral vestibular loss. In this test, subjects attempt to step in place with
eyes closed; patients with unilateral loss typically rotate
slowly toward the side of the lesion. Patients with bilateral vestibular loss have also been reported to shift their
weight forward or backward.38
Another way to investigate the role of the vestibular
system in aligning the body to gravity is to stimulate
the vestibular system electrically by delivering low-level
(2 mA), direct currents through electrodes on the mastoid processes, with an anode placed on one mastoid and
a cathode placed on the other.19,20,3946 Cathodal currents
increase the tonic firing in the vestibular nerve, and
anodal currents decrease the firing rate.47 With the head
facing forward, sway induced by galvanic current is lateral and toward the anode, because the galvanic current
simulates the vestibular nerve signal that would result if
the body were tilted toward the side of the cathode.
Subjects sway toward the anode to correct the apparent
tilt induced by the galvanic stimulation. Galvanic stimulation reliably results in tonic head tilts and weight shifts
in normal humans.19,20,3946 These responses are typically
absent or abnormal, however, in patients with vestibular
nerve sections, although they can also be normal in
patients with loss of peripheral hair cell receptors, a finding that confirms that the galvanic current directly stimulates the vestibular nerve.48,49 Postural responses to
electrical stimulation can be enhanced when subjects
stand on a sway-referenced surface that provides poor
somatosensory feedback for orientation or when galvanic
35
current is delivered during responses to a platform movement.46,48 These findings suggest that the role of the
vestibular system in automatic postural alignment is larger when somatosensory information for postural control
is unreliable.19
Studies of postural responses to electrical stimulation of the vestibular system also show that the CNS
takes both vestibular and somatosensory information into
account when organizing these responses. The direction
of body sway and the corresponding muscle activations
induced by galvanic stimulation are modulated by the
position of the head on the trunk. With the head facing
forward, galvanically induced sway is lateral and toward
the anode. If the head is turned on the trunk so that the
ear with the anode is turned forward, the galvanically
induced sway is forward.19 This observation suggests that
information about head position from neck receptors is
combined with vestibular information to trigger an
appropriate postural response regardless of head position
with respect to the body.19 When the head and lower
limbs are aligned forward, but the trunk is aligned differently, postural responses to galvanic stimulation are
appropriate to alignment of the head and feet regardless
of trunk alignment.50 Thus, equilibrium control centers
use information about body position and motion derived
from proprioceptive afferents from many body segments,
not just the neck, in combination with vestibular information to produce an accurate picture of body sway and
appropriate postural responses.51
One hypothetical explanation for the altered postural alignment of patients with vestibular deficits is that the
vestibular lesion has resulted in an altered internal map of
body orientation in space. Gurfinkel and colleagues13
have suggested that the CNS constructs a model or internal map of the direction of gravity on the basis of vestibular and other sensory information, and then aligns the
body according to this map. This hypothetical explanation could also account for the body realignments that
occur with galvanic stimulation. The galvanic current,
which simulates the pattern of vestibular nerve firing that
results when the body is tilted toward the cathode, may
lead to a change of the CNSs estimate of the position of
gravitythat is, that it has shifted toward the anode.
Subjects sway toward the anode to realign their bodies to
the new estimate of the position of gravity. The tonic
body and/or head misalignment in a patient with vestibular disorders may also occur from a faulty internal map
based on abnormal information from the malfunctioning
vestibular system.
Vestibular information also contributes to another
important internal map, the map of stability limits, and
vestibular pathology may lead to defects in this internal
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map as well. A human standing with feet planted on the

ground may sway forward or backward a small amount
(about 4 degrees backward and about 8 degrees forward)
without losing balance and taking a step. The boundaries
of the area over which an individual may safely sway are
called the stability limits.52 The actual stability limits for
any individual in any situation are determined by biomechanical constraints, such as the firmness and size of
the base of support, and by neuromuscular constraints,
such as strength and swiftness of muscle responses.53
Vestibular disorder might result in a poor match between
a patients actual stability limits and the internal map of
those limits. The internal map could be smaller or larger
than the actual stability limits, or the map could be poorly aligned with respect to gravity. As a result, patients
may align themselves near the edges of their actual stability limits. Because visual and somatosensory information may substitute for vestibular information, alignment
may be normal in patients with well-compensated
vestibular losses but may be very abnormal in patients
with deficits in multiple sensory systems. Figure 3.3
Figure 3.3 Elderly woman with loss of vestibular function,

peripheral neuropathy, and cataracts who aligns herself near
her backward limits of stability. In this photograph, she is standing on a compliant foam pad, which reduces her ability to use
somatosensory cues for orientation.
shows a patient with bilateral loss of vestibular function,

peripheral neuropathy, and cataracts, who aligns herself
near her backward limits of stability in stance.
Weighting Sensory Information

The studies of abnormal body alignment resulting from
vestibular lesions show that the vestibular system plays
an important role in the orientation of the body in space.
The fact that normal alignment can be recovered with
time even after bilateral vestibular loss, however, also
argues that vestibular information is not the only source
of sensory information that can be used for orientation.
Visual and proprioceptive information also contribute to
body alignment, as experiments with large, moving visual surrounds and tendon vibrations have shown.17,2124
Whether and how vestibular or other sensory information
is used for orientation depends, in part, on the sensory
information available in the environment.
Under normal conditions (i.e., a stable support surface and a well-lit visual environment), orientation information from all three sensory modalities is available and
is congruent; that is, all three modalities yield similar
estimates of body position and motion. Although a person
could theoretically rely equally upon vestibular, visual,
and somatosensory inputs for postural orientation, studies
now suggest that they rely primarily on somatosensory
information from the support surface in these conditions.54,55
There are, however, many environmental conditions
in which the sensory orientation references are not congruent. For example, when the support surface is compliant (like mud, sand, or a raft floating on water) or uneven
(like a ramp or rocky ground), the position of the ankle
joint and other somatosensory and proprioceptive information from the feet and legs may bear little relationship
to the orientation of the rest of the body; that is, the
bodys center of mass could be aligned well within the
stability limits despite large amounts of ankle motion
(Fig. 3.4). Under such circumstances, it is critical that the
nervous system be able to extract from the available sensory information the actual orientation of the body with
respect to gravity and the base of support, because failure
to align the bodys center of mass properly in a gravity
environment will almost certainly lead to a fall.
The relative dependence on, or weighting of, each
sensory system changes with changes in environmental
conditions.56 Peterka54 showed experimentally that sensory weighting of somatosensory. vestibular, and visual
information changes with postural orientation (Fig. 3.5).
For example, when blindfolded subjects were exposed to
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Figure 3.4 When subjects stand on a flat, firm support surface (A), ankle flexion corresponds to a forward body center of
mass (CoM) position. The position of the CoM is indicated with
an asterisk. When the support surface is compliant or tilted (B),
however, ankle flexion can correspond to an upright or even
backward body CoM position. Thus, vestibular information is
more important for postural control on the unstable surface in
B than on the firm surface in A.
Figure 3.5 As the magnitude (RMS [Root Mean Squared])

of tilt of surface rotation increased, blindfolded healthy subjects
increased their relative weighting of, or dependence on,
vestibular inputs and decreased their dependence on
somatosensory input. (Adapted from Peterka, 2003.54)
surface oscillations of various amplitudes, healthy subjects tended to align themselves to the surface for very
small amplitudes of rotation but to orient their posture
more with respect to gravity with larger amplitudes of
rotation, as if relying more on vestibular information.
Peterka54 calculated that healthy subjects standing on a
firm surface with vision available normally rely 70% on
somatosensory information from the surface, 20% on
vestibular information, and 10% on vision for postural
orientation. As surface oscillations increased from 1 to 8
degrees, however, he found a change in sensory weighting so that subjects relied 70% on vestibular information,
20% on vision, and only 10% on somatosensory information (Fig. 3.5). Because the human nervous system
normally depends primarily on somatosensory information for postural orientation, it can be difficult to identify
postural problems in patients with vestibular disorders
when they are standing on a firm support surface, even
though they may have severe balance problems on an
unstable surface.
The way in which the nervous system weights sensory information for body orientation in different environments can be measured using a Sensory Organization
Testing paradigm developed by Nashner and colleagues5759 and adapted to use in the clinic by ShumwayCook and Horak.60 In this paradigm, the subject is asked
to stand quietly in each of six different sensory environ-
ments, and the subjects postural sway is measured each

time. In the first environment, the subjects support surface and visual surround are fixed to the earth, and the
subject stands with eyes open; the second is the same, but
subject stands with eyes closed. This part of the test is
equivalent to the standard Romberg test used in clinical
evaluations of standing balance.
In the remaining four environments, either the support surface, the visual surround, or both are moved in
proportion to the subjects postural sway. This type of
stimulation is referred to as sway-referencing (Fig. 3.6).
Sway-referencing the support surface and/or the visual
surround can disrupt the normal sensory feedback relationships between the different sensory systems. For
example, when the support surface is sway-referenced,
somatosensory information from the ankle joints correlates poorly with the position of the body. Support surface sway-referencing can be mimicked by placing the
subject on compliant foam, and visual sway-referencing
can be mimicked by placing a striped dome over the subjects head.60 Vestibular information gives a more accurate estimate of body position and motion under these
circumstances, and the CNS should rely more heavily on
vestibular information for orientation.
Figure 3.7 shows how normal subjects react when
exposed to such altered sensory environments. Normal
subjects sway a small amount even under normal cir-
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Figure 3.6 This figure shows how sway-referencing the

subjects support surface and visual surround interferes with
the ability to use somatosensory and visual information to orient
the body to vertical. (A) The subject stands aligned to vertical,
and the center of mass projects directly over the foot. (B) The
subject has swayed forward, resulting in a toe-down rotation of
the platform and a forward rotation of the visual surround.
Although the ankle angle and the position of the head with
respect to the visual surround have not changed, the center of
mass is now in front of the foot, and the subject is in imminent
danger of a fall. Normal subjects can detect this forward sway
using vestibular information and avoid a fall, but patients with
vestibular losses have difficulty doing so.
cumstances (condition 1), and this sway may or may

not increase slightly when visual information is removed
by eye closure (condition 2).61 Although sway may
increase slightly when either the visual surround alone
(condition 3) or the support surface (condition 4) alone is
sway-referenced, subjects are still able to select useful
sensory information from the sources available and maintain body orientation with respect to gravity. Even
when both the support surface is sway-referenced and
visual information is eliminated by eye closure (condition 5) or altered by sway-referencing (condition 6), normal subjects are able to use vestibular cues to orient the
body, albeit somewhat less efficiently. This is not surprising; conditions 5 and 6 are similar to walking on
uneven surfaces in poorly lit environments (Fig. 3.8),
swimming in murky water, or standing in the cabin of a
shipall tasks that normal subjects can perform without
great difficulty.
Patients with clinically diagnosed vestibular disorders have also been tested with use of the same paradigm.5760 One of the most important findings of these
studies is that not all patients with vestibular disorders
respond in the same way. Patients identified in Figure 3.6
as having a vestibular loss pattern lose all sense of orientation and fall in conditions 5 and 6, in which orientation information from both the surface and vision have
been altered and the subject is forced to rely primarily on
vestibular information. One should note, however, that
these patients can perform as well as normal subjects in
conditions 1 through 4, in which at least one unaltered
source of sensory information was available to them. In
conditions 5 and 6, however, patients with vestibular loss
lose balance when forced to rely on vestibular information, as if that information is unavailable. This pattern of
results is typical of patients with long-standing, wellcompensated bilateral losses of peripheral vestibular
function (although this pattern can also be seen in any
patient whose nervous system does not use vestibular
information for postural orientation, even if he or she
may have some peripheral vestibular function). The fact
that patients with well-compensated vestibular losses can
use either visual or somatosensory information to orient
the body limits the sensitivity and specificity of the standard Romberg test (equivalent to conditions 1 and 2) as a
test of vestibular function.62
In contrast to the patients with vestibular loss,
patients who have uncompensated vestibular disorders
may show increased sway in conditions 3 through 6 (see
the sensory selection pattern in Fig. 3.6). That is, they
have difficulty with orientation whenever somatosensory
or visual information is altered or is not available. Why
some patients with vestibular disorders have difficulty
orienting in condition 3 or 4in which has normal
somatosensory or visual information, respectively, is normalis not clear. Their nervous systems appear to have
oriented their bodies to visual and support surface references that correspond poorly to gravity when these are
sway-referenced. Investigators have hypothesized that
even healthy subjects vary in how much they weigh
(rely more heavily on) sensory information from a particular source, such as vision or somatosensation,15,27
particularly when vestibular cues to orientation are unreliable. Incomplete CNS adaptation to a vestibular lesion
may also be a factor. This pattern of results is typical of
patients in the acute stages of vestibular lesions.63
However, as patients recover and the CNS adapts to
the vestibular loss, patients with profound bilateral
vestibular loss show the vestibular loss pattern, and many
patients with total unilateral vestibular loss eventually
return to normal sensory orientation for postural control.33 A surface dependent pattern, in which patients
show postural instability whenever the surface is swayreferenced, is common in patients with central cerebellar
disorders. 64,65
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Figure 3.8 Walking in a poorly lighted environment on an

uneven surface like a ramp puts demands on vestibular information for postural control.
Figure 3.7 Postural sway of healthy subjects (black bars)

and of patients with vestibular loss (gray bars) under six
sensory conditions. Peak anterior-posterior postural sway
(as a percentage of the maximum sway possible without a
fall) and standard errors are shown for patients with vestibular loss who demonstrate three types of sensory orientation
patterns: vestibular loss, sensory selection, and visually
dependent. Patients who show excessive sway only in
conditions 4, 5, and 6 are called surface dependent, but
data for that group are not shown. Stick figures along the
abscissa show the sensory information disrupted in each
condition: Blindfold indicates eyes closed, box around the
head indicates a sway-referenced visual surround, and
box around the feet indicates that the platform was swayreferenced.
Some patients who have distorted but not absent

vestibular function such as acute hydrops (see Chapter 6),
which alters but does not eliminate vestibular input, show
a visually dependent pattern of sensory organization.58
These patients demonstrate excessive sway whenever the
visual surround is sway-referenced but normal sway
when their eyes are closed. It is as if the nervous system
relies on visual information whenever the eyes are open,
even when vision is not providing accurate information
about body sway. However, when their eyes are closed,
such patients are able to rely on surface information on a
firm surface and upon vestibular information when standing on a sway-referenced surface.
In summary, these studies show that vestibular
information for body orientation is most important in
environments that lack good somatosensory or visual
cues for orientation. Patients attempting to rely on faulty
or missing vestibular information in these environments
may align themselves poorly and fall. However, they may
also choose another source of orientation information,
regardless of its usefulness, when vestibular information
is bad or missing. Figure 3.9A shows a healthy child who
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maintains a normal orientation with respect to gravitational vertical despite standing on a tilted surface. Figure
3.9B shows a child with abnormal vestibular function
who appears to rely most heavily on surface information
for orientation; he maintains a perpendicular orientation
to his tilted support surface. If the support surface is
orthogonal with respect to gravity, this strategy may work
fairly well. However, when the support surface is tilted,
as it is in Figure 3.9, this strategy works poorly.
Although the subject shown in Figure 3.9B chooses
somatosensory information for orientation, other patients
with vestibular disorders behave as if they rely most
heavily on vision for orientation and sway or fall when
attempting to stand near large moving objects (like buses
or cars). These patients appear to misinterpret the movement of external objects as self-motion in the opposite
direction. As a result, they may throw themselves into
disequilibrium as they attempt to maintain a constant orientation with reference to the moving visual object. Thus,
patients with vestibular disorders may align themselves
either with a faulty vestibular estimate of the direction of
gravity or with an estimate of the direction of gravity
from another sensory system.
Controlling Center of Body Mass

The previous sections described how the vestibular system detects the position and motion of the head and how
this sensory information is used for postural orientation.
This section describes how motor output from the ves-
tibular system contributes to static body positions and

dynamic postural movements, which help subserve the
postural goal of maintaining equilibrium or controlling
the center of body mass within its limits of stability.
We know from anatomic studies that motor output
pathways leave the central vestibular nuclei and descend
in the spinal cord, where they terminate on the neurons
that activate neck, trunk, and limb muscles. However, the
functional significance of the descending vestibular system for the control of orientation and equilibrium in alert,
intact humans and animals is still poorly understood.
Nevertheless, there is evidence that vestibular signals
probably play a variety of roles, including stabilizing the
head and trunk in space, scaling postural responses, and
contributing to the selection of appropriate postural
strategies for the environmental conditions.
Orientation and equilibrium represent two distinct
postural goals. In order to accomplish some tasks, greater
priority must be placed on achieving a specific postural
orientation, at the cost of postural equilibrium. For example, an experienced soccer or volleyball player may make
contact with a ball even though making contact requires
falling to the ground. Other tasks require equilibrium at
the cost of postural orientation. For example, balancing
across a wire may require rapid hip flexions and extensions to maintain equilibrium. In this task, trunk orientation with respect to vertical is sacrificed to achieve the
goal of equilibrium. The way in which the CNS achieves
the trade-off between control of orientation and control
of equilibrium in postural tasks is not well understood.
Both static positions and dynamic movements require a
Figure 3.9 (A) Child with normal

vestibular function orienting the head
and body with respect to gravity while
the surface is tipped and the eyes are
closed. (B) Child with absence of vestibular function orienting the head and
body with respect to the tipped surface
while the eyes are closed.
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system that prioritizes behavioral goals and uses all the

sensory information available to effectively and efficiently control the limbs and trunk to achieve both orientation
and equilibrium.
Role in Automatic Postural Responses

Triggering Automatic Postural Responses
If balance is disturbed in a standing human, limb muscles
are activated at short latencies to restore equilibrium.
Because the latencies of these muscle activations are
shorter than a voluntary reaction time, and because they
act to restore equilibrium, they are called automatic postural responses. Although the most important sensory
trigger for automatic postural responses is somatosensory inputs, vestibular inputs may also play a role. Both
cats and humans respond to sudden drops from a height
with short-latency ankle extensor activations (50100
msec in cats; 80200 msec in humans). These muscle
responses are present with eyes closed, so they can be
triggered without visual stimulation. These responses are
missing in patients with absence of vestibular function;
the responses remain, however, after procedures in animals that eliminate the canals but spare the otoliths. The
magnitude of the responses is also proportional to head
acceleration, all of which suggests a vestibular and, more
specifically, an otolith origin for fast, automatic postural
responses when surface and visual inputs are not available.61,6668
Quick displacements directly to the head during
stance also result in muscle activations in the neck
(45 msec), trunk (85 msec), thigh (90 msec), and ankle
(70 msec).63,69,70 These responses are absent in patients
with adult-onset vestibular loss, indicating a vestibular
origin. However, adults who lose vestibular function as
infants may show normal patterns of response to these
head perturbations, suggesting that cervicospinal
responses may adaptively compensate for the loss of
vestibular input early in life.69,70
Direct stimulation of the eighth cranial nerve by galvanic stimulation behind the ears can result in asymmetrical tonic activation of the vestibular system that is
associated with body tilt toward the side of vestibular
inhibition.71,72 Subjects tilt toward the side of the vestibular inhibition regardless of the direction their heads are
facing (sideways if the head is facing forward, and forward or backward if the head is rotated to the right or
left). This observation is consistent with an integration of
vestibular with somatosensory information so that the
vestibular signal in the head is interpreted with respect to
the position of the base of support. In fact, the muscles
41
activated in response to galvanic vestibular stimulation

also depend greatly on the somatosensory conditions.73,74
In subjects who are freely standing, ankle muscles are
activated first, but in those who are sitting, trunk muscles
are activated, and in those holding onto a stable support
with the hands, arm muscles are activated. The shortest
latency responses to direct vestibular stimulation are very
small and require very large currents and averaging across
many trials, whereas the medium-latency electromyographic (EMG) responses that result in measurable body
sway are very sensitive to somatosensory conditions.
Thus, direct vestibulospinal reflexes are very weak and do
not provide the functional effect on postural sway like the
longer latency vestibulospinal influences that are interpreted via a whole-body somatosensory map.72
Because limb muscles are activated in response to
sudden drops, perturbations in head position, and galvanic stimulation,4446 investigators have hypothesized that
vestibulospinal mechanisms may also play a role in automatic postural responses to stance perturbations induced
at the feet by movable platforms.75,76 Two types of platform perturbations have been used to test this hypothesis:
backward or forward translations, which induce forward
or backward sway, respectively, and platform rotations,
which induce ankle dorsiflexion or plantar flexion
(Fig. 3.10). Platform translations result in activation of the
stretched ankle muscles, which occur 80 to 100 msec after
the onset of platform movement and act to restore the
body to initial position. Vestibular inputs do not appear,
however, to contribute a great deal to these responses.
Human subjects and cats with complete absence of
vestibular function can respond to surface translations
using automatic postural responses with normal latencies
and patterns, even when vision is not present.34,57,7779
Proprioceptive information from stretched muscles
appears to be sufficient for recovery from platform translations. This conclusion is supported by the finding that
automatic postural responses to surface translations are
delayed when proprioceptive inputs are disrupted by
sway-referencing of the surface or eliminated with pressure cuffs at the thigh or in peripheral neuropathy.8082
Finally, relatively large head accelerations are required to
produce relatively weak responses in the limbs, and the
head accelerations that occur in response to platform
translations are quite small.73,69,70 Therefore vestibulospinal responses probably do not play a large role in the
recovery of equilibrium following platform translations.
In contrast to responses to translations, responses
to platform rotations may rely much more heavily on
vestibular mechanisms. Platform rotations produce ankle
dorsiflexion or plantar flexion, stretching muscles in the
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a close interaction of vestibular and somatosensory information.86 This hypothesis is supported by studies showing
that the magnitude of responses to head perturbations
increases when subjects stand on compliant or moving
surfaces.70,83 Further, responses to peripheral vestibular
stimuli are stronger in cats suspended by hammocks than
in cats who support themselves on their legs and are stronger in patients with somatosensory loss due to peripheral
neuropathy than in healthy subjects.72 Cats suspended in
hammocks and patients with neuropathy have less access
to proprioceptive information about body position and are
thus more affected by vestibular stimulation.87
Selection of Postural Strategies

Figure 3.10 Platform translations and rotations. (A) Backward horizontal translation of the platform results in stretch of
ankle plantar flexors (solid) and forward sway of the body.
Medium latency activation of ankle plantar flexors and other
muscles restores equilibrium in response to backward platform translations. (B) However, toe-up rotation of the platform, which also results in stretch of ankle plantar flexors,
results in backward sway of the body. For toe-up platform
rotations, medium latency activation of the shortened ankle
dorsiflexors (hatched) restores equilibrium. The CNS relies
more heavily on vestibular information for postural control in
platform rotations.
lower leg, but do not produce corresponding forward or

backward body sway. Responses to platform rotations
consist of two parts. First to occur is a response in the
stretched ankle muscle at 70 to 100 msec, which is probably triggered by proprioceptive inputs69,75,76,8284 and
which could, if unopposed, actually destabilize the body.
Slightly later, a stabilizing response occurs in the shortened ankle muscle (at 100120 msec), and this response
is probably more dependent on vestibular and visual
inputs. In patients with bilateral or unilateral loss of the
vestibular function, this stabilizing response is reduced in
magnitude and delayed in latency.76 The ability to adaptively reduce the magnitude of the destabilizing response
to repeated surface tilts is impaired in some patients with
loss of vestibular function.57 The cause of this failure to
adapt could be either that vestibular information is
required to trigger the adaptive process or that patients
with absence of vestibular function become hypersensitive to proprioceptive information.85
These studies, like many others, suggest that (1) the
role of the vestibular system automatic postural responses
enlarges when proprioceptive information about body
sway is lacking or inaccurate and (2) accurate, efficient
recovery of equilibrium after stance perturbation requires
Not all postural tasks require the same type of movement

for the recovery of equilibrium, and different automatic
postural responses are triggered in different situations.
These different responses, which differ in muscle activation patterns, body movements, and joint forces, are
called postural control synergies or postural control
strategies.84 Two very different strategies for moving the
bodys center of mass without moving the feet have been
identified in previous studies: ankle strategy and hip strategy (Fig. 3.11).88 An ankle strategy is used by most subjects recovering from a postural disturbance such as a
horizontal translation of the support surface while standing on a firm, flat support surface. The body sways roughly like an inverted pendulum by exerting force around the
ankle joints. A hip strategy, which consists of rapid body
motions about the hip joints, is typically used on narrow
support surfaces (beams), on compliant or tilting support
surfaces (foam, tiltboards), when stance is narrow (onefoot standing or tandem stance), or when center of mass
position must be corrected quickly (i.e., when the perturbation velocity is high). There is evidence that these postural control strategies are centrally programmed and
can be combined according to biomechanical conditions,
subject expectations, and prior experience. For example,
normal subjects typically show a mixed ankle and hip
strategy when responding to a translation of a 10-cm
beam for the first time to translations of a flat surface for
the first time after responding to a series of beam trials,
or to intermediate or fast translations of a flat support
surface.9092
Vestibular information does not seem to be essential
for initiation or execution of a normal ankle strategy,
because subjects with complete absence of vestibular
function show normal kinematic and EMG patterns associated with an ankle strategy.34,79,91,92 This finding suggests that proprioceptive information from the body is
sufficient to produce normal ankle strategy responses. In
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Figure 3.11 Normal subject using an ankle strategy (A) and a hip strategy (B) to control postural
sway. Arrows at the hips show direction of corrective center of mass movement; arrows at the head
show direction of corrective head movement. The relationship between vestibular information and
somatosensory information is different for ankle and hip strategies. In A, recovery from forward sway
using ankle strategy, ankle extension corresponds to backward movement of the center of mass and
backward pitch of the head. In B, recovery using hip strategy, ankle extension and backward movement of the center of mass now correspond to forward movement of the head and trunk. (From
Horak, 1987.89)
contrast, some evidence suggests that patients with

vestibular loss have difficulty using hip strategy. Patients
with bilateral vestibular loss show poor performance in
tasks such as one-foot standing, heel-toe walking, and
beam balancing, all tasks requiring hip strategy for good
balance control.34,77,79,9395 There is also experimental evidence that signals from the vestibular system could
act as a trigger for some postural responses. Subjects
undergoing support surface translations show horizontal
and vertical head acceleration peaks that are above
threshold for the vestibular system at 40 to 60 msec
after the onset of a platform translation.91,92 Also, subjects with loss of somatosensory information from the
feet due to ankle ischemia, who presumably must
increase their reliance on the vestibular system, use a hip
strategy when an ankle strategy would be more efficient.77 All of these findings suggest a critical link
between the vestibular system and the use of hip strategy
to control posture.
However, evidence also suggests that the relationship between vestibular information and the use of hip
strategy is not simple. In a study reported by Runge and
associates,92 patients with bilateral vestibular loss were
tested using fast platform translations, and many of them
showed bursts of abdominal muscle activity and early hip
flexion torques similar to those in normal subjects, indicating that normal vestibular function is not necessary to
trigger hip strategy responses when subjects are standing
on a firm, flat surface. Why does vestibular information
seem to be critical for a hip strategy in some circumstances, but not others?
The answers to this question may lie both in the way
sensory information from the vestibular and somatosensory systems is interpreted and in the way motor activity
produces body movements in the different postural tasks.
The tasks requiring hip strategy in which subjects with
vestibular loss perform poorly all involve changes in the
support surfacethat is, in its compliance (for foam or
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tiltboards), in its size (beams), or in the way the body contacts the surface (beams, tandem stance, or stance on one
foot). Further, these situations involve changes in the way
forces generated at the ankle result in body movements;
torques generated at the ankle cannot be used effectively
to move the center of mass on short or compliant support
surfaces. In these situations, body movements (either selfgenerated or due to a perturbation) do not result in the
same somatosensory feedback as during normal bipedal
stance on a firm surface, nor will an ankle strategy, which
relies on generation of torque at the ankle joints, be very
effective in correcting balance after a perturbation. It may
be that in these special situations, normal subjects use
vestibular information to interpret the changes in
somatosensory information in order to produce an appropriately changed postural response. Patients with bilateral vestibular loss, who lack vestibular information, may
not be able to accomplish the reinterpretation in time to
prevent losses of balance when standing on compliant or
short support surfaces. Responses to fast translations on a
large, firm support surface, however, may not require
reinterpretations of somatosensory information or
changes in the way ankle torque can be used, possibly
explaining why patients with bilateral vestibular loss do
not show obvious abnormalities in this task.
Although patients with vestibular loss appear to be
able to initiate hip strategy responses to fast platform
translations, they take compensatory steps to maintain
balance in response to these faster translations more frequently than normal subjects.92 This finding suggests that
such patients do have some difficulty with fast translations despite their ability to initiate a hip strategy. The
fact that patients with bilateral vestibular loss tend to step
more often to correct balance when responding to fast
platform perturbations also suggests a further connection
between a failure of hip strategy and vestibular loss.
Although they may be able to initiate hip torques,
patients with vestibular loss may be unable to execute hip
strategy efficiently, and so may resort to stepping, because hip strategy may require efficient control of the
trunk and good stabilization of the head with respect to
gravity, which is likely to be faulty in patients lacking
vestibular information.
Whereas vestibular loss is associated with a failure
to use hip strategy in some conditions, some patients
with disorders of the vestibular system habitually use
hip movements to control center of mass position.34,58,96
These patients typically report vertigo and ataxia consistent with vestibular dysfunction and have histories consistent with vestibular disorder but often show normal
horizontal vestibulo-ocular reflex function during rotation
testing; these findings suggest that such patients have sus-
tained damage to the vestibular system, but have not lost

a significant amount of vestibular function.34,35,58,96,97
Preliminary results suggest that some patients with
vestibular loss who show hip sway use a coordinated pattern of active hip motions similar to the hip strategy seen
in normal subjects. Other patients appear to generate large
ankle forces, which result in hip sway because the patients
exert no control over their trunks. Coordination of head
and trunk motions are abnormal in both types of patients.
Several possible explanations for an overreliance on
hip sway in some patients with vestibular disorders are as
follows:
1. As a result of disease or damage, the vestibular
system in these patients may become hyperresponsive. The hyperresponsive vestibular system
may overestimate the velocity of head motion
signals during body sway, and the CNS may
respond to small perturbations as though they
were much bigger.
2. The vestibular dysfunction may impair the
patients ability to interpret somatosensory
input from feet, so they may perform similarly
to normal subjects with acute somatosensory
loss due to ankle ischemia, and therefore use
hip strategy.
3. The abnormal vestibular information may contribute to abnormal internal representation of
stability limits, so patients may behave as if
small disturbances in stance push them beyond
their stability limits.
Patients who perceive themselves to be in a different
relation to their stability limits from where they actually
are may show inappropriate postural movement strategies in response to destabilization.35,97 For example,
some patients may not take a step necessary to recover
equilibrium in response to a displacement of center of
body mass outside their limits of stability, because they
perceive themselves to be well within their stability limits. In contrast, other patients may make exaggerated postural responses to small perturbations well within their
limits of stability, because they perceive themselves to be
at their limits of stability and therefore at risk for a fall.
The type of response may depend both on the type of
vestibular dysfunction and the requirements of the task.
In summary, vestibular information is used, with
information from other senses, to construct internal maps
of the limits of stability, which in turn affect body alignment and recovery from postural disturbances. The information provided by the vestibular system and its
relationship to information from the other senses changes
according to the movement strategy used in controlling
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equilibrium. This discussion has hypothesized that postural strategies are specific prescriptions for mapping
interactions among sensory and motor elements of postural system; these maps are, in essence, a method for
solving a sensorimotor problem. Individuals need a variety of different movement strategies to choose from,
depending on current, past, and expected environmental
conditions and task constraints. Although the vestibular
system may not be prescribing the details of the coordinated motor pattern for postural movements, it seems to
be intimately involved in the appropriate selection of
movement strategies.
Development of Motor Coordination

Consistent with the concept that the vestibular system
does not shape the details of coordinated postural patterns, intact vestibular function does not appear to be crucial for the normal development of many aspects of motor
coordination. Deaf children who sustain complete or partial loss of vestibular function within the first year of life
score within or above normal limits in tests of interlimb
coordination, such as kicking, walking, running, skipping, hopping, and fine coordination of the hands,
although they often start walking a few months later than
normal.94,98,99 Later in childhood, clinical measures of
balance function, such as duration of one-foot standing
45
and ability to walk on a balance beam, are affected by loss

of vestibular function. These tasks are difficult because
one-foot stance and balance beams compromise a persons ability to use somatosensory information to control
posture. However, these tasks also require hip strategy for
center of mass control, which is usually abnormal in
patients with loss of vestibular function.34,73,75 Thus, these
children may perform nearly normally in situations with
normal support conditions but may show abnormalities in
situations in which hip strategy is unavoidable.
In general, adults who have lost vestibular function
as infants show much better postural compensation than
those who have lost vestibular function as adults. For
example, patients with infant-onset vestibular loss are
more likely to show the vestibular loss pattern rather than
the sensory selection pattern in sensory organization testing, indicating that they can use visual and/or somatosensory inputs to compensate for missing vestibular inputs.
In response to surface translations, those with infantonset loss of vestibular function show much more normal
trunk and head stability than subjects with adult-onset
vestibular loss. Figure 3.12 shows the excessive upper
body and head displacement associated with excessive
neck EMG activity in response to a backward surface
translation in a subject with adult-onset vestibular loss
and that responses in the infant-onset vestibular loss subject are much more similar to those of the healthy control
Figure 3.12 Comparison of body and head displacement (angular velocity) and neck muscle
electromyographic (EMG) activity in response to a backward surface translation in a representative
healthy control subject and subjects with adult-onset bilateral vestibular loss and infant-onset
vestibular loss. The subject with adult-onset vestibular loss shows the most trunk and head instability
and excessive neck EMG activity in response to postural perturbations. Sternocleido. sternocleidomastoid muscle. (Adapted from Horak et al, 1994.69)
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subject.79 In addition, patients who have lost vestibular

function as young children complain of oscillopsia or of
balance or spatial orientation problems much less often
than patients who have lost vestibular function as adults.
Thus, the increased central nervous plasticity in young
children facilitates maximal compensation for loss of
vestibular function.
Stabilizing the Head and Trunk

The use of visual and vestibular information for the control of posture is complicated by the fact that these sense
organs are located in the inertially unstable head. Because
the center of gravity of the head is located above its axis
of rotation, any movement of the body results in head
motion. Uncontrolled head motion complicates the use of
vestibular information to make estimates of body motion
and position. Also, if the range of head motions exceeds
what can be compensated for by the VOR, blurred vision
could result. For these reasons, investigators have suggested that the nervous system might stabilize the head
with respect to gravity during postural control, either
to simplify the interpretation of vestibular information
or to facilitate gaze stabilization (Fig. 3.13A).100,101 In the
absence of good information about gravity from the
vestibular system, or in an attempt to simplify the coordination of head and trunk movements, the nervous system might stabilize the head with respect to the trunk
(Fig. 3.13B).100
Although there is some movement of the head in
space during most locomotor tasks, the position of the
head with respect to gravity is often held relatively constant, despite the large movements of the body that can
occur during activities like hopping and running.101103
For example, neck muscle activations are observed in
normal subjects using a hip strategy.34,79,91,92 In these
studies, the neck muscle activations occurred prior to any
Figure 3.13 Alternative strategies for control of head position during postural movements. Example is given for a subject
using hip strategy to control the center of mass. Head is stabilized with respect to gravity in A, and with respect to trunk in B.
large change in head position, and so the activations

appear to be a result of an anticipatory control strategy. In
other words, these muscle activations serve to prevent the
large tilts of the head with respect to gravity that could
occur during the large trunk movements, characteristic of
a hip strategy.
To determine the role of the vestibular system in
maintaining head position with respect to gravity, the
control of head position has also been studied in patients
with vestibular loss.34,79,104,105 During activities like walking and running, patients with profound vestibular loss
show greater variability in head position with respect to
gravity. When standing on an oscillating surface with the
eyes closed, patients with vestibular loss show large
oscillations of their trunks in space, unlike healthy control subjects, who stabilize their trunks with respect to
gravity more and more as the surface oscillations
increase in frequency.106 Figure 3.14 compares the stable
Figure 3.14 Comparison of stable trunk in space in healthy control versus large trunk instability in
a subject with bilateral vestibular loss during fast, anterior-posterior surface translations. Stick figures
show lateral view of trunk, thigh, and legs during surface oscillations. Anterior (up) and posterior
(down) trunk displacement in a representative control subject (gray line) and subject with vestibular
loss (black line). Dashed line represents platform surface oscillation.
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control of the trunk in a control subject with the large

forward-and-backward drift of the trunk in a patient with
vestibular loss during forward and backward translations of the support surface. Some patients with wellcompensated vestibular loss, however, can stabilize their
trunks in space when their eyes are open, whereas those
with poorly compensated vestibular loss cannot use
vision to compensate for the loss of vestibular function.
Figure 3.15 shows that three subjects with wellcompensated vestibular loss demonstrated very little vertical, medial-lateral or anterior-posterior variation in
head position, like contol subjects; three subjects with
poorly compensated vestibular loss, however, showed
very large variations in head position during surface
oscillations.106 Despite abnormal top-down coordination
of the head and trunk, subjects with vestibular loss
showed normal coordination of the legs at all frequencies
of surface oscillation, even with eyes closed, consistent
with a bottom-up somatosensory control of postural
coordination of the legs.
Subjects with vestibular loss are very successful in
substituting light fingertip touch on a stable surface for
the lost vestibular function to stabilize posture during
tandem stance and during surface rotations.107,108 They
can also use audiobiofeedback about trunk motion to
VS5
4
VS4
VS6
3
2
8
4
on (c
1
m)
va
VS1
M/L v
ariati
VS2
ria
tio
n
VS3
(cm
)
A/
n (cm)
Ver. variatio
Figure 3.15 Three dimensional graph of head acceleration

in the sagittal, frontal, and horizontal planes in 6 patients with
vestibular loss. Three patients with well-compensated bilateral
vestibular loss (VS1, VS2, and VS3) show very little head instability during surface oscillations with the eyes open, like normal
subjects (shaded area). Three patients with poorly compensated bilateral vestibular loss (VS4, VS5, and VS6), however,
show large variation in vertical (Ver.), medial-lateral (M/L),
and anterior-posterior (A/P) head displacements.
47
control posture when standing on a compliant foam surface with the eyes closed.109 These findings suggest that
patients with vestibular loss who complain of balance
problems would benefit from use of a cane or other
biofeedback device to provide sensory information about
trunk sway with respect to earth to substitute for their
missing vestibular function, particularly when balancing
on an unstable surface.
In summary, the vestibular system plays an important role in head and trunk stabilization with respect to
gravity. In contrast, the vestibular system appears to be
less important for the control of the position of the body
center of mass or postural coordination of the legs, especially when good somatosensory cues about body position
are available. These observations are consistent with the
hypothesis that the distal-to-proximal muscle activations
that control the center of mass are triggered by somatosensory information from the feet and legs and that the
neck and trunk muscle activations that control head position are in turn controlled by vestibular mechanisms.35
Summary
The vestibular system plays many potential roles in postural control. The role it plays in any given postural task
depends both on the nature of the task and on the environmental conditions. When the stabilization of the head
or trunk is critical for good performance, the vestibular
system is very important. Likewise, when somatosensory
(and, to a lesser degree, visual) information is not available, vestibular information for postural control has a
dominant role. Table 3-1 lists some tasks and conditions
in which vestibular information for postural control is
important as well as some balance abnormalities that
suggest a vestibular disorder. It is also important to note
that although this table and this chapter have been devoted to the role of the vestibular system in the control of
standing balance, the vestibular system is equally important during locomotion, and problems with sensing
movement, orienting to vertical, controlling the position
of the center of mass, and stabilizing the head result in
impairments in gait as well as in standing balance.
Consider, for example, a task and a set of environmental conditions that occur frequently in clinical examinations of postural control: The patient sits, with eyes
closed, on a board, which is tilted (see Fig. 3.1). This task
is appropriate to test the ability of the patient to use
vestibular information for the control of posture, because
visual and somatosensory cues for orientation are poor,
and normal subjects typically stabilize their heads with
respect to gravity while executing such tasks. When
asked to perform this task, patients who have recently
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CASE STUDY 1
A 60-year old woman required high doses of intravenous gentamicin for a bone infection after a fracture repair. After several days of treatment, she
noticed a partial loss of hearing and imbalance when
walking in a dark room on a soft carpet, such as in a
movie theater.
Assessment
Perception of Motion. Impaired perception of limits
of stability and of verticality in sitting and standing.
She had complaints of unstable vision with head
movements and during walking and riding in a car,
but no dizziness.
The patient was unable to balance

in tasks requiring use of the hip strategy, such as
standing across a beam, standing on one foot, and
heel-toe walking. Her head was actively fixed on the
trunk during gait and turns, and she complained of
neck stiffness.
Motor Strategies.
Sensory Weighting. Sway in stance on a firm surface

was normal with eyes open or closed or with swayreferenced vision. The patient free-fell when attempting to stand on compliant foam with the eyes closed
or during sway-referenced vision with a vestibular
loss pattern.
lost vestibular function demonstrate abnormalities in the

use of vestibular information in each of its four roles.
First, they have difficulty perceiving and reporting
whether their bodies or heads are properly oriented to
gravity; that is, they have difficulty identifying when they
are upright. Second, will orient head and body position
poorly to gravity, showing tilts rather than upright orientations when asked to right themselves. Third, if the
board is tipped suddenly, they may not be able to recover balance. Fourth, head position with respect to gravity
varies a great deal as such patients attempt to recover
from the perturbation.
Unfortunately, the assessment of vestibular function
in a clinical setting is not so straightforward with patients
whose vestibular losses are well compensated. What one
observes in these patients is often not the primary action
of the vestibular system but the result of the bodys
attempt to compensate for the loss. For example, patients
Discussion
The history of gentamicin treatment followed by
hearing loss and vestibular symptoms is consistent
with ototoxicity affecting both motor and sensory
strategies for postural control. Loss of vestibular
function is associated with loss of a hip strategy in
tasks with compromised surface somatosensory
information as well as fixing of the head on the trunk,
which can lead to cervical symptoms. The oscillopsia associated with head movements was likely
associated with increased imbalance. The patient
showed context-dependent instability when vestibular information was required for postural orientation in environments when both visual and surface
somatosensory information were inadequate for
stability.
Physical therapy goals focused on reduction
of oscillopsia, increasing use of remaining vestibular function, and increasing use of a hip strategy
when tasks required it. If sufficient vestibular function were remaining, treatment of neck symptoms
and practice turning the head on the trunk while stabilizing gaze on words during stance and locomotion
would allow vision to help recalibrate vestibular
function.
with vestibular loss often have stiffness of the neck and

shoulders. Assuming, however, that this neck stiffness is
a primary result of vestibular activation of tonic neck
reflexes would be a mistake. The stiffness may be the
result of an increase in gain in the cervicocollic system or
of a change in strategy; if the head can no longer be
aligned to gravity because the direction of gravity cannot
be detected, the CNS may choose to stabilize the head to
the trunk. Alternatively, the neck stiffness could result
from voluntary attempts to stabilize head position to limit
vertigo or oscillopsia.
Whereas we once assumed that the abnormal balance of patients with vestibular disorders was the simple
and necessary consequence of the loss of vestibular
reflexes, we now know that the role of the vestibular system in the control of posture is much more complex. In
addition to providing (together with vision and somatosensation) the sensory information necessary for orien-
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49
CASE STUDY 2
A 34-year-old, physically fit, mounted policeman
was kicked in the head by his horse. Afterwards, he
reported severe disorientation when riding his horse,
especially near moving traffic. Any busy visual environment, such as crowds, stores, patterns, and windshield wipers, was aversive, and he fell when trying
to walk on the beach near the ocean waves. He also
reports spinning vertigo when he pitches his head
backwards.
Assessment
Motor Strategies. Excessive hip strategy with head
instability when standing on a firm or foam surface
when wearing a visual dome that stabilized vision
and when attempting to stop suddenly while walking.
Sensory Weighting. The patient had normal sway
when standing on a firm or foam surface with eyes
open and closed. Sway was excessive, dizziness
increased, and he could not stand independently for
30 seconds when wearing a visual dome that stabilized vision.
Discussion
The visually dependent pattern of sensory organization for posture, associated with increased dizziness
symptoms with visual motion in the environment, is
consistent with an abnormally increased weighting of
visual input for postural control. His normal sway
with eyes closed on a foam surface suggests that he
still has adequate vestibular information for postural
orientation, but he relies on vision whenever his eyes
are open, even when visual inputs poorly reflect body
sway. The patients excessive use of the hip strategy
suggests that he is not using somatosensory information from the support surface to control his postural
sway strategy, resulting in larger than normal head
accelerations that may be contributing to his vertigo.
Physical therapy goals included reduction in visual
dependence by systematic exposure to moving or stabilized visual environments while increasing use of
somatosensory cues from a firm support surface. The
patient also practiced use of the ankle strategy by
swaying forward and backward slowly at the ankles
in a variety of sensory conditions and when stopping
during gait.
Table 3-1 ROLES OF THE VESTIBULAR SYSTEM IN POSTURAL CONTROL

Findings Suggestive of
Vestibular Disorder
Role of the Vestibular System
Clinical Assessment
Sensing and perceiving

self-motion
Patient performs head motions

and/or positions in different
planes
Patient reports abnormal sensations of

motion and/or vertigo
Orienting to vertical
Patient stands on inclined surface
Trunk is oriented to support surface instead

of to gravity
Patient stands on foam with eyes

closed
Patient falls or sway increases markedly
Controlling center of mass
Patient stands or walks on a

beam
Patient is not able to use hip strategy to

control center of mass, and so falls
Stabilizing the head
Patient leans or is tilted
Head is not stabilized with respect to

vertical
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tation and balance, the vestibular system also interacts

with the parts of the CNS responsible for expectation and
learning. Although it is automatic and rapid, postural
control is also flexible, capable of adapting to many different sensory environments and musculoskeletal constraints. The role of the vestibular system in postural
control cannot be fully appreciated until we better understand the complex and multifaceted nature of postural
control itself.
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70. Shupert CL, Horak FB: Effects of vestibular loss on head
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71. Lund, S, Broberg, C: Effects of different head positions
on postural sway in man induced by a reproducible
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72. Horak FB; Hlavacka, F: Vestibular stimulation affects
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73. Day BL, Cole, J: Vestibular-evoked postural responses in
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74. Storper I, Honrubia V: Is human galvanically induced
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75. Allum JHJ, Honegger F: A postural model of balancecorrecting movement strategies. J Vestib Res 1992;
2:323.
76. Allum JHJ, et al: The influence of bilateral peripheral
vestibular deficit on postural synergies. J Vestib Res
1994;4:49.
77. Horak F, et al: Postural strategies associated with
somatosensory and vestibular loss. Exp Brain Res
1991;82:167.
78. Thomson DB, et al: Bilateral labyrinthectomy in the cat:
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79. Shupert C, et al: Coordination of the head and body in
response to support surface translations in normals and
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Amblard B, et al, eds: Posture and Gait: Development,
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80. Diener HC, et al: The significance of proprioception on
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81. Mauritz KH, et al: Balancing as a clinical test in the differential diagnosis of sensory-motor disorders. J Neurol
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82. Nashner L: Fixed patterns of rapid postural responses
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83. Diener HC, et al: Stabilization of human posture during
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84. Nashner L, McCollum G: The organization of human postural movements: a formal basis and experimental synthesis. Behav Brain Sci 1985;8:135.
85. Horak FB: Comparison of cerebellar and vestibular loss
on scaling of postural responses. In: Brandt T, et al, eds:
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86. Mergner T, Maurer C, Peterka RJ: Sensory contributions
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87. Kasper J, et al: Influence of standing on vestibular

neuronal activity in awake cats. Exp Neurol 1986;
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88. Horak FB, Nashner L: Central programming of
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89. Horak FB: Clinical measurement of postural control in
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91. Runge CF, et al: Ankle and hip postural strategies
defined by joint torques. Gait Posture 1999;10;161.
92. Runge CF, et al: Role of vestibular information in initiation of rapid postural responses. Exp Brain Res 1998;
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93. Horak FB, et al: Vestibular function and motor proficiency in children with hearing impairments and in learning
disabled children with motor impairments. Dev Med
Child Neurol 1988;30:64.
94. Kaga K, et al: Influence of labyrinthine hypoactivity on
gross motor development of infants. Ann N Y Acad Sci
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95. Fregly A: Vestibular ataxia and its measurement in man.
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Applied Aspects, and General Interpretation. Berlin:
96. Shupert CL, et al: Hip sway associated with vestibulopathy. J Vestibular Res 1994;4:231.
97. Shumway-Cook A, Horak FB: Vestibular rehabilitation: An exercise approach to managing symptoms of vestibular dysfunction. Semin Hearing 1989;
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98. Shumway-Cook A, et al: Critical examination of vestibular function in motor-impaired learning disabled children. Int J Ped Otorhinolaryngol 1988;14:21.
99. Crowe TK, Horak FB: Motor proficiency associated with
vestibular deficits in children with hearing impairments.
Phys Ther 1988;68:1493.
100. Nashner L: Strategies for organization of human posture.
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Control on Posture and Locomotor Equilibrium. Basel:
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101. Pozzo T, et al: Head stabilization during various locomotor tasks in humans, I: Normal subjects. Exp Brain Res
1990;82:97.
102. Grossman G, et al: Performance of the human vestibuloocular reflex during locomotion. J Neurophys
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103. Assaiante C, Amblard B: Head-trunk coordination
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1991:121.
104. Grossman G, Leigh RJ: Instability of gaze during locomotion in patients with deficient vestibular function.
Ann Neurol 1990;27:528.
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105. Pozzo T, et al: Head stabilization during various locomotor tasks in humans, II: Patients with bilateral peripheral
vestibular deficits. Exp Brain Res 1991;85:208.
106. Buchanan, J.J., Horak, F. Vestibular loss disrupts control
of head and trunk on a sinusoidally moving platform.
Journal of Vestibular Research, 2002;11:371.
107. Lackner JR, DiZio P, Jeka J, Horak F, Krebs D, Rabin E:
Precision contact of the fingertip reduces postural sway
53
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Res 1999;126: 459466.
108. Creath R, Kiemel T, Horak FB, Jeka JJ: Limited control
strategies with the loss of vestibular function, Exp. Brain
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109. Dozza M, Chiari L, Horak F: Auditory biofeedback
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4
Postural Abnormalities
in Vestibular Disorders
When this chapter was written for the first edition of this
book, the primary role of the vestibular system was
considered to be the control of posture and balance. In
recent years, however, it has been acknowledged that
rather than initiate automatic postural reactions, the
vestibular system is responsible for governing orientation
in space.13 Whereas the somatosensory system provides
information about the position and motion of the body
with respect to the support surface and the body segments
with respect to each other, the vestibular system provides
information with respect to gravity and other inertial
forces. The central nervous system adapts quickly to the
loss of peripheral vestibular inputs from the labyrinths, so
it is sometimes difficult to objectively identify symptoms
of vestibular deficit. Identification of the role of the
vestibular system in posture and orientation has relied on
findings of postural and orientation disorders in patients
and animals with vestibular abnormalities.48
Most clinical diagnoses are based on subjective
complaints, and patient descriptions of a symptom might
differ. One might experience a perception of the world
spinning about, and another might complain of imbalance and falling, yet both could have the same vestibular
disorder.9 Because the process of central nervous system
compensation proceeds over a lengthy time, patients can
also have different symptoms when they finally arrive at
a clinic, although suffering a similar deficit. Both clinical
and experimental observations have shown that along
54
with symptoms of vertigo, past pointing, and nystagmus,

equilibrium disturbances are one of the major complaints
of patients with partial or total destruction of the vestibular labyrinths.10 Despite these fairly consistent symptoms, examination of any one patient with postural
abnormalities arising from damage to the vestibular system could yield an uncertain diagnosis.9,10
The question for the clinician and the clinical investigator is whether any one compensatory strategy is more
efficient or effective for the population of patients with a
vestibular deficit. If one strategy were better, then a systematic approach to treatment could be followed. But to
determine the effectiveness of the compensation, we
must first determine how to reliably indicate whether the
patient is suffering from postural dyscontrol, and whether
vestibular dysfunction is responsible for the symptoms.
Although the standard clinical tests of the vestibular system have not altered, new technologies, such as virtual
reality (VR), have arisen that allow us to test vestibular
function when combined with other sensory signals.11 In
this chapter, some of the methods available for testing
postural disorders that are associated with vestibular disease are briefly discussed. Then, postural behaviors that
have been quantified and associated with specific
vestibular disorders are described. Finally, the issue of
how the postural system compensates for loss or damage
to vestibular signals, including the changes that occur
with natural aging, is discussed.
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Chapter 4 POSTURAL ABNORMALITIES IN VESTIBULAR DISORDERS
Examining the
Vestibulospinal System
Advantages and Limitations
of Clinical Tests
Although vestibular disorders continue to be diagnosed
through measures of the vestibulo-ocular system such as
electronystagmography and rotational testing, these
methods cannot fully describe all disorders of the
vestibular system. One problem is that tests of vestibuloocular integrity and vestibulospinal function may not be
correlated.9 First, the well-defined loop of the vestibuloocular reflex (VOR) does not reveal the integrity of the
more complex vestibulospinal pathways that are intimately involved in the control of posture and balance.
Second, tests of the VOR are commonly performed in the
plane of the horizontal semicircular canals, whereas
vestibulospinal reflexes depend on inputs from the vertical semicircular canals and the otoliths.
A clinical test that is able to partially reveal information about vestibulospinal function is the vestibular
evoked myogenic potential (VEMP). The VEMP is a
sound-evoked muscle response that is believed to be generated from acoustical stimulation of the saccule (one of
the otoliths that transduces linear accelerations and decelerations). Thus, the presence or absence of this muscle
response provides diagnostic information about the function of the saccule or the inferior vestibular nerve.1214
The measured variable is a short-latency response from
surface electrodes over the tonically contracted sternocleidomastoid muscle. The VEMP can be recorded from
patients who have no hearing but have intact vestibular
system function. The diagnostic utility of the VEMP
has been examined for various audiovestibular and neurological disorders, including vestibular labyrinthitis,
Mnires disease, benign paroxysmal positional vertigo
(BPPV), superior canal dehiscence, Tullio phenomenon,
vestibular schwannoma, multiple sclerosis, and spinocerebellar degeneration.
Although dynamic posturography does not directly
assess peripheral or central vestibular function, it is a useful tool for identifying disorders of the vestibulospinal
system.1517 Dynamic posturography assesses balance
rather than specific vestibular function. But response patterns specific to individuals with vestibular dysfunction
are elicited with dynamic posturography, making it a
useful adjunct to more traditional methods of testing vestibular function. Diagnostic tests of the vestibulospinal
system that are more easily and inexpensively available
to the clinician than dynamic posturography are also
55
discussed in this chapter, as are some of the problems

inherent in each method of testing. Table 4-1 presents a
summary of the advantages and disadvantages of the tests
discussed here.
Automatic Postural Responses
In the 1970s, Nashner18,19 reported stereotypical, automatic responses to postural disturbances initiated at the
base of support, introducing the measurement of postural
reactions on a moving platform as a powerful experimental approach. Since that time, the majority of studies of
postural kinematics have concentrated on the electromyographic (EMG) responses from muscles in the lower limb,
from which most descriptions about restabilizing actions
have been drawn.1823 Subjects stand on a platform that
can be translated in an anterior and posterior direction, or
rotated so that the ankles are moved into plantar flexion or
dorsiflexion (see Fig. 4.1). The expected response to anterior motion of the platform is backward sway (base of
support moved in front of the center of mass), producing
a decreased angle at the ankle and a stretch of the ankle
muscles on the anterior surface of the body (i.e., tibialis
anterior). If the platform moves posteriorly, the subject
sways forward (base of support moved behind the center
of mass), thereby decreasing the ankle angle and stretching the gastrocnemius and soleus muscles. Rotating the
platform into plantar flexion or dorsiflexion would produce equivalent changes at the ankle (see Fig. 4.1), but the
center of mass remains in line with the base of support.
Although the monosynaptic stretch reflex does not
act functionally to replace the center of mass over the
base of support, EMG analysis of the lower limb muscles
revealed that the muscles being stretched also responded
at latencies longer than the stretch reflex but shorter than
voluntary reactions in order to bring the body back over
the base of support. These restabilizing ankle muscle
responses (at latencies of 90 to 120 msec) were followed
within 10 to 20 msec by the muscle in the upper leg on
the same side of the body (i.e., soleus muscle followed by
the hamstrings; tibialis anterior muscle followed by the
quadriceps). Thus, from these early studies, patterns of
muscle activation initiated by ankle proprioceptive inputs,
and arising from distal to proximal lower limb muscles,
were identified as ascending muscle synergies responsible for restabilization after platform movement.18,19
Nashners original conclusion that the body acts as a
rigid, inverted pendulum, reliant primarily on ankle proprioceptive inputs to initiate the restabilizing actions,
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Table 4-1 ADVANTAGES AND DISADVANTAGES OF CLINICAL

TESTS OF POSTURAL INSTABILITY
Advantages
Disadvantages
Easily performed in clinic
Qualitative
Does not test adaptive responses
Stabilometry
Quantitative
Can manipulate sensory inputs
Requires a force platform

Intersegmental shifts confound results
Vestibular evoked
myogenic potential
Specific test of the saccule and inferior vestibular nerve
Requires electromyography of the sternocleidomastoid muscle

Can be quantified

Has not been shown to be reliable
Tiltboards

Requires adaptation to external forces
Qualitative
Amplitude and application of force are not controlled
Posturography
Quantitative
Requires adaptation to external forces
Can manipulate sensory signals
Requires a posture platform
Virtual reality
Tests the effect of visual information

on postural reactionsincorporates
perception with postural responses
Requires expensive technology, a knowledge of programming, and some form of kinematic or physiological measurements
Static tests:
Romberg
Dynamic tests:
Stepping tests
does not accurately describe the complex, multisegmental

actions that occur during postural restabilization.21,2326
The ankle strategy is most effective when sway is slow
and the support surface is firm. When it is impossible to
exert adequate torque around the ankle joint, as when the
base of support is narrow or compliant, balance is recovered with flexion at the hip, or with a hip strategy.27
Allum and colleagues28 concluded that (1) all balance
corrections result from one of two basic synergies defined
by the timing between segmental responses and (2) the
selected synergy was amplitude-modulated according to
the initial movement velocities at all joint segments,
thereby producing a continuous repertoire of movement
strategies for balance. With more realistic stimuli (i.e.,
rapid perturbations and a center of mass moving far
beyond the base of support), the ability to take a step has
been found to be the relevant criteria for recovery of balance.29,30 Other studies have demonstrated that the initiation of the balance reactions depends greatly both on the
ability to predict the occurrence of the perturbation3134
and on the location of the disturbance on the body.3538
Identifying Vestibular Contributions

to Automatic Postural Responses
Since the earliest presentation of Nashners findings,
investigators have been attempting to define the contribution of the vestibular system to the automatic postural
responses.3943 Studies in which the labyrinthine receptors were directly stimulated by vertically dropping
human and animal subjects, thereby producing linear
acceleratory stimuli,4043 demonstrated that direct labyrinthine stimulation can produce automatic or triggered
postural reactions in the lower limb. Nashner20 hypothesized, however, that the vestibular system contributes to
the control of lower limb balance reactions only when
proprioceptive signals are absent or unreliable. With use
of a servomechanism, the posture platform was made to
match the sway at the hip, thereby maintaining a neutral
position at the ankle and, one assumes, eliminating any
change in the proprioceptive feedback from the ankle during normal quiet standing. In subjects thus tested, automatic postural responses were significantly delayed when
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ANTERIOR TRANSLATION
POSTERIOR TRANSLATION
57
generation of lower limb postural reactions. The differences between the subject groups were greatest and most
consistent during platform rotations,45 leading the
researchers to conclude that vestibular loss is best diagnosed through a rotation of the support surface. Using a
range of platform translation velocities (535 cm/sec),
Runge and colleagues46 found that equivalent head accelerations produced very different torques at the hip and
knee in healthy subjects and in patients with bilateral
vestibular deficit. These findings suggest that the magnitude and force pattern of the muscles depends on vestibular inputs from early head movements.
Altering Sensory Cues
PLANTAR FLEXION ROTATION
DORSIFLEXION ROTATION
Figure 4.1 Four directions of perturbation on the dynamic

posture platform. Note that in anterior translations and plantarflexion rotations, ankle angles increase as the person compensates for the motion of the platform. In posterior translations
and dorsiflexion rotations, ankle angles decrease.
the subjects had to rely on vestibular signals in the

absence of proprioceptive feedback from the ankles.
Most probably, the servomechanism did not fully
remove the ankle proprioceptor feedback but, rather,
produced distorted or modified signals that altered the
automatic postural reactions; alternatively, responses to
vestibular inputs during quiet stance may not be transferable to the responses observed during dynamic gait and a
loss of balance. A novel experiment reported by Allum
and colleagues44,45 appears to resolve the issue of labyrinthine involvement in the generation of postural reactions
to support surface displacements. In this experiment,
angular displacement of the ankle was kept equal for both
platform translations and rotations, thereby producing
equivalent proprioceptive signals from the ankle even
though the labyrinthine inputs differed. When head acceleration and neck and lower limb muscle EMG responses
recorded during both perturbations did not exhibit the
same response patterns, these investigators concluded
that labyrinthine signals must be directly involved in the
Manipulating the visual and somatosensory inputs that

are available during dynamic posturography is another
method employed to isolate a persons ability to use
vestibular signals. More commonly used protocols to alter
somatosensory inputs include a sway-referenced platform
that matches the normal sway at the ankle during quiet
standing and addition of a layer of dense foam to the base
of support to make somatosensory inputs less effective.47
Visual conditions have been controlled by either stabilizing or rotating the visual field in an anterior-posterior
plane.4749 The emergence of VR technology has now
enhanced the ability of scientists and clinicians to explore
the impact of visual perturbations on postural responses
(see Table 4-1).11,50
Although normal subjects, elderly individuals, and
people with vestibular deficit exhibit a greater tendency
to fall under conditions of altered sensory input,47,48,5153
concluding that the cause is a vestibulospinal system
unable to compensate for the loss of other sensory signals
may be premature. Modification of somatosensory and
visual inputs is not necessarily equivalent to a loss of
those signals, and the central nervous system may well
compensate for distorted or minimized inputs by altering
the sensorimotor transformation algorithm. For example,
the system may select a compensatory strategy that relies
upon enhancing the gains of somatosensory and visual
responsiveness to the distorted inputs rather than shifting
responsibility for the response onto the vestibulospinal
system. Disorientation of patients with labyrinthine loss
when visual48 or somatosensory54,55 information becomes
unreliable can also be explained by the fact that neither
signal can adequately specify the orientation of the body
in all situations. In natural environments we rely on both
visual and vestibular signals to define our orientation in
space, and evidence indicates that labyrinthine-deficient
individuals become more sensitive to and dependent on
visual inputs with vestibular loss.5660
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In summary, postural responses to support surface

displacements have traditionally been tested by (1) translating a standing subject along the earths horizontal
plane on a moving platform, (2) rotating the foot about
the horizontal axis of the ankle into dorsiflexion or plantar flexion, and (3) keeping the platform fixed to the earth
horizontal or using a servomechanism to match the angle
of the platform to the angle at the ankle during quiet
sway. Experiments using the posture platform have been
performed with a wide range of velocities and amplitudes
of displacement, which alter the transmission of forces
from the lower limb to the head and make it difficult
to compare vestibular influences on balance in different
laboratory settings. Instructions to the subjects and monitoring of past experiences with the paradigm are not
regulated. A further restriction on the interpretation of
results is that measurement of postural responses should
incorporate the mechanics of body sway with the threshold properties and dynamic characteristics of the labyrinthine receptors,23,46,6163 because knowing the mechanics
of the head and motions of the center of mass is necessary for predicting the role of canal and otolith feedback
in restabilization. Despite its limitations, and the multitude of variables that should be controlled, the posture
platform continues to be employed to obtain quantitative
measures of postural reactions in clinical populations.
Many of the results reported in this chapter have, in fact,
depended on the posture platform methodology to examine disturbances in postural control as a result of vestibular dysfunction.
Tests of Quiet Stance

Traditional clinical examinations of vestibulospinal function include tests of self-localization, such as the
Romberg test.64 Initially, Rombergs test of instability
was based on a population of patients with proprioceptive loss from tabes dorsalis who were unable to stand
with feet together and eyes closed. But the Romberg test
is insensitive for detection of chronic unilateral labyrinthine impairment, and its results are highly variable
even for testing the same subject repeatedly.65 Modifying
the test by having the patient stand in a tandem heel-totoe position (sharpened or tandem Romberg) has made
the test more sensitive, probably because of the narrowed
base of support. Even so, tests of quiet stance fail to
measure the adaptive components of the postural
response that are essential to dynamic balance during
most daily activities.66
Tests of quiet stance may indicate the severity of a
balance problem, because patients with vestibular system
damage demonstrate increased sway and falling when the

base of support is constrained during quiet standing.
Conclusions about the neural processes contributing to
postural imbalance are severely limited, however. The
effect of altered proprioceptive and cutaneous information on low-frequency sway stabilization cannot be
determined by tests of quiet standing. Changing velocity
of the visual field is a significant parameter controlling
body sway during quiet standing,66 but simple removal of
vision does not alter the temporal or spatial organization
of the automatic postural reactions.39 Furthermore,
behavioral measures as to how often a subject falls, or to
which direction he or she deviates, do not convey information about the motor and sensory mechanisms that
may be involved in postural control.67,68 Thus, attempting
to assess the integrity of the vestibular system through a
test of quiet standing opens the door to many confounding variables and is far from specific to the vestibulospinal disorders that may produce a postural deficit.69,70
Despite these limitations, the concept of deviation from
the vertical during quiet standing continues to underlie
clinical testing of vestibular dysfunction.
Stabilometry
Stabilometry is a clinical tool that measures anteriorposterior and lateral excursions of the body in subjects
standing quietly on a force platform, usually over
time.7173 During that time, the subject stands quietly on
a force plate, and the excursion of the center of gravity is
measured during several conditions that can include eyes
open, eyes closed, and eyes closed with head extension.
Attempts to stress the vestibulospinal system have been
incorporated into this system of measurement through
alteration of signals from other sensory pathwaysfor
example, adding a layer of foam rubber to the base
of support to make somatosensory inputs less effective47
or placing the subject within a visually controlled environment to modify visual feedback.48 This attempt to
quantify the classic Romberg test has made the measurement of postural sway during quiet standing more
objective, but the mechanisms contributing to the observation of increased sway still cannot be identified. One
problem is that changing the position of the body parts
(either randomly or through experimenter directive)
could shift the center of pressure without affecting the
stability of the subject.71 In general, because the sensory
apparatus of the vestibular system is most responsive to
changes in acceleration and orientation in space,74 and
because patients with vestibular deficits tend to have
normal Romberg responses, tests of quiet standing on a
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stabilometer are not compelling measures of vestibulospinal function.
Tiltboards
Tilt reactions, or reflexes opposing bodily displacement,
traditionally were evoked through a lateral tilt or anteriorposterior tilt of the supporting surface about a horizontal
axis.46 When the base of support was tilted, the subject
reacted to regain a stable equilibrium by moving the body
against the angular momentum and repositioning the center of gravity within the vertical projection of its base of
support.48 These reactions have also been elicited in the
clinic by simply pushing the patient at the shoulder girdle.
Problems with the accuracy of this test are threefold.
First, because the tilt reactions are measured by observational techniques, later voluntary responses ( 150 msec
after) rather than automatic postural reactions are being
evaluated. Second, the response pattern alters if the force
is applied directly to the trunk rather than to the support
surface. Third, tilt responses will be organized differently
depending on whether the patient is pushed or trips over
an obstacle in the environment, whether the application of
perturbation is predictable, and whether it is self-induced
or elicited.
Stepping Tests
The Unterberger test75 or stepping test of Fukuda76 examines the ability of patients to turn about a vertical axis
when marching or stepping in place. Marked variability
in the amount of rotation produced by even the same subject, however, makes these tests unreliable.9 Patients with
severe disruption of the vestibular system may stagger so
uncontrollably that the stepping tests cannot reliably
indicate the side of the lesion.77 A battery of tests developed by Graybiel and Fregly78 (Ataxia Test Battery)
examine subjects standing upright, on one leg, and with
feet aligned in tandem position with eyes open or closed
as well as while tandem walking in a straight line on the
floor or on a narrow rail. This test is useful for patients
who have compensated for a labyrinthine deficit, because
when a narrowed base of support is required, even those
patients score lower than normal subjects on measures of
deviation from the straight line or of the number of steps
made prior to falling from the rail.
Virtual Reality Environments

The perception of self-motion and orientation in space is
derived from a convergence of vestibular, proprioceptive,
and visual signals. In order to resolve ambiguity between
59
motion of objects in the world and self-motion, we use

multisensorial feedback and make perceptual choices
about what we believe is happening.79 VR technology
offers the sensory complexities found in the physical
world in the controlled environment of the laboratory
(Fig. 4.2).80 Individuals become immersed in the training
environment so that they feel they are part of the scene81
and perceive that the world is moving about them.82 Thus,
VR allows researchers and clinicians to create a synthetic
environment with precise control over a large number of
physical variables that influence behavior while recording
physiological and kinematic responses.83
In a VR environment, healthy subjects have demonstrated large increases in postural sway when the frequency and amplitude of visual information was incongruent
with the frequency and amplitude of the somatosensory
signals generated by a support surface perturbation.84 In
this case, the visual information had no parameters in
common with the physical disturbance and, thus, could
have been treated as irrelevant to the postural perturbation
and ignored. Instead, in both normal subjects and subjects
with labyrinthine deficit, the postural responses became
more complexly organized: an additional frequency was
incorporated into the intersegmental response, which was
also further increased in magnitude. Almost all subjects,
including those with labyrinthine deficit, shifted from a
hip strategy to a partial inverted pendulum when the visual signal varied in frequency, indicating that when the
visual signal had nothing in common with the physical
disturbance, the response was to stiffen the mechanical
system and decrease the degrees of freedom being controlled. Although the additional frequency was present in
the responses of the adults with labyrinthine deficiency,
their responses did not increase in size, suggesting either
that they were unable to produce responses of any greater
magnitude in the absence of labyrinthine inputs39 or that
modulating the response magnitude depended on an ability to calculate the visual-vestibular conflict.
Postural Reactions in
Peripheral Vestibular Disorders
A discussion of etiology and diagnostic testing of vestibular system disease is beyond the scope of this chapter but
can be found in other sources.9,85,86 The focus here is
on those vestibular disturbances that have been found to
produce a postural disturbance and that have been tested
for changes in vestibulospinal function. Dysfunction in
the vestibulospinal system can be divided into two categories: distortion and deficiency.87,88 A deficiency in the
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Head mounted display
Video capture
Back projection screen
CAVE
C
D
Figure 4.2 Some examples of virtual reality technology in which the performer can freely move
while interacting with the visual images. (A) The performer can walk about while wearing the headmounted display (Hi-Res 900, available from http://www.vrealities.com/hi-res900.html). (B) Video
capture permits performers to observe themselves interacting with virtual objects at the Laboratory
for Innovations in Rehabilitation Technology (http://hw.haifa.ac.il/occupa/LIRT). (C) In the Virtual
Environment and Postural Orientation Laboratory at the Rehabilitation Institute of Chicago, a dynamic
posture platform (NeuroCom International, Inc., http://www.onbalance.com/) has been placed in
front of a full field-of-view, back-projection screen in order to simultaneously perturb the base of
support and the visual system of the performer (http://www.smpp.northwestern.edu/index.php?
option-com_content&taskview&id66&Itemid85). (D) The visual image is projected on three
walls and the floor of the CAVE Virtual Reality System, and the performer is free to walk about within
the virtual environment (http://www.evl.uic.edu/pape/CAVE).
system usually implies that the sensory (i.e., labyrinthine)

inputs have been reduced or abolished, resulting mostly
in complaints of unsteadiness and instability. Distortion
means that the signal is present but disturbed and does not
correspond with expectations about the sensory feedback.
The result would be inappropriate or false motor responses to the existing situation (e.g., vertigo and ataxia). A
summary of postural disturbances is presented in Table
4-2 for the disorders discussed in this chapter.
Deficient Labyrinthine Inputs

With damage along the VIIIth nerve or within the vestibular labyrinth, signals from the peripheral vestibular apparatus are lost or diminished.74 Central disturbances
originate at the vestibular nuclei or in the higher central
pathways that communicate with the vestibular nuclei. In
both cases, patients can experience disequilibrium, imbalance, and ataxia. With unilateral lesions of the peripheral
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Table 4-2 POSTURAL DISTURBANCES

OBSERVED WITH
VESTIBULAR DISORDERS
Peripheral vestibular disorders:
Need more energy to maintain the
Deficient inputs
upright position
Instability increases in the presence
of inappropriate sensory signals
Amplitudes of EMG and torque are
inversely related to severity of
deficit
Distorted inputs
Still able to process vestibular inputs

Falls increase in the presence of
inappropriate sensory signals
Impaired perception and location of

Central vestibular disorders the gravitational vertical
Direction-specific ataxia
Falling tends to occur in the direction of quick-phase nystagmus
Aging
Longer response latencies and

delayed reaction times
Diminished sensory acuity and
impaired signal detection
Temporally disordered postural
response patterns
system, the normal symmetry of inputs from the right

and left labyrinths become disordered, resulting in a decreased firing rate of the vestibular nuclei on one side. A
unilateral lesion affects the system as if the intact side
were being stimulated, thus generating an illusion of
change in head orientation and movement. The inherent
disequilibrium then activates the vestibulospinal system
to respond inappropriately, resulting in vertigo, nystagmus, and postural instability.
Another effect of vestibular system stimulation,
maintaining tone of the muscles against gravity, appears
to be directly correlated with labyrinthine inputs, because
the activation of extensor muscles in the extremities of
both monkeys89 and humans90 with unilateral deficit was
found to be enhanced contralateral to the side of the
lesion. But postural reactions are more complex than single pathway vestibular reflexes and cannot be traced and
localized as easily as these direct-line responses. For ex-
61
ample, when both labyrinths are lesioned, an artificial

sense of motion does not occur, and neither do the symptoms of nystagmus and vertigo. Yet equilibrium is still
disturbed, suggesting that the balance function of the
vestibular system is not a simple response to stimulation
of the labyrinthine receptors.
Indicators of Vestibulospinal Deficiency

Unilateral and Bilateral Labyrinthine Deficit
Variability of the responses measured from the many
methods of posturography confirms the complexity of
control of these disordered postural responses. After
repeated attempts to quantify the results of the Romberg
test, the most reliable effort seems to be measuring energy of the power spectral densities of the center of force
trajectories while subjects maintain an upright position.91
Both in the study using this approach and in others using
force plates to record sway during quiet stance,10,73 intersubject variability and overlap between normal and clinical populations reduced the strength of the findings.
Results suggest, however, that more energy needs to be
expended to maintain an upright position when visual
inputs are removed (eyes closed) from patients with a
labyrinthine deficit.
In a series of papers presented by Black and colleagues,52,87,91 postural sway was recorded through a
potentiometer placed at the level of the hips. Patients
stood on a platform that could be either earth fixed or
moved proportional to body sway (servoed). The visual environment was then manipulated so that patients
experienced a visual field that was either: (1) earth fixed,
(2) proportional to body sway, or (3) removed by eye closure. Patients in whom labyrinthine inputs were reduced
or absent were more unstable than normal controls only
when ankle proprioceptive references were proportional
to body sway and visual references were either removed
or inappropriate (condition 2 or 3). It was believed that
when the only reliable source of feedback was the
vestibular inputs, patients with vestibular deficiencies
would fall because they depended on the somatosensory
and visual reference to correctly organize their postural
responses. From their studies, the researchers suggested
that vestibular deficits could be quantified by systematically altering the sensory information provided by the
support surface and the visual surround.
Several problems limit our reliance on these results
for clinical diagnosis and measurement. First, patients
with unilateral or partial bilateral deficits were sometimes
as unstable as patients with total loss of vestibular function,67 rendering this approach a poor test of graduated
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function in the vestibular system. Second, the researchers

tested only patients with well-compensated deficits. As
discussed later, compensation could occur as a central
reorganization in the system. Thus, these experiments
may be testing not a vestibular deficit but, rather, a compensatory subsystem that responds inadequately to the
presented stimuli. Third, patients with postural instability
from other, non-vestibular disorders may have test results
similar to those of patients with vestibular deficits (T.
Hain, S.J. Herdman, personal communication, [1999]).
Allum and colleagues21,39,44,45,68,92,93 examined both
the latencies and the amplitudes of muscle EMG responses on a platform that dorsiflexed the ankle. Areas under
the EMG bursts in the ankle muscles as well as soleus
and tibialis anterior muscles, and ankle torque recordings
of patients with complete bilateral labyrinthine deficit
were significantly diminished compared with those in
normal subjects with eyes both open and closed.
Using these data, Allum and associates69 explored
the presence of a linear correlation between EMG amplitudes and the extent of the peripheral vestibular deficit.
The population measured included subjects with intact
labyrinths (normal subjects) as well as those with acute
unilateral labyrinthine deficit, chronic unilateral labyrinthine deficit, and bilateral labyrinthine deficit, thus
covering a graduated range of labyrinthine function. A
stepwise discriminant analysis technique performed on
the data suggested that muscle response amplitudes in the
soleus and tibialis anterior muscles, as well as amplitude
of torque exerted on the platform, were inversely related
to the severity of the labyrinthine deficit. Muscle and
torque responses diminished in amplitude as the reception of labyrinthine inputs decreased. Because lower limb
EMG activity was still present in the patients with complete loss of labyrinthine inputs, a linear correlation of
the amount of EMG activity with extent of peripheral
vestibular deficit suggests that lower limb postural reflexes could be triggered by proprioceptive stretch reflexes,
but that amplitude modulation is under the control of, or
requires the presence of, vestibulospinal signals. EMG
activity in the neck muscles was not obviously altered in
these patients, implying local control of neck muscle
responses. Thus, the effectiveness of the ankle muscle
responses to produce a functional forward torque in
patients rotated backwards on a platform was diminished,
and these patients tended to fall backwards.
EMG responses of patients with vestibular deficit
during horizontal translations of a platform were also examined.45,55 Although latencies of the postural reactions
were produced without significant time delays, segmental organization of the postural response were disordered.
Allum and colleagues93 found that angular velocity
measures of rotation of the trunk about the hip were not
significantly altered in patients with a bilateral peripheral vestibular deficit and that a hip strategy was a common
component of the postural response to platform rotations.
These investigators suggested that the selection of movement strategy depended on the initial direction of trunk
and head acceleration (which is oppositely directed in
platform rotations and translations) and that the strategy
was executed as if preprogrammed from the beginning.
Although Horak and coworkers55 previously stated that
hip strategies were not seen in patients with vestibular
disorders, new measures of hip torques emphasize the
importance of identifying the proper response variables
when dynamic posturography is used as a diagnostic tool.
Runge and associates46 found that the joint torques at the
hip and knee were abnormal over a range of velocities
during rearward translations in patients with bilateral
deficit. Because head accelerations were the same in the
patients and healthy subjects, these investigators findings agreed with others21,39 that the magnitude and force
pattern of the muscles depends on vestibular inputs from
early head movements.
One can conclude that patients with partial or total
loss of labyrinthine input exhibit diminished amplitudes
of EMG response and thus require greater energy expenditure to maintain balance, particularly when another
source of stimulation to the system (e.g., visual inputs)
has been removed. These patients also exhibit greater
sway in sensory conflict situations, and variability
between patients is a common clinical occurrence
because of the dynamic central compensatory processes.
With unilateral deficit, the initial perception of apparent
body motion is directed away from the side of the lesion.
Postural reactions are usually in a direction opposite to
the direction of vertigo, causing a tendency to fall and to
deviate toward the affected side. Severe postural disturbances occur when these individuals must rely on
vestibular inputs, but the deficit is compensated within 2
weeks after the lesion.94 Individuals with bilateral deficit
exhibit normal postural sway in quiet stance.55 Removal
of vision via eye closure increases this sway by only a
small amount.87 These patients tend to fall backward
when their eyes are closed during dorsiflexion tilts of a
platform. Their diminished amplitudes of muscle activity
presumably result in the reduced restabilizing torques
recorded at the ankle, knee, and hip.95
Mnires Syndrome
Mnires syndrome, or endolymphatic hydrops, is considered a vestibular deficiency even though it manifests
as fluctuating vestibular function. Symptoms of acute
Mnires syndrome include hearing loss, tinnitus, and a
sensation of fullness or pressure in the ear.9 Patients with
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this syndrome exhibit a normal Romberg response during

remission,96 but symptoms of dizziness and instability
can occur for several days after intermittent episodes of
vertigo. These episodes appear at irregular intervals for
years, and about one third of the patients eventually have
bilateral involvement.9
Objective diagnosis of Mnires syndrome has
depended on long-term documentation of the fluctuating
hearing loss. Quantitative posturography measures have
been able to identify consistent changes in the postural
response of affected patients, even during periods of
remission. In one study, the movement pattern of the center of gravity was measured during a stepping test after
the researchers observed that patients deviated toward the
affected side even during the remission period.96 The
stepping test was performed in the dark with eyes open
and closed, and patients were required to perform at a
frequency that both was optimal for normal walking and
elicited a smooth rhythmical pattern (i.e., 1.2 Hz). When
their eyes were closed, the patients exhibited angular
deviations of 30 degrees or more toward the affected side
after 8 to 12 seconds of stepping. Time to deviation indicated a degrading central motor program that was initiated by visual inputs but that required vestibular inputs (in
the absence of vision) to be maintained over time.
Measures of sway during quiet standing have
included analyses of the pattern of motion, displacement,
and power spectrum of the center of gravity. With all of
these measures, position of the center of gravity changed
in an irregular fashion and deviated primarily toward the
affected side.97,98 High-frequency components of standing sway were observed during acute phases of Mnires
syndrome, but not during remission periods.98 Patients
with Mnires syndrome in whom vestibular hypofunction had not developed, as determined from VOR gains,
were also tested under conditions of sensory conflict during quiet standing (see earlier description in section
Indicators of Vestibulospinal Deficiency).91 These
patients responded very much like patients with wellcompensated unilateral or bilateral loss of labyrinthine
inputs. The group had nearly normal responses on all trials with the platform fixed to earth horizontal. Responses
fell outside the normal range when either the platform or
the visual field was perceptually stabilized, again suggesting dependence on reliable inputs from the vestibular
labyrinths during these test conditions.
Indications of Vestibulospinal Distortion

Benign Peripheral Positional Vertigo
In order to study the effects of distorted labyrinthine
inputs on posture, patients with BPPV have been exam-
63
ined.91 The key to this syndrome is that brief episodes of

vertigo (usually less than 1 minute) are generated with
position change. Paroxysmal positional nystagmus can be
observed with rapid changes of position. After a period of
several attacks, symptoms can become more prolonged;
they include dizziness and nausea lasting for hours or
days.9 Degeneration of the utricular macula, releasing
otoconia that settle on the cupula of the posterior semicircular canal, is strongly implicated as the cause of
BPPV and could have a variety of etiologies (e.g., trauma, infection, ischemia). The intensity of BPPV depends
on the velocity of the positional changes, and attacks can
be avoided if positions are assumed very slowly.99
Because of the positional component of this syndrome, postural changes are easily recorded during quiet
standing by having a patient with BPPV alter the position
of the head in space. After tilting of the head, large amplitudes of anterior-posterior sway and sway ipsilateral to
the direction of head tilt were observed in one study.99
Instability gradually decreased as the vertigo diminished,
but with eyes closed, the sway could not be compensated
by other inputs, and the patients fell.
Unlike patients with a loss of vestibular inputs,
patients with distorted inputs from BPPV reacted normally on a moving platform when forced to rely only
upon their vestibular inputs. More disturbing to this
group of patients were inappropriate (perceptually stabilized) visual circumstances whether the platform was
earth-fixed or moving proportional to body sway.67,87,91
Patients with BPPV probably rely primarily on visual
information to organize their postural reactions and have
suppressed their response to the potentially unreliable
vestibular inputs.
Postural Reactions in
One could erroneously assume that function of the
vestibular labyrinths is directly representative of the functional integrity of the vestibular system. Although receiving direct inputs from the peripheral labyrinths, the
vestibular nuclear complex also receives visual and
somatosensory inputs.74 Convergence of vestibular and
somatosensory inputs on the vestibulospinal and reticulospinal100 neurons can take place at the level of the
vestibular nuclear complex, at the adjacent reticular formation, and upon spinal interneurons101,102 and motoneurons.100 But growing evidence103,104 suggests that correct
alignment of the head with the trunk and with the gravitoinertial vertical105 requires that the vestibular system
receive ascending somatosensory inputs. To attain an
appropriate postural response, a convergence of sensory
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information from the vestibular, somatosensory, and visual systems is needed to align the body with respect to
earth vertical. Thus, with labyrinthine loss, even if the
otoliths remain intact, the ability to identify the upright
orientation may be impaired.106 Inputs from either of
these modalities are not necessarily redundant, because
each represents different parameters and is effective within a particular frequency domain.107109 In fact, the frequency of stimulation is important to control in patients
with compensated loss, because motor output of the visual system as well as the vestibular system has been found
to be frequency dependent.63,110113 Thus, it is unlikely that
normal postural responses are reflective of the isolated
labyrinthine and neck reflexes observed in the decerebrate
animal.114116 Instead, postural reactions probably emerge
from a dynamic coupling of all available sensory signals.
Body posture can be oriented to a visual, somatosensory, or vestibular reference frame, depending on the task
and behavioral goals. It may also be based on an estimated internal representation of body orientation with
respect to the environment from memory, thereby incorporating the expected multisensory inputs and flexible
postural reactions occurring for each task.117,118 A convergence of inputs from more than one sensory modality
would then be necessary to create this estimated postural
orientation. Studies by Keshner and Kenyon119 in a virtual environment demonstrated that converging inputs controlled postural orientation during rotations of the visual
scene in pitch and roll. The head and trunk were linked in
magnitude and phase, whereas the ankle produced small
compensations that were largely out of phase with the
upper body. These researchers inferred, as in a previous
study on a posture platform, that the upper body responded to visual-vestibular signals but the ankle responded to
proprioception and changes in ground reaction forces.24
Buchanan and Horak120 also reported differential controls
of the head and trunk and of the lower limbs when examining segmental organization of postural responses. Thus,
the cause of instability in labyrinthine-deficient individuals may be due to a disorder of head and trunk spatial orientation rather than lower limb instability.121
Several clinical findings have been suggested to differentiate between a peripheral disturbance and a central
disturbance in the vestibular system. Gradually increasing disturbances of standing, walking, and falling in the
direction of the quick phase of spontaneous nystagmus
have been identified as indications of a central vestibular
lesion.122 Balance disorders due to abnormalities of the
vestibular nuclear complex have been observed123,124 but
are poorly documented. The majority of the literature
about central vestibular brainstem lesions reports only
oculomotor abnormalities, but Brandt and colleagues124
have attempted to relate well-defined central vertigo syndromes to characteristics of postural imbalance. Briefly,
these investigators reported five conditions for which
postural imbalance have been consistently reported:
downbeat nystagmus vertigo syndrome, ocular tilt reaction, Wallenbergs syndrome, paroxysmal and familial
ataxia, and brainstem lesions that mimic labyrinthine
dysfunction. One should recognize, however, that structures other than the vestibular system may be damaged
and therefore may affect balance.
Downbeat nystagmus is specific for a lesion of the
paramedian craniocervical junction (30% of cases due to
Arnold-Chiari malformation), inducing a directionspecific vestibulospinal ataxia. Static head tilts modulate
the intensity of the nystagmus and the postural sway, suggesting involvement of otolith function. The typical postural imbalance in this condition is an anterior-posterior
sway with a tendency to fall backwards, but many affected patients do not complain of vertigo or balance problems. Brandt and colleagues124 suggest that the backward
sway is vestibulospinal compensation for the forward
vertigo resulting from the downbeat nystagmus. Ocular
tilt reaction is actually a triad of responses, consisting
of ipsilateral head-trunk tilt, ocular torsion, and ocular
deviation. This condition has been observed in patients
with brainstem abscess, multiple sclerosis, and acute
Wallenbergs syndrome. Patients seem to have a readjustment in their perception of the vertical that matches tilt
deviation of the eye, head, and trunk.
Wallenbergs syndrome is an infarction of the dorsolateral medulla resulting in ipsilateral dysmetria of the
extremities, pain and temperature loss, and a lateropulsion of the eyes and head that causes the body to deviate
toward the side of the lesion and, consequently, fall.
Paroxysmal and familial ataxias share the broad-based,
unsteady gait that defines ataxia. Finally, pontomedullary
lesions near the vestibular nuclei at the entry of the VIIIth
nerve can mimic a peripheral labyrinthine disorder, and
drop attacks (sudden, unpredictable forward falling) can
occur with basilar insufficiency. Thus, the evidence from
clinical reports suggests that a central vestibular dysfunction results in impairment of perception and location of
the gravitational vertical exhibited throughout the whole
body postural system. But with all of these syndromes,
other motor structures are affected as well and may contribute to the impairment.
Postural Dysfunction with Disorder

of Other Sensory-Motor Centers
The vestibular nuclear complex communicates with
motor as well as sensory centers.122 In fact, extensive
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reciprocal connections between the vestibular nuclei and

the cerebellum125 argue for a prominent role of the cerebellum in regulating the output of the vestibulospinal system, and lesions of the cerebellum result in severe
postural disturbances. Three kinds of cerebellar ataxia
have been identified, suggesting different pathophysiological mechanisms that depend on the site of the
lesion.126 A test of the sway-stabilizing responses on a
posture platform of patients with late cortical atrophy of
the anterior lobe of the cerebellum revealed that response
latencies were within normal limits after dorsiflexion
rotations and backward translations on a platform, but
amplitudes and durations of response were two to three
times greater than normal,127,128 and habituation to the
stimulus was absent.129 Postural response magnitudes in
the patients with anterior lobe damage were scaled correctly when they relied on current somatosensory feedback, but the patients were unable to scale their responses
when relying upon prior experience. Thus, the major
effect of anterior lobe cerebellar damage on postural
responses may be an impairment of responses based on
predictive central set.128
A characteristic sway frequency of 3 Hz has been
recorded in this population.130 Intersegmental counterbalancing actions were enhanced in these patients, so that
falling was not commonly observed, but they tended to
exhibit a stiff-legged gait. Stance ataxia was found to
improve with visual feedback, unlike that appearing with
vestibulospinal lesions.131,132 Thus, in these patients, stabilizing responses occurred, but they lacked the balance
between opposing muscle forces and grading of response
over time.
The postural system of patients with lesions of the
vestibulocerebellum (flocculus, nodulus, and uvula) may
be so severely impaired that they cannot walk. Ataxia of
the head and trunk is observed during sitting, standing,
and walking. These patients exhibit unusually large sway
in all directions with predominantly low frequencies of
less than 1 Hz, and visual stabilization appears to be
reduced when the Romberg responses with eyes open and
closed are compared. These patients tend to fall even
when sitting down, which may be due to diminished
intersegmental movement for counterbalancing or to
truncal ataxia.126,131 Neocerebellum lesions produce little
postural instability or disturbance of stance even with eye
closure. Control of position of the bodys center of mass
seems to be disturbed, because patients with these lesions
exhibit ataxia during a limb and trunk pursuit task.126
Reports of head and trunk deviation to the side of the
lesion have also appeared.131
With basal ganglia disorders, such as Parkinsons
disease, equilibrium reactions are often delayed or
65
absent.4 An anticipatory postural response in the soleus

muscle, normally seen in response to a perturbation of the
forearm, is absent or reduced in patients with such disorders,133 although long-latency responses to direct stretch
of a muscle have been observed to be enhanced in the
Parkinson population in both the arm134 and leg.135
Response latencies to sudden platform displacements
were found to be within the normal range,136,137 although
the ability to suppress long-latency muscle reactions to a
perturbation was impaired in these patients even under
supported conditions.138 When required to scale the magnitude of their responses to amplitude and velocity of
backward platform translations, patients with Parkinsons
disease produced smaller than normal extensor bursts,
larger than normal flexor bursts, and smaller torque
responses.139 On a sinusoidally moving treadmill, patients
with Parkinsons disease were able to maintain their balance with eyes open by using their leg flexor muscles,
whereas healthy subjects activated their extensor muscles. Timing and amplitude of this muscle activity were
also impaired.140 The inability to generate adequate force
in the stabilizing muscles appears, therefore, to be hampering successful postural reactions in these patients.
Inferring that the contribution of the basal ganglia or the
impairment of vestibular information during dynamic
postural reactions in this patient population is difficult,
however, because the motor impairments could be as
much an effect of akinesia, rigidity, or aging as of disruptions in the postural control system.
Lesions in motor cortex have also resulted in disturbances to the automatic postural reactions. Patients with
spastic paresis rarely exhibit disturbances of posture during quiet standing as in the Romberg test, but reactions to
rapid displacements of the support surface indicate
deficits in the dynamic postural reactions.141 Hemiplegic
adults demonstrate delayed onsets, a failure to respond,
and disparate responses of agonist and antagonist muscles in the paretic lower limb during postural perturbations on a platform.142 With augmented feedback, such as
a warning tone and knowledge of perturbation direction,
however, timing of the postural responses improved.143
When balancing on a seesaw apparatus, patients with
spastic hemiparesis minimized the high-frequency,
anterior-posterior sway on the affected side with a corresponding reduction of the EMG response in the tibialis
anterior muscle.144,145 Electrical stimulation of the tibial
nerve in patients on the seesaw revealed a delayed and
diminished EMG response of the tibialis anterior muscle
in the affected leg, thereby interfering with the normal
compensatory response to displacement of the support
surface. Spastic paraparetic patients were observed to
produce qualitatively similar results.144,145
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Children with cerebral palsy have also been studied

with a posture platform.146 Their instability seemed to
correlate with the clinical diagnosis, so that children with
spastic hemiplegia exhibited reversals in the expected
order of muscular activation, whereas children with ataxia demonstrated normal muscle sequencing but fell frequently. The timing, direction, and amplitude of their
postural reactions were disturbed, particularly when the
expected sensory inputs had been altered (see paradigm
described in section Indicators of Vestibulospinal
Deficiency). Thus, postural abnormalities of children
with cerebral palsy were due either to muscle incoordination or to instability as a result of an inability to deal
with sensory conflict.
Results of these clinical studies suggest that the
long-latency, polysynaptic postural adjustments can be
elicited at the spinal level but require modulation by
supraspinal structures to develop a sufficient response
threshold and gain. Possibly there are an inappropriate
number of nerve fibers within the damaged motor pathway to excite the motoneuron pool, or the damaged pathway sends a reduced drive to the interneurons at
segmental levels that would normally facilitate the polysynaptic reflex response.141
Mechanisms for Recovery

of Postural Stability
Identification of compensatory mechanisms will improve
therapeutic interventions that teach compensation for, or
adaptation to, destabilizing conditions. These mechanisms are studied through clinical research, but we must
be cautious about conclusions drawn about the function
of an anatomical site that are based strictly on the
absence of motor control in the presence of specific
deficits or damage. We must remember that responses
generated in the absence of a sensory or motor signal do
not reveal the function of that input. Rather, these
responses demonstrate how the system operates in the
absence of certain inputs.
Sensory Substitution
Vestibular, visual, and somatosensory signals influence
the organization of a normal postural response. When any
one of these signals is lost or distorted, a central reweighting occurs so that the remaining sensory inputs are used
to elicit postural reactions, albeit in some altered fashion
(Box 4-1). Changes in the postural response organization
with loss of labyrinthine inputs have been described in
detail earlier in this chapter. Two modifications in particular should be noted. First, in the absence of labyrinthine
Box 4-1
MODIFICATIONS OF POSTURAL
STABILITY AFTER LOSS OF
SPECIFIC SENSORY INPUTS
Labyrinthine deficits:
Stiffening between body segments
Increased sway at high frequencies
Somatosensory deficits:
Low-frequency sway during quiet stance
Delayed restabilization
Increased lateral sway
Visual deficits:
Increased sway at low frequencies
Increased sway at high frequencies when
labyrinthine inputs are also absent
signals, the normal postural reactions to dorsiflexion of

the ankle are elicited, but with significantly diminished
amplitudes.92 Thus, the response does not reach an appropriate gain to maintain stability, and restabilizing torques
at the ankle are inadequate to prevent falls.
Second, the patient with peripheral vestibular
deficits tends to hold the neck stiff so that little free head
movement occurs. An analysis of the temporal relationship between angular acceleration of the head and trunk
in the flexor and extensor directions demonstrates that
patients move their heads in the same direction as their
bodies (head locked to trunk) in association with absence
of neck torques,147 whereas normal subjects exhibit a
counter-rotation of the head and body in the sagittal
plane.61,93 This finding correlates with clinical observations that patients with vestibular deficits increase the
gain of neck muscles to hold the head stiff in relation to
the body. A fast Fourier transform performed on the head
and trunk angular acceleration recordings revealed a loss
of the normal 2- to 3-Hz peak in the power spectrum of
patients with bilateral labyrinthine deficit.39 This frequency has been cited as the operating frequency for the
vestibulocollic reflexes in studies of normal subjects
attempting to stabilize the head during vertical and horizontal rotations in the seated position63,111 and is typical
of natural head movements during locomotion.148,149
Stiffening of the muscles may, therefore, be one compensatory strategy that actually works against successful
restabilization by interfering with the normal balance of
movement-dependent torques at the different body segments and with the reception of stimuli necessary to produce vestibular adaptation.
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Somatosensory inputs provide powerful feedback

about motion of the limbs and stabilize body sway at the
lower frequencies (1 Hz). Studies have shown that sensory input to the hand and arm through contact cues at the
fingertip or through a cane can reduce postural sway in
individuals who have no impairments and in patients
without a functioning vestibular system, even when contact force levels are inadequate to provide physical support of the body.138,150 When proprioceptive feedback
from the ankle is excluded or suppressed in normal subjects during perturbations on a posture platform,18,151 a
characteristic low-frequency (1-Hz) sway emerges.
Postural abnormalities have been observed with impairment of spinal pathways such as occurs with Friedreichs
ataxia, a hereditary disorder affecting the spinocerebellar
pathways and posterior columns.152 In the absence of
feedback from these pathways to the cerebellum, a significant delay of the restabilizing response of the tibialis
anterior muscle after dorsiflexing ankle rotations on a
posture platform has been observed.127 Affected patients
exhibit large lateral sway deviations in the low-frequency
range (1 Hz) with eyes closed, as do patients with tabes
dorsalis.151 Patients with sensory polyneuropathy of the
lower extremities demonstrate ataxia and instability during quiet stance. Falls tend to occur when the eyes are
closed,152 suggesting that visual inputs are necessary
along with vestibular inputs in the absence of lower limb
proprioceptor signals.
Finally, cervical proprioceptors have been the focus
of investigations related to the diagnosis of dizziness and
ataxia.153,154 The neck proprioceptors have intimate connections with the vestibular system and are probably used
both as feedforward and feedback to the vestibulocollic
reflexes.155 Cervical ataxia has been a controversial diagnosis, however, because there are no hard signs to identify the neck as the source of the dizziness.154 Karlberg and
colleagues156158 have engaged in a series of studies to
verify ataxia or vertigo of cervical origin. Using posturography in which stance was perturbed by a vibratory
stimulus applied towards the calf muscles, they studied
patients with recent onset of neck pain and vertigo but
normal otoneurological findings. Results demonstrated
disturbed postural control in the patients with cervical
vertigo that differed from that in patients with vestibular
neuritis, suggesting that disorders of the neck should be
considered in the assessment of patients complaining of
dizziness, vertigo, and balance disturbances.
Visual signals are used to accurately detect and
reduce motion relative to the surround.159,160 In normal
subjects, vision is very influential but does not appear to
be an essential input for the recovery of balance. Many
studies have shown that simply removing vision does not
67
produce significant changes in the postural response

organization, although greater sway amplitudes may
appear.39,49,51 Instead, visual information is thought to be
redundant unless both vestibular and somatosensory
inputs are lost.160 To test the importance of visual inputs
in the absence of labyrinthine inputs, sway was measured
in subjects standing on a stabilometer placed within a laterally tilting room.48 At low frequencies of sinusoidal tilt
(0.0025 to 0.1 Hz), patients with unilateral and bilateral
labyrinthine deficits exhibited sway similar to that of normals. At higher frequencies (0.2 Hz), the patients sway
increased beyond normal limits, indicating that patients
with vestibular deficit could rely upon visual inputs at
lower frequencies, but suffered for the loss of vestibular
signals at higher frequencies.66,161 Patients with labyrinthine deficit tested with a stabilometer were better able to
stabilize sway when fixating on a stationary light.162
When an optokinetic stimulus was introduced, the
patients became unstable, suggesting that velocity information received through peripheral vision was the cause
of the increased sway.
In summary, patients lacking labyrinthine inputs
become more dependent on accurate ankle proprioceptive and visual references to correctly organize their postural responses. Inappropriate or distorted signals along
either of these sensory pathways produce increased sway
and falls in these patients. Although the sensory signals
often provide congruent information, inputs from any of
these modalities are not necessarily redundant, because
each represents different parameters and is effective
within a particular frequency domain.66,107,108 Thus, the
falls observed in patients with vestibular deficits, particularly after a platform perturbation or in the absence of
other sensory signals, may be due to uncontrolled or
poorly compensated oscillations of intersegmental structures at particular frequencies of sway.
Compensatory Processes
Compensation for vestibular disorder is a gradual process
of functional recovery that is probably of central origin.163,164 Although adaptation (i.e., long-term changes in
gain) of lower limb postural reactions has been observed
in patients with labyrinthine deficit,90,165 these individuals still evidence a great deal of instability. Thus, adaptation to support surface inputs alone is not an effective
compensatory process. Numerous structures have been
identified as participating in vestibular compensation,
including the vestibular nuclei, spinal cord, visual system, cerebellum, inferior olive, and more.164 Thus, focusing specifically on a single site for functional recovery of
postural control would be difficult. In fact, studies have
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shown that in both humans and animals, methods of compensation for vestibular dysfunction are not comparable
either among subjects or in a particular subject for different functions.164,166 The only consistency seems to be that
the goal of postural compensation is to reorganize the
neural circuitry so that bilateral stimulation of the
vestibular system is kept in balance.
The role of central processing in posture control can
be observed in anticipatory adjustments that are preprogrammed and can create the inertial forces necessary to
counterbalance an oncoming balance disturbance.167169
Subjects asked to co-contract their neck muscles to counteract random sum-of-sines rotations exhibited neural
control over a greater bandwidth than when distracted or
relaxed,170 suggesting that feedforward signals could
alter the reactive components of the response. Horak and
Nashner27 found that prior experience as well as current
feedback information influenced the selection of postural strategies on a translating platform. When subjects had
some knowledge of the characteristics of a forthcoming
visual displacement, they were able to reduce their postural readjustments even when they did not exert active
control over the visual motion.60
Central control over postural responses can be
measured in studies examining predictive processes. For
example, Guitton and associates110 assessed the influence
of mental set on the relative importance of visual and
vestibular cues for head stabilization in humans. Normal
subjects and patients with bilateral vestibular deficit were
tested on their ability to stabilize their heads voluntarily
with visual feedback and in the dark, and while distracted with a mental arithmetic task while being rotated horizontally using a random (white noise) stimulus with a
bandwidth of 0 to 1 Hz. Normal subjects stabilized their
heads best when voluntarily attempting to keep the head
coincident with a stationary visual target. Patients with
vestibular deficits had comparable response amplitudes
with vision present but much lower amplitudes when
vision was removed. The apparent absence of head stabilization when subjects performed mental arithmetic suggested that the short-latency (approximately 50 msec)
head-stabilizing reflexes provided little effective head
stabilization at these frequencies of rotation. An analysis
of response latencies revealed that long-latency or voluntary mechanisms (occurring at 150 msec) were primarily responsible for the observed head stabilization.
Anticipatory presetting of the static and dynamic
sensitivity of the postural control system also assists in
stabilization of the head at high frequencies.169,171
Practice or prior experience with a postural task influences EMG output. With practice, decreasing size of the
EMG response to a plateau level has commonly been

observed during stabilizing reactions,19,39 suggesting central habituation of these responses at the cortical or spinal
level. Selection of postural strategies on a translating
platform is influenced by prior experience as well as current feedback information.27 When the task is well practiced, subjects are able to combine complex movement
strategies and respond quickly under a variety of different posture platform paradigms. Even patients with
chronic labyrinthine deficits eventually demonstrate normal sway,73 indicating that a central regulatory mechanism is compensating for the peripheral dysfunction.
A study of head-stabilizing responses with random
frequencies of sinusoidal rotation may have revealed
the method by which the CNS is regulating postural
compensation.172 With testing in the dark at high frequencies (up to 4 Hz), compensation for bilateral peripheral labyrinthine deficit manifested as a shift in system
mechanics. In the horizontal plane, patients were able to
compensate for trunk rotation by increasing stiffness of
the head and neck. In the vertical plane, patients maintained a stable head over a broader frequency range than
healthy adults, possibly by changing stiffness or increasing the gain of the cervicocollic reflex to compensate for
instability at higher frequencies. The inability of patients
to stabilize at low frequencies (below 1 Hz) in the sagittal plane suggests that the system requires otolith inputs
for quiet standing. The ability to maintain a stable head
at more functional higher frequencies, however, suggests
that individuals with a labyrinthine deficit have acquired
an adaptive strategy, revealing the complex integration
of CNS control over the mechanical properties of the
system.
Changes in Postural Reactions with Aging

An impaired vestibular system is believed to be involved
in the greater instability of the elderly, because anatomic
studies have revealed a gradually decreasing density of
labyrinthine hair cell receptors beginning at age 30 years,
and a steeper decline in the number of vestibular receptor
ganglion cells beginning around age 55 to 60 years .173175
Although caloric measures of the peripheral vestibular
system have demonstrated declining function with age,174
these changes are not present in the central vestibular
neurons. The gradual loss of labyrinthine acuity with age
prompts viewing the elderly population as a model for
compensation to vestibular dysfunction. But in the elderly, sensory loss occurs as a slow process along several
feedback pathways, not just the vestibular pathways.173177 Thus, their compensatory approach to postur-
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al instability may not be the same as that in patients who

have experienced an acute but sustained loss of a single
input (see Table 4-2).
Age-related trends in the VOR and optokinetic
reflexes have been shown to correlate well with anatomic
changes found in the peripheral vestibular system.176,177
Declining gains and greater time delays have been seen in
the optokinetic response (OKR), and decreased VOR
gains with larger phase leads appeared at frequencies
below 1.5 Hz. These findings would suggest that elderly
subjects rely more on the visual tracking reflexes, and
that longer visuomotor processing time could contribute
to feedback delays and poor performance.176 Thus, elderly individuals have more difficulty detecting sensory signals, indicating a loss of stability, and when they do,
longer response latencies may well interfere with their
ability to produce timely stabilizing reactions.
If conflicting sensory information is not suppressed,
but instead can influence and modify the weighting of all
other sensory inputs, older individuals may be particularly disturbed in the presence of conflicting visual and
somatosensory information. Postural responses of older
subjects have been observed to be poorly organized during combined support surface perturbations and mental
distraction tasks178,179 and the predictive components of
posture were noted to be absent.180 Results from a number of studies181183 suggested that when two simultaneous tasks were required (e.g., postural stabilization and
manipulation), postural adjustments were delayed in the
elderly. In an elderly subject with disruption or deterioration of the mechanisms controlling balance, any distraction from postural control may be dangerous. In fact,
when maintenance of an upright position and stabilizing
gaze were both required, an increased incidence of falling
appeared in the elderly subjects in several studies.184186
Falls among the elderly are a major public health
concern because they are the leading cause of injuryrelated death and of nonfatal injury in the United
States.187,188 The dynamic process of maintaining an
upright posture is compromised in the elderly, as evidenced by this higher incidence of falling. Lengthened
response latencies, increased static sway, and muscle
weakness have been cited as contributing to falls in the
elderly,189,190 but none has been identified as a causal factor. Attentional demands and disorganized postural
strategies are more global parameters that have been targeted as potentially generative causes of falls.95,178,191193
Increased instability on a moving platform194,195 and during locomotion196198 has also been attributed to an
increasingly rigid trunk with aging. It has been observed
that older adults stiffen the trunk in order to decrease the
69
controlled degrees of freedom in an effort to make themselves more stable,192,199 yet they still produce reduced
head stabilization in space.200,201
A longitudinal study of elderly people who have fallen has found significant changes in the mean frequency of
postural sway in the medial-lateral direction.202 A lowfrequency component was identified in this plane, suggesting a slow postural drift during quiet standing.203 On
a posture platform, the stabilizing muscle synergies,
found to appear in a temporally consistent fashion in
young healthy subjects, exhibit a disorganized order of
onset in the elderly.204 Latencies of EMG responses and of
reaction times are increased in the elderly population,191,204,205 as is quiet sway.206,207 Although measures of
both sway induced by platform perturbation and quiet
sway demonstrated significant aging-related decreases in
stability,208 the differences between young and elderly
were more pronounced for the perturbed sway data. Some
of the quiet sway measures, however, were more successful in distinguishing elderly fallers from nonfallers.208
A study of elderly individuals on a rotating posture
platform95 has explored whether delayed latencies of
lower limb muscle responses are responsible for the failure to produce torque outputs necessary to compensate
for unexpected falling. Results indicate that a disordered
temporal relationship between tibialis anterior and soleus
muscles, which are concurrently activated in younger
individuals,39 lead to decreased stabilizing ankle torques.
Weakness of the tibialis anterior muscle has been
described in the elderly190 and could be a major contributor to this diminished torque response.
Greater stiffening between the head and trunk has
also been reported in elderly subjects attempting to keep
the head stationary in space when the trunk was moving199,200,209 and during whole-body postural control.36
Elderly subjects exhibited larger joint torques and greater
trunk motion than young adults when attempting to stabilize on a translating platform and when standing on a
narrow beam,36,200,210,211 which could be due to a stiffer
mechanical system. If elderly individuals lock the head to
the trunk in order to decrease the controlled degrees of
freedom, these greater torques would be transmitted to
the head. These data imply that elderly subjects rely upon
active trunk mechanics to coordinate head and trunk
motion but the stiffer trunk results in less damping of the
ascending forces and, therefore, poorer stabilization.
Thus, impaired balance in the elderly may be produced
by altered response synergies that are generated by
delayed vestibulospinal and propriospinal reflex responses and a postural strategy to increase stiffness of the
aging musculoskeletal system.
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Summary
The following conclusions can be drawn about mechanisms that contribute to postural stability from the existing data. First, central neural processes influence stability
in the form of automatic, long-latency reactions, voluntary movements, and changes in both the passive mechanical properties (e.g., stiffness) and active force outputs
(e.g., joint torques) of the system. Second, the presence or
absence of specific sensory inputs (e.g., vestibular or proprioceptive) alters the magnitude or temporal onset of the
muscle response pattern, whereas distortion of sensory
inputs seems to rearrange the directional organization of
the muscle response patterns. Third, learning, attention,
and predictive processes influence the performance of
postural reactions, as does the motor activity in which the
individual is currently engaged when the postural behavior is required. Finally, a particular compensatory strategy adopted by a patient may interfere with, rather than
assist, postural stability.
Thus, clinicians and researchers should identify the
preplanned and automatic components of a postural
response to determine how best to influence the postural
response organization. Recognizing the multiple factors
that contribute to the outcome of a postural response
should help clinicians determine the approach and effectiveness of their intervention strategies for retraining and
restoration of postural function in patients.
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5
Vestibular Compensation:
Clinical Changes in
Vestibular Function with
Time after Unilateral
Vestibular Loss
Sudden, complete unilateral loss of vestibular function in

normal, healthy individuals results in a dramatic series of
symptoms: rapid eye movements, postural instability,
inadequate compensatory responses to head movement,
as well as changes in the perception of body orientation
and movement. We use the term uVD (unilateral vestibular deafferentation) syndrome to refer to these symptoms,
which are discussed in more detail later. Within a few
days or weeks, some of these symptoms diminish and
some do not; the term used to describe the general recovery from this syndrome is vestibular compensation. The
symptoms of the uVD syndrome are complex and varied,
and many factors can affect their occurrence and diminution. Simply listing the symptoms and their change over
time does not help the understanding of the uVD syndrome and the recovery from it. To clarify what happens,
we will examine the neural basis of the symptoms and
their diminution.
Why does a uVD cause these symptoms? Why are
these symptoms not permanent? The answers lie in the
neural basis of the uVD syndrome and the changes in the
pattern of neural activity over time, mainly in the vestibular nuclei of the brainstem. Immediately upon loss of one
76
labyrinth, there are major changes in neural activity in

each of the two vestibular nuclei on either side of the
midline of the brainstem. During vestibular compensation, the altered pattern of neural activity returns to something approaching normal, and as it does so, some of the
symptoms of the uVD decrease.
The following three facts must be taken into account:
1. Neurons in the first vestibular relay nucleus in
the brainthe medial vestibular nucleus in the
brainstemreceive input from the peripheral
vestibular receptors and relay output to many
destinations, most importantly to oculomotor
(vestibulo-ocular), postural (vestibulo-spinal),
and also thalamic structures probably responsible for the sensation of body position and
movement.
2. Neurons in the paired vestibular nuclei on each
side of the brainstem communicate across the
midline with each other. This commissural
interaction plays an important role in normal
vestibular function and in vestibular compensation.
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Chapter 5 VESTIBULAR COMPENSATION
3. Most importantly, the activity of neurons in the

vestibular nuclei is not determined solely by
input from the peripheral vestibular system.
These neurons also receive input from many
other neural structures and any of those inputs
can modulate their activity and so influence the
behavioral responses (and perception) during
uVD and its recovery. For example, visual
input, spinal input, reticular input, and cerebellar input all project to neurons in the vestibular
nucleus and can modify their activity (Fig. 5.1).
The multiple-input character of neurons in the
vestibular nuclei is important for understanding why so
many seemingly unrelated sensory inputs can affect the
uVD syndrome and recovery from it (see Fig. 5.1). The
transmission of vestibular activity can be affected by the
cerebellum. For example, axons from cerebellar neurons
project directly onto neurons in the vestibular nucleus,
allowing a very direct, fast, and powerful control of transmission from the periphery to the neurons controlling
vestibular responses. That cerebellar modulation can
range from silencing the transmission of vestibular information to enhancing the gain of the transmission!
In this chapter, we review the behavioral, clinical,
and experimental evidence concerning neural transmission of vestibular information, how it is modified by unilateral loss, and what happens over time as recovery takes
place. For other reviews of vestibular compensation, see
references 1 through 18.
Overview
Similar patterns of responses after uVD occur in different
species, which recover quickly over time in a way that
parallels human recovery, although the exact speed of
77
recovery varies considerably from one species to another.

For example monkeys, cats, rats, guinea pigs, and humans
show ocular nystagmus after uVD. But in some of these
species (rats and guinea pigs), this spontaneous nystagmus disappears in about 1 day, whereas in other species
(such as humans), the disappearance takes longer. Given
this similarity among species, one can reasonably assume
that similar neural processes underlie the recovery in
these different species; that assumption is the basis for
using results from experimental studies on animals to
understand human vestibular compensation. Although
vestibular compensation appears to be a single recovery
process, there is overwhelming evidence that many different processes are changing during vestibular compensation and that the various processes recover at different
rates or, in some cases, do not recover at all.
One conundrum is that, although most patients recover from uVD and lose their acute symptoms quickly,
others experience incomplete recovery. The term used to
describe such partial recovery is poorly compensated.
In other patients who have recovered completely and
appear to be fully functional (who are well-compensated ), there can be a near total relapsecalled decompensationunder particular conditions, such as severe stress.
Causes
Patients with uVD are not a homogeneous group but
the very opposite: They constitute a very heterogeneous
group, and that heterogeneity is a major reason for the
heterogeneous results of vestibular compensation. The
cause and extent of the loss of vestibular input are factors
that must be considered in individual patient cases. There
are many possible causes of unilateral loss of peripheral
vestibular function, including disease, trauma, surgery
INPUT
MODULATION
OUTPUT
cerebellar inhibition
Figure 5.1 A simple general schematic

illustration to represent the responses that
can be controlled by vestibular input and how
transmission of the vestibular input to govern
those responses can be modulated by various
sourcesvisual, spinal, reticular, and cerebellar. This scheme should not be taken too literally; for example, there is evidence that visual
input differentially affects eye movements and
posture.
eye movements
Vestibular input
postural control
perception
spinal
visual
reticular
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(e.g., for removal of acoustic neuroma), and therapeutic

intratympanic injection of gentamicin for the treatment
of peripheral vestibular disorders.
The reason for the uVD can be a determinant of the
severity of the symptoms and the rate of recovery. A normal healthy person who suddenly loses all peripheral
vestibular input from one ear experiences dramatic symptoms (nystagmus, postural instability, and perceptual
phenomena). At the other extreme, someone who has had
a slowly growing acoustic neuroma on one vestibular
nerve and then has undergone surgical removal of the
neuroma and the entire VIIIth nerve may exhibit almost
no uVD symptoms. The reason for lack of symptoms in
such a patient is presumably a progressive vestibular loss
for which the patient has been progressively compensating as the neuroma grew. So by the time the surgery takes
place, the patient has no effective vestibular function in
the affected ear. Therefore, he or she has no uVD syndrome and so no vestibular compensation after surgery.
Without knowledge of the preoperative level of vestibular function and an understanding of the mechanism of
vestibular compensation, these totally different uVD syndromes would be inexplicable.
The anatomy of the peripheral vestibular nerve is
also important for understanding the symptoms experienced by the patients, their recovery, and the variability
among patients. Although most vestibular afferent neurons course in the vestibular divisions of the VIIIth cranial nerve, some vestibular neurons course in the cochlear
division of this nerve. If a patient still has hearing after
undergoing a procedure such as surgical vestibular
neurectomy, it is highly likely that residual vestibular
neurons still project from the affected labyrinth to the
brainstem, where this residual vestibular input may trigger postoperative vestibular symptoms.
Many procedures are used for therapeutic intervention in peripheral vestibular function. For example, neuroma removal usually involves entire removal of the
VIIIth nerve, whereas vestibular neurectomy involves
sectioning only one division of the nerve (e.g., the
superior vestibular nerve). The various vestibular sensory
regions project their information to the vestibular nucleus
in different bundles of fibers within the vestibular nerve,
so neurectomy will spare some vestibular neurons. That
knowledge is also important for understanding recovery
processes, because if just one division of the vestibular
nerve is surgically sectioned (e.g., the superior vestibular
nerve), then there is still substantial vestibular input projecting to the vestibular nuclei via the other branch (the
inferior vestibular nerve).
One procedure now very widely used to treat unilateral peripheral vestibular dysfunction, largely because of
its safety, is intratympanic injection of a solution of the

ototoxic antibiotic gentamicin via a fine needle inserted
through the eardrum into the middle ear (see Carey19 for
a review). The gentamicin is taken up into the inner ear
through the round window of the cochlea and selectively
attacks vestibular receptors in preference to cochlear receptors, even though both auditory and vestibular receptors are hair cells.
At low doses, gentamicin attacks the cilia of
vestibular receptors, disabling their response to natural
vestibular stimuli but having little effect on cochlear
receptors, so hearing is minimally affected. Interestingly,
gentamicin attacks vestibular receptors in a progressive
fashion; type I receptors at the striola of the otoliths and
the crest of the crista are most vulnerable.20 Physiological
evidence shows that these receptors and the afferent neurons terminating on them convey information primarily
about changes in vestibular stimulation; one would
expect that if they are lost, information about changes in
vestibular stimulation would be affected early. Evidence
now shows that behavioral changes correspond to that
progressive loss.21 It is worth noting that the cell bodies
of the receptors may be preserved during the course of
the gentamicin treatment, and the receptor cilia on these
vestibular receptor cells may regrow afterwards, so that
vestibular function (and possibly vestibular symptoms)
may reappear following gentamicin treatment.22
The intratympanic gentamicin injection procedure is
now so successful that surgical uVD procedures are, with
the exception of neuroma surgery, becoming less common. However the final level of residual vestibular function is uncontrolled after gentamicin treatment and unless
post-procedural testing is undertaken, is unknown. After
the same intratympanic gentamicin injection procedure,
some patients may lose almost all vestibular function,
and others may lose much less.
One of the themes of this chapter is the importance
of having baseline data about the level of vestibular function before any therapeutic procedure. This should be
complemented by data about the level of vestibular function after the procedure. Obtaining such data requires a
very modest investment of time in relation to the possible
outcome in a patient who compensates poorly for the loss
due to the procedure because the supposedly healthy
other ear was, in fact, dysfunctional. Such a patient may
spend many years in therapy and rehabilitation in an
attempt to overcome the poor vestibular compensation
that was due to an inappropriate procedure.
To measure precisely the pattern and resolution of
the uVD syndrome in humans, it is best to study the same
patients before and after surgical deafferentation of one
intact labyrinth. Although such patients and the facilities
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for studying them are few, some long-term quantitative

data on the precise sensory and motor consequences of
uVD in humans are available.2325 In particular, some
patients with Mnires disease probably have normal or
near-normal labyrinthine function between attacks of
vertigo, and some of these patients have been studied
before and after unilateral vestibular neurectomy.
The uVD Syndrome

What are the symptoms after uVD? Humans have intense
disequilibrium with both sensory and motor components,
which can be categorized into static or dynamic symptoms. Static symptoms are present continuously, even
when the person is totally stationary. Dynamic symptoms
become apparent during movement. We discuss each
category in turn.
Static Symptoms
Immediately after uVD, there is a spontaneous, mainly
horizontal, ocular nystagmus. Both eyes show rapid eye
movements, so that they appear to be beating away from
the affected (lesioned) side. In fact, recordings of eye
position show there are slow eye deviations (called slow
phases) toward the affected side, followed by rapid eye
movements (called quick phases) away from the affected
side (Fig. 5.2). Those slow deviations are not apparent to
an observer and can be detected only by careful recording procedures. To the observer, therefore, both eyes
appear to be beating away from the affected ear. Because
this nystagmus can be reduced or entirely suppressed by
visual stimuli, a way of viewing eye movements in darkness or without any visual fixation stimuli present is
needed in order to observe it. Two ways of doing so are
the use of Frenzel glasses and video recordings of eye
movements in total darkness with the eye illuminated by
(invisible) infrared light. In the week after the occurrence
79
of uVD, the strength of the spontaneous nystagmus in

darkness declines, but for some patients, a very small
spontaneous nystagmus in darkness remains as a permanent legacy of the uVD.
The horizontal component of the spontaneous nystagmus occurs because the uVD removes peripheral
vestibular input to one vestibular nucleus, creating an
imbalance in average neural activity between the two
vestibular nuclei.26,27 This imbalance in neural activity is
very similar to the imbalance produced by a large maintained horizontal angular acceleration to the intact side.
In both cases the nystagmus is the vestibulo-ocular
response generated by that vestibular neural imbalance.
In spontaneous nystagmus, the vertical eye movement components are small or absent, presumably because the two vertical semicircular canals in the labyrinth
cause essentially opposite eye movements (anterior canal
causes upward movements, and posterior canal causes
downward movements). The loss of both of these sensory
regions will result in a net cancellation of vertical components.
Ocular Tilt Reaction

In addition to spontaneous nystagmus, there is a static
otolith component called the ocular tilt reaction.28 It
seems that these static otolithic symptoms are also due to
the neural imbalance between the vestibular nuclei.
Removing all otolithic input from one vestibular nucleus
results in an imbalance in neural activity between the two
vestibular nuclei similar to that occurring during a large
maintained roll head tilt toward one side.29 The otolithic
responses to unilateral vestibular loss can be seen as
compensatory responses for such a head tilt
Head tilt to the lesioned side
Skew deviation to the lesioned side
Conjugate ocular torsion to the lesioned side
Figure 5.2 Peripheral vestibular nystagmus. Oculographic recording showing a left-beating

primary-position nystagmus that is obvious only when visual fixation is removed (open arrow) and
that is quickly suppressed again when visual fixation is permitted (solid arrow). One can detect
peripheral vestibular nystagmus clinically by viewing the fundus of one eye while occluding the
other. This patient had undergone a right vestibular neurectomy the previous day. Upward deflections indicate rightward eye movements, and downward deflections indicate leftward eye movements.
Bars represent 10 degrees and 1 second.
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In skew deviation, the ipsilesional eye is positioned

lower in its orbit relative to the position of the contralesional eye in its orbit. This can result in double vision
(diplopia), but the extent of the skew deviation is rarely
large and resolves rapidly.28,30,31 In ocular torsion, both
eyes roll with the upper pole toward the lesioned ear and
take up a maintained ocular torsional position, which can
be up to 15 degrees of ocular torsion relative to the preoperative torsional position (Fig. 5.3).25,28,30,32,33
This aberrant ocular torsion position resolves slowly

over time, but some residual ocular torsion seems to be a
permanent legacy of a uVD.25 How can it be measured?
Examination of the fundus of the eye of affected patients
shows that the torsional position of the eye has changed:
The upper pole of both eyes has rolled to the lesioned
side.25 However, when the torsion is small, it is difficult to detect with fundus observation. A more sensitive
way is to use the change in perception of the subjective
Figure 5.3 Fundus photographs of the left and right eyes of a patient before (top) and 1 week
after (bottom) right vestibular neurectomy. After unilateral vestibular deafferentation (uVD) there is
tonic torsion of the 12 oclock meridian of each eye toward the patients right side. The change in
torsion angle measures 17 degrees in the right eye and 15 degrees in the left eye. When the patient
was asked to set a luminous bar to the perceived visual horizontal in an otherwise darkened room,
he set the bar tilted toward his right side by 14.2 degrees when viewing with the right eye and by
15.1 degrees when viewing with the left eye (From Curthoys et al., 1991.25)
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visual horizontal, which closely corresponds to the

change in ocular torsional position.25,34 The clinician can
so measure visual perception by asking subjects in an
otherwise darkened room to set a rotatable visible line so
that it is where they perceive the visual horizontal to be.
Patients with unilateral vestibular loss set this line so that
it is too low on their affected side.25,31,3537 Comparison
of the ocular torsional position and the subjective visual
horizontal shows that patients rotate this visual line so
that its image lies along their (torted) retinal meridian.
We have studied patients before and after unilateral
vestibular neurectomy and demonstrated that the size of
the change in the perception of the subjective visual horizontal corresponds almost exactly to the change in ocular torsional position and that the torsion position and
perception recover in parallel over time (see Chapter 9).
Our findings have been confirmed by others. The change
in visual perception of the horizontal (or vertical) is a
useful indicator of the recovery of otolithic function over
time.3840
The clinical significance of these findings is that
careful standardized measurement of the subjective
visual horizontal of patients seated with head erect in an
otherwise totally darkened room using a dim light bar
gives valuable diagnostic information about vestibular
(mainly otolithic) function (see Chapter 9).25,40 A significant tilting of the subjective visual horizontal (more than
3 degrees from the true horizontal) indicates vestibular,
probably mainly otolithic, hypofunction on the side to
which the patient tilts the bar. It is reasoned to be mainly
otolithic, because semicircular canal activation or loss in
alert, drug-free humans generates not a tonically maintained eye position but, rather, a changing eye position
(nystagmus). Although the tilting of the visual horizontal
appears to be due to ocular torsion, the mechanism by
which the unilateral otolithic loss causes this ocular torsion itself is speculative. It is most likely similar to the
mechanism of the spontaneous nystagmus that occurs
after uVD: It probably reflects an imbalance in average
neural activity in the two lateral vestibular nuclei (LVNs)
due to decreased resting activity in otolithic secondary
vestibular neurons in the ipsilesional vestibular nucleus,
which itself results from the loss of input from primary
otolithic neurons.29
Lateropulsion
After uVD, there is an offset in posture toward the
affected side that can be demonstrated by a variety
of simple tasks showing that patients with uVD tend to
lean or fall toward the affected side, especially in the
early period after the uVD.41 This position offset, called
81
lateropulsion, decreases and disappears within about a

month.42
Recovery from Static Symptoms

The static oculomotor and postural components resolve
progressively over the first month or so. In contrast,
detailed measures show that the dynamic symptoms following a uVD do not change very much over time,
although they may appear to resolve. It seems that these
dynamic symptoms are progressively masked by other
behaviors as time goes by. Careful testing with posture
platform tests shows a permanent deficit in postural stability after uVD.43
Dynamic Symptoms
The dynamic vestibulo-ocular reflex (VOR) response is
tested by accelerations of the subject, either angular or
linear. For practical reasons, low-frequency (less than 1
Hz), low-acceleration sinusoidal horizontal rotation has
been used extensively in the past to test dynamic vestibular function.4446 Unfortunately the results of such tests
are indefinite, because at low frequencies, the oculomotor
response to the acceleration can be controlled by a variety of different sensory and motor systems apart from the
vestibular system.24,47 Because of the failure to exclude
extraneous sources of oculomotor control, there may
appear to be vestibular recovery, but careful measures
with specific vestibular tests show that there is no such
recovery. It can appear that recovery takes place, possibly
as patients learn new modes of responding to the sinusoidal rotational test stimulus. These very low sinusoidal
frequencies are not physiologicalmost natural head
movements are high-acceleration, high-frequency stimuli. The head accelerations during walking or running
that patients with uVD complain about have high acceleration (20003000 degrees per second per second
[deg/sec/sec]) and high frequency (512 Hz).
In order to measure dynamic vestibular function
specifically, it is necessary to use high accelerations. One
test that does so is the head impulse test, which uses
short-duration angular accelerations in the natural range
(20003000 deg/sec/sec). A simple version of this test can
be conducted anywhere. The clinician faces the patient,
holds the patients head at arms length, and then turns the
patients head in an abrupt, unpredictable horizontal head
rotation of about 20 degrees in less than 1 second while
asking the patient to stare at the tip of the clinicians nose
and to not blink. Although it is very brief, this kind of
abrupt head rotation has a peak angular velocity of around
200 deg/sec and a peak angular acceleration of 2500
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HEAD ROTATION TO INTACT SIDE
HEAD ROTATION TO LESIONED SIDE
EYE
EYE
HEAD
HEAD
100 0/s
0 0/s
100 0/s
0 0/s
TIME
100 msec
deg/sec/sec. In normal subjects this head rotation results

in a short-latency (about 10 msec) smooth compensatory
eye movement, so that the gaze remains fixed on the clinicians nose irrespective of whether the rotation is to the
left or right. This means that in normal subjects, VOR
gain (the ratio of eye velocity to head velocity) is close to
1.0. For a patient with a unilateral vestibular loss, the
result is very different. If the patients head is rotated
to the affected side, the uVD causes a marked reduction
in VOR gain for such so-called ipsilesional head rotations, whereas the VOR gain for head rotations to the
healthy side (contralesional rotations) is only modestly
reduced (Fig 5.4).
The inadequate eye movement response during the
ipsilesional head rotation means that during the head
rotation, the patients eyes are dragged with the head and
so accumulate a position error, which is usually corrected
by a saccade at the end of the head movement that takes
the patients gaze back to the clinicians nose. It is that
corrective saccade that the clinician can (with a little
training and practice) detectthe telltale sign of an inadequate VOR (Fig. 5.5).24,48
Testing over time shows that the ipsilesional VOR
gain during the first 100 msec, before other sources of
oculomotor control can affect the response, remains at
around 25% of normal, whereas the contralesional VOR
gain remains at around 80% of normal values.24,49,50 This
VOR asymmetry also applies to animals.5154 That permanent deficit of dynamic VOR function after uVD shows
that vestibular rehabilitation of uVD patients should be
aimed at developing new behaviors that overcome or substitute for the dynamic vestibular loss, rather than trying
to restore something that cannot be restored.
If patients with unilateral vestibular loss are asked to
maintain gaze in a comparable fashion to the passive test
TIME
100 msec
Figure 5.4 Time series of the eye

velocity and head velocity response during a single horizontal passive head
impulse from a patient who had undergone unilateral vestibular neurectomy
3 years previously. Head velocity is
represented by dashed lines, and eye
velocity by continuous lines. For rotation
to the intact side, eye velocity mirrors
head velocity. In contrast, for rotations to
the lesioned side, eye velocity is systematically smaller than head velocity from
the onset of head rotation. (From
Halmagyi et al., 1990.24)
just described while actively turning the head abruptly to

left or right, most patients learn to pre-program a small
saccade to correct the inadequate VOR after some trials,
but they learn to insert this saccade during the head
movement (Fig. 5.6).43 This is an important observation,
because it shows that there is a substitution of a saccade
for the deficient vestibular slow phase, and this saccade
EYE VELOCITY (deg/sec)
100
-200
-100
0
0
100
200
HEAD VELOCITY (deg/sec)
-100
HEAD ROTATION TO LESIONED SIDE
HEAD ROTATION TO INTACT SIDE
-200
Figure 5.5 Plots showing the relationship between horizontal eye velocity and the corresponding horizontal head velocity
during a head impulse for repeated horizontal head impulses in
a patient who had undergone a left vestibular neurectomy 3
years previously. There is a profound vestibulo-ocular reflex
(VOR) deficit in response to head impulses directed toward the
affected side. In contrast, the VOR in response to head
impulses directed toward the intact side is close to normal.
(From Halmagyi et al., 1990.24)
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Contralesional
Position (RV)
0.2
Velocity (deg/s)
Ipsilesional
300
0.1
Active head impulse
Passive head impulse
83
Ipsilesional
Contralesional
0
2 3
H
150 1
0
0
200
400
200
400
200
400
200
400
Time (ms)
Figure 5.6 Time series of eye and head velocity during typical passive (A) and active (B) head
impulses for both ipsilesional and contralesional head rotations. The eye velocity response has been
inverted to allow close comparison with the head velocity. The start of the head rotation is indicated
by the arrow (1), the start of the compensatory saccadic eye movement by 2 and the end of that
compensatory saccade by 3. (A) During passive ipsilesional head rotations, a large gaze error develops during the head rotation, persists until the saccade occurs after the end of the head rotation,
then acts to return the patients eyes to the target. (B) With a comparable active head rotation to the
ipsilesional side, this compensatory saccade occurs during the head rotation, so the gaze error is
small and no corrective saccade is needed after the end of the head rotation. Only close inspection
of this low-noise search-coil record shows the presence of this small but very effective saccade
during the active head rotation. (From Black et al., 2005.43)
acts to minimize the effect of the uVD on the patients

permanent dynamic VOR deficit; in this way the saccade
minimizes retinal smear.5558 Another way of concealing
a VOR inadequacy is with a blink, which, by completely
removing the retinal image, very effectively prevents
smear of the retinal image. Blinks are common during
head movements in normal healthy subjects and in
patients with uVD. Ironically, most tests of VOR (including the head impulse test) require the patient to keep the
eyes open during testing. In other words, the testing procedure itself may require the patient to suppress one of
the strategies (blinks) that they may have learned to assist
vestibular recovery.
After uVD there is a small symmetrical loss of VOR
gain for pitch head rotations for both pitch nose-down
and pitch nose-up. 5963 But there is a larger loss for roll
rotations. When the roll head movement is toward the
lesioned side, there is a large reduction in VOR gain;
when the movement is toward the healthy ear, the drop in
gain is not as great. In fact, when the rapid head rotation
is aligned to be in the plane of one pair of the vertical
canals (at about 45 degrees to the main pitch and roll

planes), the uVD effect becomes clear and the asymmetric VOR can be detected because each vertical canal
forms a synergistic pair with its opposing partner.63
Otolithic Dynamic Responses

In normal healthy people, during dynamic otolithic stimulation, as the head is rolled at constant velocity the magnitude of the otolithic stimulation on the receptors
in the inner ear changes, and the result is that both
eyes show a small compensatory ocular torsion response
called ocular counter-rolling (OCR). This small ocular
torsion is in the direction opposite to roll tilt. OCR is one
of the few accepted measures of otolith function.64,65
After uVD there are deficits in otolithic dynamic
responses. Schmid-Priscoveanu and colleagues,66 testing
patients before and after uVD, found that shortly after
uVD, there was an asymmetry in the OCR response, with
smaller OCR for roll-tilts of the head toward the affected
side. However, they found this otolithic asymmetry
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recovers fairly quickly; it is not like the permanent asymmetry of the angular VOR.
Impulses of linear acceleration (so-called head
heaves) whereby the patients head is moved laterally
toward or away from the affected ear67,68also show an
asymmetrical response.6971 This lateral or horizontal
head movement causes a horizontal eye rotation in normal subjects that appears to be due to the otoliths because
there are no angular head rotations. These head heave
responses after uVD show an asymmetry, with a smaller
horizontal eye velocity for linear accelerations directed
to the operated ear (again, ipsilesional stimulation reveals
the smaller response) than for linear accelerations directed to the intact ear. However this otolithic response
asymmetry also disappears fairly quickly.71
Sensory Components
After uVD, patients exhibit two different false spatial
sensations. Both illusions occur while patients are stationary, and both usually resolve quickly (within a few
days). One illusion is of an angular rotation in yaw, and
the other is an illusion of roll-tilt toward the side of the
uVD. In darkness or with eyes closed, patients judge
themselves to be rotating around the long axis of the
body, toward the side of the uVD (i.e., ipsilesional rotation). However, if their eyes are open, the patients perceive that they are stationary and that the world is
rotating around them in the opposite direction, toward
the intact side. This false sensation of rotation, called
vertigo, is powerful but complex and can be difficult for
patients to describe.
Measures of the perception of angular and linear
acceleration after uVD show poorer perception for accelerations directed to the lesioned ear. Patients with uVD
underestimate the magnitude of both angular and linear
accelerations directed to the ipsilesional side.23 The linear acceleration perception has been studied with the use
of roll-tilt stimuli; Dai and associates23 found that
patients with uVD underestimate roll-tilts to the affected
ear, compared with the same patients accurate performance before uVD. Other researchers have confirmed
asymmetries of roll-tilt perception.35,37,38,73 This perceptual deficit is reduced with time, but the recovery is never
total.
Box 5-1 lists the permanent legacies of unilateral vestibular loss. Table 5-1 summarizes the uVD symptoms and the general extent of recovery from them.
Most symptoms are at their maximum shortly after the
uVD procedure (when effects of anesthesia, etc., have
worn off).
Clinical Evidence Concerning

Factors Affecting the uVD
Syndrome and Vestibular
Compensation
The processes of compensation are unlikely to help
patients with short recurrent bouts of paroxysmal
vestibular dysfunction as occurs in Mnires disease,
because the process of compensation takes some time
(days or weeks) to be implemented, whereas in patients
with fluctuating vestibulopathies such as Mnires disease, the attacks of vertigo are brief compared with the
time required for compensation. In humans, vestibular
compensation takes 3 to 5 days to get under way and a
month or more to achieve a functionally useful level.
Most human patients recover well after uVD and
have an apparently normal lifestyle with good quality of
life. But some patients do not. The reason for the poor
recovery is puzzling; in many cases, these patients present with symptoms similar to those of the patients with
good compensation and the uVD procedures were similar,
but they do not recover as well as others. Recovery has
a large subjective component, and it is probable that some
patients had expected a much better outcome. Detailed
comparison of the vestibular performance of such patients
has not been able to identify any clear differences after
uVD procedures between those with good compensation
and those with poor compensation (see Box 5-1).
Patients with poor compensation exhibit a syndrome
called chronic vestibular insufficiency, which consists
of sensations of dysequilibrium, gait ataxia (especially
with restricted vision on unstable surfaces), and oscillopsia. The ataxia is particularly evident when vision is disrupted and proprioception is challenged (e.g., by asking
Box 5-1
PERMANENT LEGACIES OF uVD

1. Spontaneous nystagmus directed away from
the lesioned ear.
2. Ocular torsional position with both eyes
rolled to the lesioned side.
3. Inadequate perception of roll-tilt toward the
lesioned side.
4. Inadequate perception of horizontal angular
acceleration directed to the lesioned side.
5. Inadequate horizontal VOR for high accelerations directed to the affected ear.
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85
Table 5-1 uVD SYNDROME: SYMPTOMS AND EXTENT OF RECOVERY

uVD Syndrome
Description/Type
Extent of Recovery
Rhythmic eye movements with quick phases

directed away from the affected ear and toward
the intact ear. Visible when all visual fixation has
been removed
Decreased at 1 week
Largely but incompletely
recovered at 1 year
Ocular torsion
Maintained roll position of both eyes so the upper

poles of both eyes roll toward the lesioned side.
Visual perception is affected in a corresponding
fashion
Largely recovered within

6 months (but not totally
some torsion still present
12 months after uVD)
Skew deviation
Maintained disconjugate vertical eye position with

the ipsilesional eye being lower in the orbit than
the contralesional eye
Resolves within a few days
Caloric nystagmus
Absent nystagmus to caloric stimulation of the

horizontal canal of the affected ear
Permanent loss
Horizontal VOR to passive

low angular accelerations
Reduced VOR gain for low frequency low

angular acceleration stimulation in an ipsilesional
direction
Steady improvement over

months and virtually
resolved within 1 year
Horizontal VOR to high

(natural) angular accelerations (head impulses):
Substantially reduced VOR gain (25% of normal

values) for high frequency high angular acceleration stimulation (natural values) in an ipsilesional
direction
Reduced VOR gain (80% of normal values) for
high frequency high angular acceleration stimulation (natural values) in a contralesional direction
Net resultasymmetrical VOR
Little change over 1 year

and apparently a permanent loss
Pitch VOR to passive high

angular accelerations
Reduced VOR gain for both pitch nose-down and

pitch nose-up accelerations

apparently permanent
Roll VOR to passive high

angular accelerations
Substantially reduced VOR gain for high angular

acceleration to stimulation in an ipsilesional
direction
Reduced VOR gain for high angular accelerations
in a contralesional direction
Substantially reduced VOR gain (25% of normal

values) for high frequency high angular acceleration stimulation (natural values) in an ipsilesional
direction
Reduced VOR gain (80% of normal values) for
high frequency high angular acceleration stimulation (natural values) in a contralesional direction
Net result asymmetrical VOR
Oculomotor symptoms:
Spontaneous nystagmus
Canal plane head impulses

(left anteriorright
posterior or right
anteriorleft posterior)

and apparently a permanent loss
and apparently a permanent VOR asymmetry
(continued on following page)
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Table 5-1 uVD SYNDROME: SYMPTOMS AND EXTENT OF RECOVERY (continued)

uVD Syndrome
Description/Type
Extent of Recovery
Ocular counter-rolling
Decreased ocular torsion during head

rotations toward the ipsilesional ear
Large asymmetry initially and

decreased asymmetry over time
Horizontal eye movements to

impulses of interaural linear
acceleration (head heaves)
Smaller eye rotations for linear accelerations directed toward the affected ear
Resolution unknown
Roll head tilt toward the affected side

present when visual fixation has been
removed
Resolves within weeks but a

small roll head tilt may be a
permanent legacy (especially
in animals after uVD)
Postural disequilibrium at rest
Poor postural stability when vision is

removed
Reduces but incompletely

resolved within a year
Dynamic postural disequilibrium
Poor postural stability when given

dynamic challenges
Reduces over 1 year
Vestibular evoked myogenic

potential (VEMP)
Absent short latency inhibition of

ipsilesional sternocleidomastoid
response to intense air-conducted
clicks
Permanent loss
Sensation of falling or being pushed

toward the affected side
Improved by 1 week; resolved

within 1 year
Vertigo
In darkness: illusion that the patient is

rotating in yaw toward the affected
side
OR
In light: illusion that the world is rotating in yaw toward the healthy side
Resolved within a few days
Roll-tilt illusion
In darkness, the illusion is that the

person is roll-tilted toward the
affected side
Completely resolved within a

few days
Yaw angular acceleration

perception
Underestimation of the magnitude of

yaw angular accelerations toward the
affected ear
Resolution unknown
Linear acceleration perception
Underestimation of the magnitude

of linear accelerations toward the
affected ear
Largely but incompletely

resolved at 1 year
Vestibulospinal symptoms:
Roll head tilt
Perceptual symptoms:
Lateropulsion
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the patient to stand with eyes closed on a soft, thick, foam

rubber mat). Oscillopsia refers to the sensation of apparent movement of a physically stationary object during
head movement (e.g., the world appears to bounce during
jogging, or it appears to slide or smear during a rapid horizontal head movement during driving). Oscillopsia is
evident when the persons head is moved abruptly (high
accelerations) either passively or activelysuch as while
running, while looking from side-to-side to cross a road,
or during a sudden head turn while driving.
Why should this poor compensation occur? In some
cases it seems that events (such as postoperative complications) within the first few days after the operation may
be important determinants of the success or otherwise of
the eventual recovery. There is some evidence that the
early stages of compensationthe initiation of vestibular
compensationare vulnerable and may be interrupted by
other events. In other words, there may be a sensitive period for the establishment of vestibular compensation.74,75
Certainly there is neural and behavioral evidence from
animal studies that underpins this distinction between the
initiation and maintenance of vestibular compensation.76
The uVD procedure itself may inadvertently generate the
conditions for poor compensation; if the uVD procedure
leaves some vestibular fibers intact and operational, the
neural signals from these fibers may interfere with the
vestibular compensation process.
Some of these patients with poorly compensated
vestibular loss may have had inadequate vestibular
function or even central (i.e., cerebellar) deficits before
the uVD procedure. Thus, the uVD procedure is potentially dangerous. That is why careful testing is needed
to ensure an adequate level of function of the remaining labyrinth and an absence of central deficits before
the procedure is undertaken. Patients may suffer postural disequilibrium and gait ataxia for virtually the rest
of their lives if the uVD procedure is carried out inappropriately. Rehabilitation procedures (see later) are
of great potential value to patients with poorly compensated vestibular loss, but prevention is preferable to
rehabilitation.
In human patients, it is unwise to contemplate a uVD
when the level of vestibular function in the supposedly
healthy ear is not adequate. For example, in Mnires
disease it is common for both ears to be affected by the
disease, but one ear more than the other. If a uVD procedure is carried out on the more affected ear, the patient is
relying on a partly dysfunctional ear to provide full
vestibular input.77 It is not too surprising that in such
cases the eventual result is poor compensation or chronic
vestibular insufficiency.
87
A simple principle for a uVD procedure is that the

sole remaining labyrinth will provide all the vestibular
input for oculomotor, postural, and perceptual control for
the rest of the patients life. Is the level of function in that
remaining, supposedly healthy, labyrinth adequate to
carry that burden? How can the level of functioning in the
supposedly healthy labyrinth be established? Horizontal
canal function can be assessed clinically with the caloric
test and the head impulse test. Another important test of
a different vestibular sensory region is the vestibular
evoked myogenic potential (VEMP) to air-conducted
sound delivered by headphone to the ear under test.78,79
The VEMP is a short-latency inhibitory potential detected
in the ipsilateral sternocleidomastoid (SCM) muscle
about 12 msec after the onset of the auditory click or brief
tone burst (see Chapter 9).
Decompensation
An apparently related phenomenon is decompensation.
Decompensation refers to situations in which vestibular
compensation is nullified and the patient experiences a
partial or complete relapse. The behavioral evidence of
compensation disappears, and the uVD syndrome
returnsthe spontaneous nystagmus, the sensations of
vertigo, and the postural disequilibrium reappear.
Some situations, such as highly stressful ones, may
trigger decompensation,80,81 but even changing the
vestibular environment may also do so: Reber and associates82 reported that when rats with well-compensated
vestibular loss were exposed to a brief interval of microgravity during parabolic flight, they experienced decompensation, showing spontaneous nystagmus and other
symptoms upon removal of 1 g. That decompensation
disappeared within seconds of a return to 1 g. This finding indicates that changing the otolithic stimulation of
the intact ear was sufficient to elicit this brief decompensation. This study and others17,83 suggest that otolithic
input from the remaining ear plays an important role in
compensation. One assumption that also must be considered is that central neural function, especially cerebellar
function, is normal. The patient may be put at risk of poor
compensation or chronic vestibular insufficiency if that
assumption is incorrect.
Psychological Factors
Of course, psychological factors play a major role in
compensation,84 but it is difficult to determine their precise role. Are psychological factors causal in determining
the outcome of uVD, or are they caused by the procedure
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itself? Bowman,85 measuring the personality characteristics of patients with well-compensated and poorly compensated vestibular loss, found that those with poor
compensation showed higher scores on tests of somatic
awareness (attention to bodily sensations) than control
subjects. It is not clear, however, whether this result
occurred because their poor compensation had encouraged them to focus attention on themselves or whether
this personality style had been present before the uVD
procedure and caused their poor compensation. That people with a predisposition to hypochondriasis would find
the symptoms after uVD distressing is not surprising.
Patients who have undergone a uVD procedure for treatment of a life-threatening neuroma may be expected to
respond rather differently from patients who have chosen
to have such a procedure to alleviate a much less threatening condition.
Medication
At the start of this chapter, we discussed the variety of
influences on transmission of neural information in the
vestibular nucleus. Vestibular neurons not only use a variety of different neurotransmitters themselves but also
receive input from many other brain regions that can
modulate the activity of these neurons as well as the
transmission and processing of vestibular information.
Because of the multiple-input character of these neurons,
a host of different medications can influence the uVD
syndrome and its recovery. Whether any one neurotransmitter is the key in such a complex system may well be
a rather useless question. For reviews of medications, see
references 5, 9, and 86 through 88.
Evidence from Animal Studies

Despite the similar time course of vestibular compensation in humans and animals, the data from animal studies
of vestibular compensation does not transfer directly to
human studies. The reason is that in animal studies, the
uVD is carried out on normal, healthy, young animals
and is usually surgical and usually complete. There is no
attempt in most animal studies to preserve hearing. The
analogous human patients would constitute a tiny minority of patients undergoing a uVD procedure. In most
patients, who tend to be middle-aged, a chronic progressive disease of one labyrinth that has been ongoing for
months or years, the other labyrinth may be affected, and
the surgeon endeavors to preserve hearing.
Referring again to the simple schematic diagram
of information transmission in the vestibular system (see
Fig. 5.1), one can understand that many different sensory

manipulations can influence uVD and the rate of recovery. Deprivation of all visual input after uVD impedes
the compensation of dynamic VOR responses to lowacceleration stimulation89 and the static component of
roll head tilt,90,91 but seems to have little effect on the
reduction of spontaneous nystagmus after uVD.92 Visual
inputs do augment the diminished motor responses to linear acceleration93 and the deficient righting reflexes94
that occur after uVD. Visual motion deprivation delays
recovery of locomotor equilibrium.9598
Similarly, stimulation of proprioceptive receptors
appears to facilitate the recovery of dynamic postural
equilibrium,99 and deprivation of proprioceptive input
appears to retard the recovery of postural equilibrium.
Cervical proprioceptive input could be important in static compensation because head restraint retards resolution
of head tilt and spontaneous nystagmus.100 Somatosensory proprioceptive deprivation appears to retard static
compensation,93 whereas somatosensory proprioceptive stimulation appears to facilitate the restoration of
dynamic postural equilibrium.99 Acute spinal lesions can
produce a temporary decompensation of static postural
symptoms.80,81
There are only scant data on the effects of vestibular
stimulation or deprivation on static or dynamic compensation. In frogs, otolithic stimulation hastens but otolithic deprivation delays static compensation of roll-tilt of
the head.101 In cats, low-frequency combined visualvestibular stimulation helps reverse the deficit in VOR
gain that occurs in response to low-frequency stimulation
after uVD102 but has no effect on the asymmetry of the
VOR at high frequencies.
One idea prevalent in this literature is that the
relative importance or salience of other non-vestibular
sensory inputs may change during the course of vestibular compensation.103 Support for this idea comes from
the results of neck vibration. Vibration of neck muscles
usually causes no detectable nystagmus or changes
in postural perception in normal, healthy subjects. However, after uVD, the same vibration causes horizontal nystagmus and ocular torsion and changes in the
visual perception of a horizontal line even in well compensated patients.104 Interestingly, this result occurs
for vibration on either the ipsilesional or contralesional neck muscles105: the nystagmus has quick phases
directed away from the affected side, and such vibration has been proposed as a means of supplementing
vestibular diagnostic testing. This nystagmus may be
an example of a stimulus producing a temporary decompensation.
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Plasticity of the Vestibulo-Ocular Reflex

There is a long history of studies of vestibulo-ocular
responses showing that the gain of the VOR is modifiable
in normal, healthy subjects. Gonshor and Melvill
Jones106,107 required subjects to wear reversing spectacles
during the course of their usual daily activities. In order
to attain a stable retinal image in this situation, the VOR
gain must decrease and even reverse. VOR testing in
darkness at regular intervals during this procedure
showed that the VOR gain did decrease, although not by
the full amount required, and there was no reversal.
(Unfortunately, the VOR testing in this study used predictable low-frequency sinusoidal rotations rather than
pure tests of VOR function using natural angular accelerations, so we cannot be sure that the measured VOR gain
increase was purely vestibular.) This result triggered an
explosion of interest in VOR plasticity (references 55 and
108 list many papers on this topic). It appeared that
patients with uVD may use mechanisms responsible for
this VOR plasticity to assist their recovery.
There is no doubt that the gain of the VOR can be
modified with quite remarkable speed in normal, healthy
subjectseven within a few minutes. But closer consideration shows that such evidence is not really relevant for
the situation confronting the patient with uVD who is
undergoing vestibular compensation. Some of the procedures that have been developed for the study of VOR
plasticity do help patients improve their normal everyday
functioning. We suggest, however, that these improvements are not due to any change in the intrinsic vestibular component of the VOR. If VOR was as modifiable as
the VOR plasticity literature suggests, then diagnostic
tests of vestibular function would be useless and even
unnecessary. Patients would learn to overcome their inadequate vestibular input and generate compensatory
responses even when they had total unilateral peripheral
vestibular loss.
It is certainly the case that during vestibular compensation patients do learn a variety of behavioral strategies to minimize the effect of their vestibular deficit, but
all indications are that any plasticity of the purely
vestibular dynamic VOR is very modest at natural head
angular accelerations. We think that for the patient
with uVD, most of the plasticity takes place because of
contributions of other sensory systems and cognitive control: the patient learns new behaviors to conceal the
vestibular deficit. Of course, this achieves the soughtafter goal of returning the patient to normal lifestyle, but
for us, it is important to identify the mechanism by which
it occurs.
89
Patients with uVD differ in many important ways

from normal healthy subjects. The entire peripheral
vestibular input from one labyrinth has been removed or
severely compromised, thereby depriving the brainstem
of both the resting discharge of these neurons and its
modulation by head movement. Possibly the challenge
of such a loss for processes of vestibular plasticity is
too large. The uVD itself disrupts central vestibular processing of vestibular information; in particular, a group
of neurons concerned with perseverating the vestibular
neural response (the velocity storage integrator) is compromised or disabled, possibly disrupting the neural substrate needed for vestibular modification.
Rehabilitation
Many years ago, Cawthorne109 and Cooksey110 suggested
a number of exercises to assist in the rehabilitation of
patients with vestibular disorders. Those exercises are
similar to exercises in use today. Doubts about the efficacy of such exercises have now been largely dispelled.111114 If there is no change in purely vestibular
function, how can these exercises benefit patients? How
can patients improve? As we have shown, substitution of
other responses can effectively conceal the vestibular
deficit and so protect the patient from receiving smeared
retinal images during head movements. Such substitution
is possible when the patient has active control of the
response, and we suggest that the Cawthorne-Cooksey
exercises and others are acting to teach patients how to
substitute these other responses to conceal and thus overcome the sensory deficit. The results of others115 agree
with our own.43 The active VOR gain is enhanced during
active voluntary head movements, and during active
head impulses patients can learn to preprogram a small
eye movement response (a small corrective saccade) during the ipsilesional head movement that can effectively
hide the inadequate VOR during that ipsilesional head
rotation.43
We suggest that the process of vestibular rehabilitation should be thought of as an opportunity for other nonvestibular sensory inputs and cognitive-behavioral
strategies to assume larger roles in controlling the
patients equilibrium.
Neural Evidence Concerning

Recovery after Unilateral
Vestibular Deafferentation
The neural evidence about recovery after uVD is a huge
area; in this chapter we refer only to the major features.
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For reviews of neural processing of vestibular sensory

input, see references 4 and 116 through 119.
One simple principle helps us understand the neural
basis of vestibular responses and vestibular compensation: balance. That term is often used to denote the function of the whole vestibular system, but it also
coincidentally applies to the neural mechanism of
vestibular operation. When a person has the head still, the
neural activity in the pair of vestibular nuclei (one on
each side of the brainstem) is approximately equal. A
horizontal (yaw) angular acceleration in one direction
(e.g., to the persons left) causes an imbalance in neural
activity between the vestibular nuclei. Many neurons in
the ipsilateral (left) vestibular nucleus increase their rate
of firing of action potentials, whereas many neurons in
the right vestibular nucleus concurrently decrease their
rate of firing, and the result is an imbalance in neural activation between the two nuclei. Changes in perception and
also in corrective responses (vestibulo-ocular and
vestibulo-spinal) are generated by that neural imbalance.
If the acceleration is prolonged, nystagmus occurs.
Another way of generating such an imbalance is by
silencing the input from one labyrinth in a patient at rest,
as occurs in a uVD. In both cases, the responses and the
sensations are similar the person perceives the self as
rotating, there is a nystagmus, and corrective postural
responses occur. Most real-life angular and linear accelerations are usually fairly short, and at the end of the acceleration the system returns to its balanced state. But after
uVD, the imbalance at restwithout any imposed angular or linear acceleration stimuluspersists for hours or
days. Recordings of neural activity in guinea pigs have
shown that the imbalance at rest is progressively reduced
within the first few daysthe very active cells in the contralesional vestibular nucleus decrease their activity, and
silenced neurons in the ipsilesional vestibular nucleus
start to fire again. As that imbalance is reduced, the
behavioral and perceptual symptoms decline.26,27
Why should rebalancing occur? What processes act
to remove the imbalance and equalize firing in the two
nuclei? In the guinea pig after a uVD, this process happens in the space of about 1 day, and by 52 hours after
uVD, the average activities on the two sides are about
equal.26,27 The spontaneous nystagmus disappears,
although the dynamic deficits remain. As the balanced
activity returns, the behavioral symptoms disappear.
Concurrently, other sources of control of neural transmission through the vestibular nuclei (e.g., cerebellar
input) are changing. The following discussion describes
this process in more detail (Fig. 5.7), summarizing material from references 26, 27, and 120 through 126.
Within the medial vestibular nucleus are two types

of neurons responding to horizontal (yaw) rotation. Both
types discharge spontaneously when the head is stationary. During yaw angular head accelerations in one direction, type I neurons in the vestibular nucleus on the side
to which the head turns increase their firing; these neurons decrease their firing for yaw head accelerations in
the contralateral direction. These neurons receive direct
input from the ipsilateral peripheral vestibular labyrinth.
Other neurons within that vestibular nucleus (type II neurons) show precisely the opposite pattern of response;
they increase their firing for contralaterally directed head
accelerations and decrease it for ipsilateral head accelerations. The reason these type II neurons respond in such
a mirror-image fashion is that they are driven (indirectly)
by cells from the other labyrinth on the other side of the
head. These indirect connections cross the midline and
are called commissural connections. Type II neurons are
inhibitory and project their inhibition onto type I neurons. Type I and type II neurons work synergistically.
During an acceleration, type I neurons increase their firing because they are receiving activation from the periphery and also simultaneously receiving reduced inhibition
from type II neurons. These synergistic mechanisms
mean that there is enhanced sensitivity of type I neurons
during acceleration compared with peripheral vestibular
neurons. This arrangement is called a push-pull system,
and it functions to generate a fast, sensitive response.
Immediately after uVD, changes occur in the activity of both types of neurons on the lesioned side while the
animal is absolutely stationary. The resting discharge rate
of ipsilesional type I neurons is substantially decreased,
and that of ipsilesional type II neurons is substantially
increased.26 These type II neurons thus exert even more
inhibition than usual on the ipsilesional type I neurons,
presumably driving them to silence and so completely
disinhibiting the type I neurons on the intact side.
As the input from one labyrinth is removed by a
uVD, type I neurons in the ipsilesional nucleus are
silencedresulting in an imbalance in neural activity
between the paired vestibular nuclei. Their silence
relieves type I neurons in the opposite (contralesional)
vestibular nucleus of inhibition, which can fire at a higher rate. As the type I neurons on the lesioned side progressively start to fire again, the neurons in the intact side
receive progressively more inhibition, further enhancing
the restoration of balanced neural activity. Therefore, the
decreased activity of ipsilesional type I neurons reflects
the loss of peripheral excitatory drive and the increased
inhibition from the contralateral labyrinth mediated by
the inhibitory type II neurons.
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Slow phases to right
Slow phases to right
Midline
Midline
Head rotation
to left
91
Right
Labyrinthine
damage
Oculomotor
Nucleus
Abducens
Nucleus
Vestibular
Nuclei
Primary
Semicircular
Canal Afferents
A. Healthy subject during angular

acceleration to the left
Excitatory
B. Patient after right uVD. Stationary
Excitatory
Inhibitory
Inhibitory
Figure 5.7 To show the neural basis of the nystagmus after unilateral vestibular deafferentation
(uVD) and how a patient with uVD at rest (B) has vestibular activity closely similar to that of a person
undergoing a rotation in the direction of the intact ear (A). The left panel shows the responses in
some of the identified neural connections of the vestibulo-ocular pathways during a leftward yaw
head acceleration. Open hexagons excitatory neurons; solid hexagons inhibitory neurons; solid
lines activated neurons; dashed lines disfacilitated neurons. . The sequence occurs as follows:
during ipsilateral acceleration the primary neurons from the left semicircular canal are activated while
those from the right are inhibited. The excitatory input projects to the ipsilateral (left) vestibular nucleus and activates two types of neurons; first, excitatory type I neurons, which project to contralateral
abducens nucleus, excite those neurons, and so generate the slow compensatory eye movement
response, and second, inhibitory type I neurons in the left vestibular nucleus, which project to the
ipsilateral abducens and so act to silence the ipsilateral abducens neurons during the slow phase. As
a result of this perfectly complementary excitation and inhibition, there is a smooth conjugate slowphase eye movement response to the acceleration stimulus. Note that this response of the type I
neurons is further enhanced because the excitatory type I neurons synapse on (inhibitory) type II
neurons in the contralateral vestibular nucleus silencing their activity even further.
In the hours, days, and weeks that follow, the activity of vestibular nucleus neurons changes remarkably.
The discharge rates of both type I and type II neurons on
the lesioned side return much closer to normal, even
though the cells in the ipsilesional nucleus are no longer
receiving any neural input from its labyrinth.
Are these changes due merely to a neural process
such as adaptation, or is there an error signal that triggers them? Does the removal of peripheral vestibular
input trigger synaptic or membrane changes that act to
restore the balance between the two nuclei? There is evi-
dence for changes both at the synaptic level and the cell
membrane level during compensation.127129
How could the balance be restored? Adaptation is
one possibility. Another is that the neurotransmitter receptors in the ipsilesional type I neurons become less sensitive to the inhibitory transmitter released by the overactive
inhibitory type II neurons. Most interest has focused on
gamma-aminobutyric acid (GABA).128,130136 A reduction
in the efficacy of the neurotransmitter receptor for GABA
would allow for greater activity of ipsilesional type I neurons. In this way, ipsilesional type I neurons would start
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to return to normal levels of resting discharge because

they would not be affected by as much inhibition as
before. This idea, referred to as downregulation of GABA
sensitivity, may be partly responsible for the restoration of
balanced activity in the two vestibular nuclei.
The uVD generates a cascade of neural changes; for
example, astrocytes and microglia rapidly increase in the
vestibular nucleus.137,138 After uVD, the response of
ipsilesional type I neurons shows a decreased sensitivity,
as would be expected from the preceding analysis.121
Over time, there are significant anatomical changes in the
vestibular nuclei,139142 although it seems that the behavioral effects of compensation occur before sprouting.143
Evidence from Campos-Torres and colleagues144
indicates that the effects of silencing peripheral neurons
by chemical means (tetrodotoxin) and those of silencing
by surgical sectioning of the nerve are not identical.
Tetrodotoxin does not cause degeneration, and CamposTorres and colleagues 144 found that it causes no glial
changes in the vestibular nuclei, as opposed to the dramatic increase in glia after sectioning or damage to the
vestibular nerve. Results such as these suggest that the
error signal may well be a chemical factor released by
the injured neurons.
Studies have also recorded the characteristics of
neurons in slices of brainstem tissue taken from animals
with compensation at various durations after uVD. These
studies record neurons either extracellularly or intracellularly from such brainstem slices. In this situation, it is not
possible to identify type I and type II neurons because
there is no peripheral vestibular input. The cells are divided arbitrarily according to their membrane characteristics
into type A and type B neurons, which have very different action potential profiles. Type A neurons are tonically firing neurons, and type B neurons tend to be phasic.
Beraneck and associates145,146 have reported that after
uVD, the membrane characteristics of type B neurons
appear to change. These previously phasic neurons
appear to take on much more tonic characteristics. Other
studies have reported very long-lasting changes in intrinsic membrane characteristics after prolonged inhibition.147,148 It is likely that membrane changes are
responsible in part for the changes in global neural activity after uVD previously described.
Angular versus Linear Acceleration

Otolithic neurons project to the lateral and descending
vestibular nuclei but also send a branch to the cerebellum. Recordings from LVN neurons during ipsilateral
roll-tilts show that most neurons show an increase in fir-
ing for such stimuli.29 After a uVD, there is a decrease in

the proportion of ipsilesional LVN neurons and a
decrease in their average resting activity.149,150 So a similar imbalance occurs to natural linear accelerations as
described previously for natural angular accelerations.
That imbalance is mimicked by a removal of all the
peripheral vestibular neural input from one side.
Cerebellum
Finally, the cerebellum may play an important role in
vestibular compensation that has not been fully recognized because so much focus has been put on the vestibular nucleus. Data on the effects of lesions of the
cerebellum or its connections on vestibular compensation
are contradictory. Whereas some cerebellar lesion studies
show a marked delay in the resolution of spontaneous
nystagmus,151 others show no effect.152 Although bilateral occipital lobectomy has no effect on the resolution of
spontaneous nystagmus, it does impede the recovery of
the VOR to low-acceleration stimulation.92 Lesions of the
brainstem153 or transcerebellar vestibular commissures154
do not impede the vestibulospinal symptoms of static
compensation, at least not in mammals. This finding suggests that input from the contralesional (intact) vestibular
nucleus is not essential for static compensation. Kitahara
and associates155,156 have shown that neurons in the flocculus of the cerebellum play an important role in the
early stages of vestibular compensation for static symptoms. They have proposed that neurons in the flocculus
may inhibit the hyperactive type I neurons in the contralesional vestibular nucleus and so act to reduce the
overactive type I neurons, a reduction that would in turn
act to relieve inhibition on the ipsilesional type I neurons.157159 Human patients with cerebellar lesions show
slow compensation.160
Neural Network Models of Vestibular

Function and Compensation
These physiological changes have been incorporated into
neural network models of the VOR that model the possible mechanisms of the uVD syndrome and compensation.161164 The physiologically realistic neural network
model developed by Cartwright and associates,162,163,165
which was trained on guinea pig eye movement responses before and after uVD, showed that changes in activity
in various stages through the neural network determine
the responses. The model pointed to neurons on the intact
side as being especially important because their gain
changes most.
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Summary
How do these neural changes relate to the uVD syndrome
and its recovery? The static motor symptoms and the perceptual illusions of vertigo and roll-tilt are likely due to
the imbalance in average neural activity between cells in
the vestibular nuclei on each side of the brainstem. The
deficits in dynamic responses are probably due to the
decreased dynamic sensitivity of vestibular nucleus neurons as documented by Markham and colleagues.121
It should be noted that in general, the restoration of
static equilibriumi.e., static compensationis remarkably robust: Very little appears to hasten or hinder it. That
robustness is in contrast to the restoration of dynamic
equilibriumdynamic compensation which appears to
depend at least in part on intact visual, vestibular, and
proprioceptive sensory inputs; dynamic compensation is
usually incomplete.
Acknowledgments
The revision of this chapter is supported by the
Australian National Health and Medical Research
Council. We owe thanks to Ann Burgess for her meticulous proofreading of this manuscript.
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6
Vestibular System
Disorders
Michael Fetter, MD
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 patients 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 patients diagnosis. This chapter
describes the clinical presentation of the more common
peripheral vestibular disorders. The results of diagnostic
tests and the medical, surgical, and rehabilitative management of each of these disorders is presented as an
overview only, because this material is covered in detail
in other chapters.
Benign Paroxysmal
Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is the most
common cause of vertigo. Typically, a patient with BPPV
complains of brief episodes of vertigo precipitated by
rapid changes of head posture. Sometimes symptoms are
brought about by assuming very specific head positions.
Most commonly these head positions involve rapid extension of the neck, often with the head turned to one side (as
when looking up to a high shelf or backing a car out of a
98
garage) or lateral head tilts toward the affected ear. The

symptoms often appear when a patient rolls from side to
side in bed. Patients can usually identify the offending
head position, which they often studiously avoid. Many
patients also complain of mild postural instability
between attacks. The vertigo lasts only 30 seconds to 2
minutes (usually less than 1 minute) and disappears even
if the precipitating position is maintained. Hearing loss,
aural fullness, and tinnitus are not seen in this condition,
which most commonly occurs spontaneously in the elderly population but can be seen in any age group after even
mild head trauma. Women are more commonly affected
than men. Bilateral involvement can be found in 10% of
the spontaneous cases and 20% of the traumatic cases.
Spontaneous remissions are common, but recurrences can
occur, and the condition may trouble the patient intermittently for years.
Evaluation should include a careful otoneurologic
examination, the most important part being the history. A
key diagnostic maneuver is the Dix-Hallpike positioning
test1 while the examiner observes the patients eyes with
a pair of Frenzel lenses or in combination with
electronystagmography (ENG) monitoring. A typical
response is induced by rapid position changes from the
sitting to the head-hanging right or left position. Vertigo
and nystagmus begin with a latency of 1 or more seconds
after the head is tilted toward the affected ear and
increase in severity within about 10 seconds to a maximum accompanied by a sensation of discomfort and
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Chapter 6 VESTIBULAR SYSTEM DISORDERS
apprehension that sometimes causes the patient to cry out

and attempt to sit up. The symptoms diminish gradually
after 10 to 40 seconds and ultimately abate, even if the
precipitating head position is maintained. The nystagmus
is mixed upbeat and torsional with a slight horizontal
component: The direction corresponds very closely to the
plane of the offending semicircular canal, very similar to
experimental stimulation of the afferents of the posterior
semicircular canal of the dependent ear.2 The nystagmus
changes with the direction of gaze, becoming more torsional as the patient looks toward the dependent ear and
more vertical as the patient looks toward the higher ear.
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 nystagmus
being directed opposite to the initial nystagmus.
Repeating this procedure several times decreases the
symptoms. This adaptation of the response is of diagnostic value, because a clinical picture similar to that of
BPPV can be created by cerebellar tumors. In the latter,
though, there is no habituation of the response with repetitive testing. 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. BPPV must be differentiated
from positional nystagmus in Mnires disease, perilymphatic fistulas, and alcohol intoxication.
A few patients do not display the typical torsional
upbeat nystagmus but, for example, show a strong horizontal nystagmus, which nevertheless follows a similar
pattern of buildup and decline but often over a longer
period. This horizontal nystagmus may indicate a lateral
canal variant of BPPV.
The classic explanation of the underlying pathophysiology (cupulolithiasis) was first described by
Schuknecht3 in 1969. His study of the temporal bones of
two patients afflicted with this disorder showed deposition of otoconial material in the cupula of the posterior
semicircular canal. The cupulolithiasis theory suggests
that the debris adheres to the cupula, making it denser
than the surrounding endolymph and thereby susceptible
to the pull of gravity. This theory, however, implies that a
positioning maneuver should result in an enhanced positioning response with a nystagmus initially beating in the
direction of an ampullopetal stimulation. This nystagmus
should occur immediately after the positioning maneuver
and should change direction as gravity drags the cupula
99
down. The nystagmus, however, should not subside as

long as the head-down position is maintained; that is, one
would expect positional instead of positioning nystagmus. None of these features is typically seen.
Brandt and Steddin4 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 the
canal. When the head is moved in the plane of that canal,
the debris sinks to the lowest point in the canal, causing
the endolymph to move and deflecting the cupula by suction or pressure (like a plunger), depending on the direction it moves. This theory accords with the direction of
the nystagmus and also allows for a latency.
If symptoms persist longer than expected, further
investigation, such as magnetic resonance imaging
(MRI), should be made to assess for unusual causes of
positional vertigo, such as acoustic neuroma and tumors
of the fourth ventricle.
BPPV is usually a self-limiting disorder and commonly resolves spontaneously within 6 to 12 months.
Simple vestibular exercises or maneuvers aimed at dispersing the otolithic debris from the cupula can speed
recovery; antivertiginous drugs are not helpful. One
approach is to instruct the patient to assume repeatedly
the positions that bring on the symptoms.5 In 1988,
Semont and colleagues6 introduced a single liberatory
maneuver, and Epley,7 in 1992, proposed a variation,
later modified by Herdman and associates8 (see also
Chapter 17). With these newer liberatory maneuvers,
most patients can be treated successfully. The period of
recovery varies from immediate after one positioning
maneuver (physical displacement) to usually 6 weeks to
6 months. Only in a few patients, usually the more elderly, do the symptoms persist in spite of compliance with
vestibular exercises. For more severe symptoms unresponsive to exercises, three surgical options are available
for relief. The first is transmeatal posterior ampullary
nerve section (also known as singular neurectomy). The
other two options are partitioning of the labyrinth using a
laser technique and nonampullary plugging of the posterior semicircular canal. Nonampullary plugging seems
to be a safe and effective alternative to singular neurectomy for the small group of patients with physically
intractable BPPV.
Vestibular Neuritis
Acute unilateral (idiopathic) vestibulopathy, also known
as vestibular neuritis, is the second most common cause
of vertigo. Although in most cases a definitive cause is
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never proved, evidence to support a viral etiology (similar to that for Bells palsy or sudden hearing loss) comes
from histopathologic changes of branches of the vestibular nerve in patients who have suffered such an illness9
and the sometimes epidemic occurrence of the condition.
Onset is often preceded by the presence of a viral infection of the upper respiratory or gastrointestinal tract. The
associated viral infection may be coincident with the
vestibular neuritis or may have preceded it by as long as
2 weeks. The chief symptom is the acute onset of prolonged severe rotational vertigo that is exacerbated by
movement of the head, associated with spontaneous horizontal-rotatory nystagmus beating toward the good ear,
postural imbalance, and nausea. Hearing loss is not usually present, but when it is, mumps, measles, and infectious mononucleosis, among other infections, have been
implicated. The presence of hearing loss together with
acute onset rotational vertigo should alert the physician
to consider other diagnoses (e.g., ischemia of labyrinth
artery, Mnires disease, acoustic neuroma, herpes
zoster, Lyme disease, neurosyphilis). The condition
mainly affects those aged between 30 and 60 years, with
a peak for women in the fourth decade and for men in the
sixth decade.
If examined early, the patient may manifest an
irritative nystagmus from the acute phases of the inflammation. Usually the patient is examined after these initial
findings have given way to a more paralytic, or hypofunctional, pattern. Caloric testing invariably shows
ipsilateral hyporesponsiveness or nonresponsiveness
(horizontal canal paresis). The possibility that the three
semicircular canals and the otoliths (utricle and saccule)
may be separately involved in partial labyrinthine lesions
is suggested by the occasional observation of an acute
unilateral vestibulopathy and a benign paroxysmal positioning vertigo simultaneously in the same ear of an
affected patient.10 With three-dimensional measurements
of the vestibulo-ocular reflex in patients with vestibular
neuritis, this notion could be confirmed. Patients with
this condition most often showed a partial involvement of
only the superior vestibular nerve portion (subserving the
anterior and lateral semicircular canals, the utricle, and a
small part of the saccule), which left part of the saccule
and the posterior semicircular canal afferents intact.11
The symptoms usually abate after a period of 48 to 72
hours, and gradual return to normal balance occurs over
approximately 6 weeks. Rapid head movements toward
the lesioned side, however, can still cause slight oscillopsia of the visual scene and impaired balance for a short
moment. Recovery is produced by the combination of
central compensation of the vestibular tone imbalance,
which is aided by physical exercise, and peripheral
restoration of labyrinthine function. The latter is found in

about two-thirds of the patients.
The differential diagnosis should initially include
other causes of vertigo, and careful history-taking, physical examination, and an audiogram are required.
Physical examination should include a neurological
examination with attention to cranial nerve findings and
cerebellar testing. Careful otoscopy is performed to rule
out the presence of a potential otologic infectious process
as the source of a toxic serous labyrinthitis. Fever in the
presence of chronic ear disease and labyrinthitis suggests
suppuration and meningitis. Commonly, a toxic labyrinthitis is the result of a well-defined event such as surgery or trauma.
Initial treatment is accomplished with the use of
vestibular suppressants, such as the antihistamine dimenhydrinate or the anticholinergic scopolamine. In addition,
bedrest is very helpful early in the course of the disease.
After the most severe vertigo and nausea have passed
(after 24 to 72 hours), the patient may resume ambulation
with assistance; independent ambulation may be achieved
over the next few days. At the same time, the administration of vestibular suppressants should be greatly diminished or, even better, stopped completely, because they
prolong the time required to achieve central compensation. To further speed up the process of recuperation,
vestibular exercises challenge the compensatory mechanisms of the central nervous system (CNS), stimulating
adaptation. These exercises are designed to improve both
gaze stability and postural stability (see Chapter 20.)12
Animal experiments have shown that alcohol,
phenobarbital, chlorpromazine, diazepam, and adrenocorticotropic hormone (ACTH) antagonists retard compensation; caffeine, amphetamines, and ACTH accelerate
compensation.13 In 141 patients with vestibular neuritis,
Strupp and coworkers14 performed a prospective randomized trial of methylprednisolone, valacyclovir, and the
two in combination within 3 days after the onset of symptoms. The researchers showed that methylprednisolone
significantly improves the recovery of peripheral vestibular function (from 39% in the placebo group to 62% in
the methylprednisolone group), whereas valacyclovir
does not. The study shows that steroids significantly
improve the recovery of peripheral vestibular function in
humans with vestibular neuritis.
Mnires Disease and

Endolymphatic Hydrops
Mnires disease is a disorder of inner ear function that
can cause devastating hearing and vestibular symptoms.
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The typical attack is experienced as an initial sensation of

fullness of the ear, a reduction in hearing, and tinnitus,
followed by rotational vertigo, postural imbalance, nystagmus, and nausea and vomiting after a few minutes.
This severe disequilibrium (vertigo) persists anywhere
from approximately 30 minutes to 24 hours. Gradually,
the severe symptoms abate, and the patient is generally
ambulatory within 72 hours. Some sensation of postural
unsteadiness persists for days or weeks, and then normal
balance returns. During this recuperation time, hearing
gradually returns. Hearing may return to the pre-attack
baseline, or there may be residual permanent sensorineural hearing loss, most commonly in the lower frequencies. The rare transient improvement of hearing
during the attack is known as the Lermoyez phenomenon.
Tinnitus also usually diminishes as hearing returns. As
the disease progresses, hearing fails to return after the
attacks, and after many years, the symptoms of vertigo
may gradually diminish in frequency and severity. Some
patients may suddenly fall without warning; these events,
which may occur in later stages of the disease, are
referred to as Tumarkins otolithic crisis and should be
differentiated from other forms of drop attack.
The typical form of Mnires disease is sometimes
not complete. In vestibular Mnires disease, only
vestibular symptoms and aural pressure are present, and
in cochlear Mnires disease, only cochlear symptoms
and aural pressure are encountered.15
The disease is about equally distributed between the
sexes and usually has its onset in the fourth to sixth
decades of life. However, there are reports of children
as young as 6 years with classic Mnires disease.16
About 15% of the patients have blood relatives with
the same disease, suggesting genetic factors. The incidence of bilaterality of involvement ranges between 33%
and 50%.17
A phenomenon fundamental to the development of
Mnires disease is endolymphatic hydrops. Whether
endolymphatic hydrops itself is the cause of the symptoms characteristic of Mnires disease or is a pathologic change seen in the disease is still unclear. The
development of hydrops is generally a function of malabsorption of endolymph in the endolymphatic duct and
sac. Malabsorption may itself be a result of disturbed
function of components of the endolymphatic duct and
sac, mechanical obstruction of these structures, or altered
anatomy in the temporal bone. Endolymph is produced
primarily by the stria vascularis and flows both longitudinally (along the axis of the endolymphatic duct toward
the endolymphatic sac) and radially (across the membrane of the endolymphatic space into the perilymph system). Mnires disease is generally a consequence of
101
altered longitudinal flow, usually evolving over a course

of many years. Experimental obstruction of the endolymphatic duct routinely results in endolymphatic hydrops in
many animal models.18 Lesions in the temporal bone that
have been associated with the development of hydrops
include fractures of the temporal bone, perisaccular
fibrosis, atrophy of the sac, narrowing of the lumen in the
endolymphatic duct, otitis media, otosclerotic foci
enveloping the vestibular aqueduct, lack of vascularity
surrounding the endolymphatic sac, syphilitic osteitis of
the otic capsule, and leukemic infiltrations, to name just
a few. Anatomically, ears affected by Mnires disease
are likely to demonstrate hypodevelopment of the
endolymphatic duct and sac, periaqueductal cells, and
mastoid air cells. Therefore, one can postulate a causeand-effect relationship between constricted anatomy in
the temporal bone and malabsorption of endolymph.
Any explanation of the clinical symptoms of
Mnires disease should account for all of the symptoms, including rapid or prolonged attacks of vertigo, disequilibrium, positional vertigo during and between
attacks, fluctuating progressive sensorineural hearing
loss, tinnitus, aural pressure, inability to tolerate loudness, and diplacusis. These symptoms probably result
from both chemical and physical mechanisms. Physical
factors can cause tamponade of the cochlear duct, contributing to fluctuating progressive sensorineural hearing
loss and other cochlear symptoms, whereas distention of
the otolithic organs can physically affect the crista
ampullaris, resulting in vestibular symptoms. The prolonged nystagmus and vertigo are commonly believed to
be caused by periodic membrane ruptures with subsequent transient potassium palsy of vestibular nerve fibers.
Useful diagnostic tests for Mnires diesase
include an audiogram and ENG. Typically, the audiogram displays an ipsilateral sensorineural hearing loss
involving the lower frequencies. Fluctuation in discrimination scores is often seen, with a long-term trend toward
poor scores. ENG may demonstrate a unilateral vestibular weakness on caloric testing, again involving the ear
symptomatic for pressure, hearing loss, and tinnitus.
Electrocochleography is useful in cases that are unclear.
The finding of enlarged summating potentials in the suspected ear is diagnostic of endolymphatic hydrops.
A brainstem-evoked acoustic response (BEAR)
procedure must be performed in patients with findings
of retrocochlear disease on routine audiometry, to
screen for cochlear nerve or brainstem pathology. If the
BEAR is found to be positive, MRI with the use of
intravenous gadolinium should be obtained to assess
for central nervous system pathology or VIIIth nerve
schwannoma.
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Treatment in the remission phase aims to reduce the

frequency of the attacks and preserve hearing without distressing tinnitus. Dietetic programs, including restriction
of salt, water, alcohol, nicotine, and caffeine, are as valueless in treating the disease as are physical exercise and
avoidance of exposure to low temperatures. Stellate ganglion blocks, diuretics, vasoactive agents, tranquilizers,
neuroleptics, and lithium have been employed under the
mistaken assumption that it is possible to diminish
endolymphatic hydrops by changing inner-ear blood flow,
osmotic diuresis, or central sedation; there has never been
prospective proof of the efficiency of these therapies.
The histamine derivative betahistine has been advocated as the drug of first choice. Findings from a 1-year
prospective double-blind study showed that this treatment is preferable to leaving the disease untreated.19 The
action is attributed to improvement of microcirculation of
the stria vascularis, but betahistine also has inhibitory
effects on polysynaptic vestibular neurons. Adjunct medications in the form of vestibular suppressants other than
betahistine should be used primarily during the acute
episodes of vertigo and should be discouraged as longterm daily medications.
In addition to pharmacologic therapies, many
patients with Mnires disease require psychological
support to help them cope with the frustrations and
changes brought about by their medical condition. Those
patients in whom the vertigo becomes disabling by virtue
of greater severity or frequency of attacks despite maximal medical therapy would be considered candidates for
surgical intervention. Only about 1% to 3% of patients
ultimately require surgical treatment, because the success
of regular endolymphatic sac shunt operations has been
shown to be a placebo effect.20
Sacculotomy has been proposed by a variety of
authorities as a method of relieving the pressure buildup
in the endolymphatic chamber. Long-term success rates
for this procedure are not yet available, but significant
hearing loss is observed in 50% of patients undergoing
cochleosacculotomy. Advantages are ease of performance, utility in elderly patients as a first procedure performed with local anesthesia, and little risk other than
hearing loss.
Intratympanic treatment with ototoxic antibiotics
such as gentamicin sulfate, instilled via a plastic tube
inserted behind the annulus via the transmeatal approach,
is obviously able to selectively damage the secretory
epithelium (and thereby improve endolymphatic hydrops)
before significantly affecting vestibular and cochlear
function.21
The current treatment that is most successful is
vestibular nerve section. This procedure is indicated in
individuals with serviceable hearing in whom maximal

medical therapy has been unsuccessful in controlling vertigo. Success rates in the range of 90% to 95% have been
reported by numerous investigators. The newer technique
of focused ultrasound seems to have an advantage over
open surgery, in that partial ablation of vestibular function (with preservation of hearing) can be performed
without invading the labyrinth.
In patients with hearing loss, destructive procedures
are also possible, such as transmeatal, transmastoid, or
translabyrinthine labyrinthectomy. The success rate is
95%. An extension of this surgery is the translabyrinthine
vestibular nerve section, shown to eliminate vertigo in
98% of cases. However, particularly in elderly patients,
ablative surgical procedures may cause long-lasting postural imbalance because of the reduced ability of central
mechanisms to compensate for the postoperative vestibular tone imbalance.
Vestibular exercises are not appropriate in patients
with Mnires disease unless they have permanent loss
of vestibular function. Vestibular exercises are designed
to induce long-term changes in the remaining vestibular
system or to foster the substitution of other strategies to
compensate for the loss of vestibular function. In
Mnires disease, the vestibular dysfunction is episodic,
and between episodes, the system usually returns to normal function. Some patients experience a loss of vestibular function at the end stages of the disease, and for these
patients, vestibular rehabilitation may be appropriate.
Vestibular exercises are also beneficial in patients with
surgical destruction of the inner ear.
Perilymphatic fistula may lead to episodic vertigo and
sensorineural hearing loss because of the pathologic elasticity of the bony labyrinth. Most commonly, these fistulas occur at the round and oval windows of the middle
ear. Classically, a history of (often minor) head trauma,
barotrauma, mastoid or stapes surgery, penetrating injury
to the tympanic membrane, or vigorous straining precedes the onset of sudden vertigo, hearing loss, and loud
tinnitus. The patients often report a pop in the ear during the precipitating event. Later on, patients with fistula
may complain of imbalance, positional vertigo, and nystagmus as well as hearing loss. Tullio phenomenon
vestibular symptoms that include vertigo, oscillopsia,
nystagmus, ocular tilt reaction, and postural imbalance
induced by auditory stimuliis usually due to perilymphatic fistula, in most cases from superior canal dehiscence, but subluxation of the stapes foot plate and other
ear disease may be responsible. The symptoms often sub-
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side while the patient is at rest, only to resume with activity. Sneezing, straining, nose blowing, and other such
maneuvers can elicit the symptoms after the initial event.
Perilymphatic fistulas probably account for a considerable proportion of patients presenting with vertigo
of unknown origin. Diagnosing perilymphatic fistula is
difficult because of the great variability of signs and
symptoms and the lack of a pathognomonic test. In the
acute phase, medical treatment is universally recommended, because these fistulas usually heal spontaneously and the results of surgical interventions are not
encouraging.22
Physical examination, particularly otoscopy, is
important. In the cases of head trauma and barotrauma,
hemotympanum is often seen as an early finding. In cases
of penetrating injury to the ear, a tympanic membrane
perforation makes the likelihood of ossicular discontinuity with fistula very high. A useful clinical test consists of
the application of manual pressure over the tragus or to
the tympanic membrane with the pneumatic otoscope; a
positive response is indicated by the evocation or exacerbation of vertigo (Henneberts sign) or the elicitation of
nystagmus. Audiometric findings usually demonstrate a
mixed or sensorineural hearing loss, depending on the
mechanism of injury. This loss may be quite severe and
usually involves the high frequencies more than the low
frequencies. ENG with caloric testing may be normal or
may show a unilateral weakness in the affected ear. The
specificity of the clinical fistula tests can be augmented
by recording eye movements or measuring body sway
as pressure on the tympanic membrane is increased.
Despite refinements, these tests remain unreliable in
detecting all fistulas. The diagnosis remains essentially a
historical one, and in patients with a suggestive history
and symptoms, treatment is indicated. Often the diagnosis is made definitively only at the time of surgical exploration by tympanoscopy as the patient performs Valsalva
maneuvers.
Medical treatment consists of absolute bedrest with
the head elevated for 5 to 10 days. Mild sedation with
tranquilizers; avoidance of straining, sneezing, coughing,
or head-hanging positions; and the use of stool softeners
are important for reduction of further explosive and
implosive forces that may activate perilymph leakage.23
When symptoms persist for longer than 4 weeks, or
if hearing loss worsens, exploratory tympanotomy is
indicated. Considerable controversy persists surrounding
the frequency with which perilymphatic fistulas are
found at surgery. Surgical management consists of middle ear exploration and packing of the oval and round
window areas with fat, absorbable gelatin sponge
(Gelfoam), and areolar and/or fibrous tissue. These areas
103
are packed whether or not a clear-cut fistula is demonstrated. Reported success rates for this treatment vary
between 50% and 70%, likely reflecting some element of
variable patient selection.
A variant of perilymphatic fistula causing episodic
vertigo has been described by Minor and coworkers.24
The disease is due to dehiscence of the superior semicircular canal. It is probably the most common form of a
fistula and probably the most often overlooked.
Hallmarks are vertigo spells induced by pressure increase
such as happens with coughing, sneezing, or loud noises
(Tullio phenomenon). Vertical-torsional eye movements
in the plane of the defective superior semicircular canal
can be observed in precipitating conditions. In more than
half of the cases, symptoms start after even mild head
trauma or barotrauma. The diagnosis can be made with
high-resolution computed tomography (CT) of the temporal bone, which shows a dehiscence of the apical part
of the superior semicircular canal.
Vestibular Paroxysmia
(Disabling Positional Vertigo)
Neurovascular cross-compression of the root entry zone
of the vestibular nerve can elicit disabling positional vertigo.25 The term describes a heterogeneous collection of
signs and symptoms rather than a reliable diagnosable
disease entity. Brandt and Dieterich26 proposed the following criteria: (1) short and frequent attacks of rotational or to-and-fro vertigo lasting from seconds to minutes,
(2) attacks frequently dependent on particular head positions and modification of the duration of the attack by
changing of the head position, (3) hypacusis and/or tinnitus permanent or during the attack, (4) measurable auditory or vestibular deficits by neurophysiological methods,
and (5) positive response to antiepileptic drugs (carbamazepine).
Neurovascular cross-compression can cause local
demyelinization of the root entry zone of the VIIIth
nerve. Ephaptic transmission between bare axons and
central hyperactivity initiated and maintained by the
peripheral compression are the suggested mechanisms.
As in trigeminal neuralgia, antiepileptic drugs are the
first choice of medical treatment of the condition, before
surgical microvascular decompression is contemplated.
Bilateral Vestibular Disorders

Bilateral vestibulopathy may occur secondary to meningitis, labyrinthine infection, otosclerosis, Pagets disease,
polyneuropathy, bilateral tumors (acoustic neuromas in
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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,27 characterized by a progressive, bilateral sensorineural hearing
loss often accompanied by a bilateral loss of vestibular
function. Other autoimmune-mediated disease is often
present in the afflicted patients; examples are rheumatoid
arthritis, psoriasis, ulcerative colitis, and Cogans syndrome (iritis accompanied by vertigo and sensorineural
hearing loss).
The history is the most useful diagnostic tool.
Support for the diagnosis can be obtained via blood testing for complete blood count, erythrocyte sedimentation
rate, rheumatoid factor, and antinuclear antibodies.
Western blot precipitation studies to look for anticochlear
antibodies can be performed in some research centers and
may be the future definitive test of choice in these cases.
Little is known about how autoimmune disorders
cause otologic symptoms. As with other autoimmune
conditions, the otologic symptoms may occur as a direct
assault by the immune system in the form of humoral and
cellular immunity directed at the inner ear. Another
mechanism of injury may be related to the deposition of
antibody-antigen complex in capillaries or basement
membranes of inner ear structures. Further immunologic
studies of temporal bones harvested from deceased
patients who had clinical evidence of autoimmune inner
ear involvement may shed some light on the underlying
process.
Because autoimmune vestibulopathy usually affects
both ears, therapy is almost exclusively medical. Vestibular suppressants are most useful in controlling the more
severe exacerbations of vertigo. The use of corticosteroids
and some cytotoxic agents (cytoxan, methotrexate) has
been shown to provide relief in some patients. There is
some newer evidence to suggest that serum plasmapheresis may play a more prominent role in controlling
this disease in the future. The natural history of the disease leads to eventual bilateral vestibular ablation. This
end result is almost inevitable unless the underlying
process can be arrested with treatment or arrests spontaneously.
The most common toxic cause of acute vertigo is
ethyl alcohol. We know that positional changes exacerbate the vertigo of a hangover. The reason may be that
alcohol diffuses into the cupula and endolymph at different rates and so creates a density gradient, making the
cupula sensitive to gravity.28 Other agents that may produce vertigo are organic compounds of heavy metals and
aminoglycosides. The aminoglycosides are notorious for
causing irreversible failure of vestibular function without
vertiginous warning or hearing loss. Thus, monitoring of
vestibular function may be necessary during therapy with
such agents.
Independent of vestibulopathies produced by ototoxins, single cases of progressive vestibular degeneration of unknown origin have been described, with the
following factors in common: repeated episodes of dizziness relatively early in life, bilateral loss of vestibular
function with retention of hearing, and freedom from
other neurological disturbances.29
Alports syndrome (inherited sensorineural deafness
associated with interstitial nephritis), Ushers syndrome
(inherited sensorineural deafness associated with retinitis
pigmentosa), and Waardenburgs syndrome (inherited
deafness associated with facial dysplasia) usually cause
bilateral labyrinthine deficiency when they affect the
vestibular system. Congenital vestibular loss is secondary
to either abnormal genetic or intrauterine factors, including infection (most commonly rubella and cytomegalovirus), intoxication (thalidomide), and anoxia.
Controlled physical exercises can improve the condition in patients with permanent bilateral vestibulopathy
by recruiting non-vestibular sensory capacities such as
the cervico-ocular reflex and proprioceptive and visual
control of stance and gait (see Chapter 21).
Summary
This chapter describes the clinical presentations of the
more common peripheral vestibular disorders and their
differential diagnosis from central origins of vertigo.
Although the symptomatology of a certain peripheral
vestibular disorder might be rather specific, as in acute
unilateral vestibular loss, the cause can be rather different, ranging from infection to ischemia to traumatic
lesions. Therefore, a thorough evaluation should always
include, in addition to the specific otoneurological investigation, a detailed history and a general physical examination. For a quick review, Table 61 summarizes the
hallmarks of the peripheral vestibular disorders treated in
this chapter.
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Table 6-1 SUMMARY OF VESTIBULAR SYSTEM DISORDERS

Benign
Paroxysmal
Positional
Vertigo
Vestibular
Neuritis
Mnires
Disease
Vertigo
Type
Rotational
Nystagmus
Fistula
Nerve
Compression
Bilateral
Vestibular
Disorder
Rotational
Rotational
Rotational/linear
Rotational/linear
Duration
30 sec2 min
4872 hr
30 min24 hr
Seconds
Seconds to min- Permanent

utes
Nausea
/()
Postural
Ataxia
/()
Specific
symptoms
Onset latency,
adaptation
Acute onset
Fullness of
ear, hearing
loss, tinnitus
Frequent
Loud tinnitus,
attacks, tinniTullio phenomenon, Henneberts tus, hypacusis
sign
Precipitating
action
Positioning,
turning in
bed
Head trauma, ear

surgery, sneezing, straining,
nose blowing
Changing of
head position
Gait ataxia
absent, present; /() variable; very strong.
References
1. Dix R, Hallpike CS: The pathology, symptomatology and
diagnosis of certain common disorders of the vestibular
system. Ann Otol Rhinol Laryngol 1952;6:987.
2. Fetter M, Sievering, F: Three-dimensional eye movement analysis in benign paroxysmal positioning
vertigo and nystagmus. Acta Otolaryngol (Stockh)
1995;115:353.
3. Schuknecht HF: Cupulolithiasis. Arch Otolaryngol 1969;
90:765.
4. Brandt T, Steddin S: Current view of the mechanism
of benign paroxysmal positioning vertigo: cupulolithiasis
or canalolithiasis? J Vestib Res 1993;3:373.
5. Brandt T, Daroff RB: Physical therapy for benign
paroxysmal positional vertigo. Arch Otolaryngol
1980;106:484.
6. Semont A, et al: Curing the BPPV with a liberatory
maneuver. Adv Otorhinolaryngol 1988;42:290.
7. Epley JM: The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo.
Otolaryngol Head Neck Surg 1992;107:399.
8. Herdman SJ, et al: Single treatment approaches to benign
paroxysmal vertigo. Arch Otolaryngol Head Neck Surg
1993;119:450.
9. Schuknecht HF, Kitamura K: Vestibular neuritis. Ann Otol
Rhinol Laryngol 1981;90(Suppl 79):1.
10. Bchele W, Brandt T: Vestibular neuritisa horizontal
semicircular canal paresis? Adv Otorhinolaryngol 1988;
42:157.
11. Fetter M, Dichgans J: Vestibular neuritis spares the
inferior division of the vestibular nerve. Brain 1996;
119:755.
12. Strupp M, Arbusow V, Maag KP, et al: Vestibular exercises improve central vestibulo-spinal compensation after
vestibular neuritis. Neurology 51:1998;838.
13. Zee DS: Perspectives on the pharmacotherapy of vertigo.
Arch Otolaryngol 1985;111:609.
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14. Strupp M, Zingler VC, Arbusow V, et al: Methylprednisolone, valacyclovir, or the combination for vestibular
neuritis. N Eng J Med 2004;351:354.
15. Paparella MM, Kimberley BP: Pathogenesis of Mnires
disease. J Vestib Res 1990;1:3.
16. Paparella MM, Meyerhoff W: Mnires disease in children. Laryngoscope 1978;88:1504.
17. Balkany T, et al: Bilateral aspects of Mnires disease: an
underestimated clinical entity. Otolaryngol Clin North Am
1980;13:603.
18. Kimura R: Animal models of endolymphatic hydrops. Am
J Otol 1982;3:447.
19. Meyer ED: Treatment of Mnires disease with
betahistin-dimesilatea double blind, placebo controlled
study. Laryngol Rhinol Otol 1985;64:269.
20. Thomson J, et al: Placebo effect in surgery for Mnires
disease. Arch Otolaryngol 1981;107:271.
21. Lange G: Intratympanic treatment of Mnires disease
with ototoxic antibiotics. Laryngol Rhinol 1977;56:409.
22. Singleton GT, et al: Perilymph fistulas: diagnostic criteria

and therapy. Ann Otol Rhinol Laryngol 1978;87:1.
23. Brandt T: Episodic vertigo. In: Rakel RE, ed: Conns
Current Therapy. Philadelphia: WB Saunders, 1986:
723.
24. Minor LB, Solomon D, Zinreich JS, Zee DS: Soundand/or pressure-induced vertigo due to bone dehiscence of
the superior semicircular canal. Arch Otolaryngol Head
Neck Surg 1998;124:249.
25. Jannetta P, et al: Disabling positional vertigo. N Engl J
Med 1984;310:1700.
26. Brandt T, Dieterich M: Vestibular paroxysmia: vascular
compression of the VIII nerve? Lancet 1994;i:798.
27. Hughes GB, et al: Clinical diagnosis of immune inner ear
disease. Laryngoscope 1988;98:251.
28. Brandt T: Positional and positioning vertigo and nystagmus. J Neurol Sci 1990;95:3.
29. Baloh RW, et al: Idiopathic bilateral vestibulopathy.
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TWO
Medical
Assessment
and Vestibular
Function Tests
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7
History and Clinical
Examination
Management of the dizzy patient depends on history, bedside clinical examination, and laboratory testing. The first
two portions of this evaluation are covered in this chapter.
History is key to determining the onset of the problem,
description of the symptoms, and, most important, how
the symptoms affect the individuals lifestyle. This last
element is crucial to obtain because some individuals
may have clinical and laboratory evidence of chronic
vestibular loss on one side but may be primarily affected
by some other cause of dizziness, such as migraine or
anxiety. The bedside clinical examination can be used to
distinguish peripheral from central vestibular problems,
the extent of loss, and how acute the problem may be.
Laboratory testing (see Chapter 8) confirms the provisional diagnosis that was based on history and clinical
findings, quantifies the degree of loss, provides evidence
of central compensation, and shows evidence of an
aphysiological component.
Elements that Help with the Diagnosis

The tempo, symptoms, and circumstances of the complaint are the three key items in the history (Table 7-1).
Tempo
The objective of establishing tempo is to determine
whether the patient has an acute attack of dizziness (within 3 days or less), chronic dizziness (more than 3 days),
or spells of dizziness. To do so, the clinician must be sure
the patient describes the first onset of the dizziness. Did
it happen suddenly, or did it develop very slowly? Was it
provoked by anything, or did it occur spontaneously? Did
the patient have a cold or some other illness around that
time? If the patient suffers from spells, the clinician
should try to determine the average duration of the spells
in seconds, minutes, or hours. It is important to have the
patient describe in detail the first spell, the most severe
spell, or the last spell that he or she can clearly recall.
History
The history is by far the most important part of the
evaluation. Unfortunately, taking a good history from
start can be extremely tedious, because the patients
complaints are often vague and are frequently filled with
anxiety-provoked symptoms. The history can be divided
into those elements that help with the diagnosis and those
that lead to goals for management, including physical
therapy.
108
Symptoms
What the patient means by dizziness should be expanded upon. Dizziness is an imprecise term used to describe
a variety of symptoms, each of which has a different
pathophysiological mechanism and significance (Table
7-2). If the patient cannot describe the symptoms, the clinician should ask whether the dizziness causes problems
primarily in the head or with balance. If the patient has
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Chapter 7 HISTORY AND CLINICAL EXAMINATION
109
Table 7-1 KEY ITEMS IN THE HISTORY OF THE DIZZY PATIENT

Disorder
Tempo
Symptoms
Circumstances
Vestibular neuritis
Acute dizziness
Vertigo, dysequilibrium, nausea and vomiting, oscillopsia
Spontaneous, exacerbated by
head movements
Labyrinthitis
Acute dizziness
Vertigo, dysequilibrium, nausea and vomiting, oscillopsia, hearing loss and tinnitus
head movements
Wallenbergs infarct
Acute dizziness
Vertigo, dysequilibrium, nausea and vomiting, tilt, lateropulsion, ataxia, crossed

sensory loss, oscillopsia
head movements
Bilateral vestibular deficit

or 7 days from a
unilateral vestibular defect
Chronic dizziness
Dizzy, dysequilibrium, occasionally oscillopsia
Induced by head movements,

walking. Exacerbated when
walking in the dark or on
uneven surfaces
Mal de dbarquement
Chronic dizziness
Rocking or swaying as if on a
boat
Spontaneous while lying or

sitting
Rarely occurs while in
motion
Oscillopsia
Chronic dizziness
Subjective illusion of visual

motion
Spontaneous with eyes open
Anxiety/depression
Chronic dizziness
Lightheadedness, floating, or
rocking
Induced by eye movements

with head still
Benign paroxysmal
positional vertigo
Spells: seconds
Vertigo, lightheadedness,
nausea
Positional: lying down,

sitting up or turning over
in bed, bending forward
Orthostatic hypotension
Spells: seconds
Lightheadedness
Positional: standing up
Transient ischemic attacks
Spells: minutes
Vertigo, lightheadedness,
disequilibrium
Spontaneous
Migraine
Spells: minutes
Vertigo, dizziness, motion

sickness
Usually movement-induced
Panic attack
Spells: minutes
Dizziness, nausea, diaphoresis, fear, palpitations, paresthesias
Spontaneous or situation
Motion sickness
Spells: hours
Nausea, diaphoresis, dizziness
Movement induced, usually

visuovestibular mismatch
Mnires disease
Spells: hours
Vertigo, disequilibrium, ear

fullness from hearing loss
and tinnitus
head movements
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Section TWO MEDICAL ASSESSMENT AND VESTIBULAR FUNCTION TESTS
Table 7-2 SYMPTOMS OF DIZZINESS

Symptoms
Mechanism
Disequilibrium: imbalance or unsteadiness

while standing or walking
Loss of vestibulospinal, proprioception, visual, and/or motor

function, joint pain or instability, and psychological factors
Lightheadedness or presyncope
Decreased blood flow to the brain
Sense of rocking or swaying as if on a ship

(mal de dbarquement)
Vestibular system adapts to continuous, passive motion and must

readapt once environment is stable
Anxiety
Motion sickness
Visuovestibular mismatch
Nausea and vomiting
Stimulation of medulla
Oscillopsia: illusion of visual motion
Spontaneous: acquired nystagmus

Head-induced: severe, bilateral loss of the vestibulo-ocular reflex
Floating, swimming, rocking, and spinning

inside of head (psychologically induced)
Anxiety, depression, and somatoform disorders
Vertical diplopia
Skew eye deviation
Vertigo: rotation, linear movement, or tilt
Imbalance of tonic neural activity to vestibular cerebral cortex
Lightheadedness
Lightheadedness, or presyncope, is usually related to
momentarily decreased blood flow to the brain. Patients
with anxiety or depression also commonly use the symptom of lightheadedness to describe their dizziness.
Most patients respond to reassurance. Some individuals

continue to have this symptom for weeks to years after a
voyage, and others complain of the same symptom arising spontaneously.
The reason for prolonged symptoms in these cases
is unknown. No consistent abnormalities are found on
magnetic resonance imaging (MRI) or electronystagmography (ENG) testing.1,2 It may be due to a problem in
the otoliths, which is not immediately accessible to clinical testing. It may also be due to or exacerbated by anxiety or a somatoform disorder. When symptoms are
prolonged, patients are extremely bothered to the point
that their lifestyle is disrupted. Such patients are very
difficult to manage. They usually feel better when in
motion, and I encourage such patients to engage in physical activity. Small doses of anti-anxiety medication are
sometimes helpful (see Chapter 13).
Rocking or Swaying as if on a Ship

Patients can find the sensation of rocking or swaying, as
if on a ship, very disturbing. It frequently occurs for a few
days after a prolonged sea or air voyage and is called mal
de dbarquement. Most likely it is due to a vestibular
adaptive process to the continuous, passive motion during travel. Once individuals are back in a stable environment, this symptom persists until readaptation occurs.
Motion Sickness
Motion sickness consists of episodic dizziness, tiredness,
pallor, diaphoresis, salivation, nausea, and, occasionally,
vomiting induced by passive locomotion (e.g. riding in a
car) or motion in the visual surround while standing
still (e.g., viewing a rotating optokinetic stimulus).
Motion sickness is believed to be due to a sensory mismatch between visual and vestibular cues.3 Patients with
spells, have him or her describe in detail the initial spell

and the last severe spell.
Disequilibrium
Disequilibrium is an imbalance or unsteadiness while
standing or walking. It is caused by a variety of factors,
including diminished or double vision, loss of vestibular
function, defects in proprioception from peripheral neuropathy or spinal cord lesions, defects in motor function
from central nervous or peripheral nervous system abnormalities, joint pain, and psychological factors.
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migraine disorder are particularly prone to motion sickness, especially during childhood. Twenty-six percent to
60% of patients with migraine have a history of severe
motion sickness, compared with 8% to 24% of people in
the normal population.4,5 The cause for this relationship
is not clear. Symptoms of increased motion sensitivity
are often reproduced when the patient is exposed to moving full-field visual target.
Nausea and Vomiting
Nausea and/or vomiting is due to stimulation of the solitary and vagus centers in the medulla. In peripheral
vestibular lesions, these symptoms are usually mild and
in proportion to the degree of vertigo: In benign paroxysmal positional vertigo (BPPV), nausea is usually mild
and vomiting is rare; in labyrinthitis and vestibular neuritis, nausea is moderate and vomiting may occur during
rapid head movement. Severity of symptoms varies for
central lesions. For pontine strokes (e.g., anterior inferior
cerebellar artery [AICA] syndromes) the degree of nausea and vomiting is similar to that in peripheral vestibular defects. For dorsal medulla strokes (e.g., posterior
inferior cerebellar artery [PICA] syndromes), nausea and
vomiting are extreme and out of proportion to the level of
vertigo.6 For all other central vestibular structures (cerebellar, fourth ventricle floor, interstitial nucleus of Cajal,
thalamus, and vestibular cortical lesions), nausea and
vomiting are usually mild or absent.
Oscillopsia
Oscillopsia is the subjective illusion of visual motion. It
differs from vertigo, in that oscillopsia occurs only with
the eyes open, whereas vertigo occurs with the eyes open
or closed. Patients occasionally interpret oscillopsia as
dizziness. There are two types of oscillopsia. Spontaneous oscillopsia is caused by acquired nystagmus and
is due to apparent motion of the visual scene from movement of the retina (retinal slip). Patients with congenital
nystagmus usually do not report oscillopsia because of
feedback of the involuntary eye movement to the central
nervous system (efference copy).
Head-induced oscillopsia occurs in patients with
severe, bilateral loss of the vestibular-ocular reflex
(VOR), which is frequently experienced after ototoxicity
due to aminoglycosides. This form of oscillopsia occurs
only during head movements and is caused by the lack of
the gaze-stabilizing features of the VOR.
Floating, Swimming, and Spinning inside
the Head (Psychological Symptoms)
Sensations of floating, swimming, or swimming inside
the head are frequently the symptoms of anxiety (panic
111
attacks, agoraphobia, obsessive-compulsive disorder),

somatoform disorders (including conversion), or depression.
Vertical Diplopia
Vertical diplopia is double vision in which the two
images line up vertically. The diplopia is not present if
either eye is covered. Vertical diplopia is commonly due
to a skew eye deviation from peripheral or central otolith
dysfunction.
Vertigo
Vertigo is the illusion of movement of the self or the environment due to sudden imbalance of tonic neural activity
in the vestibulocortical pathway (labyrinthVIIIth
nervevestibular nucleusvestibular thalamusvestibular
cortex). It is due either to normal head movements (physiologic) or to lesions that cause loss of function (ablation) of vestibular pathways on one side (e.g., vestibular
neuritis) or mechanical problems of the inner ear (e.g.,
BPPV). The direction of vertigo depends on the structures involved. Rotational vertigo in the horizontal plane
is due to horizontal semicircular canal (SCC) dysfunction, which commonly occurs from labyrinthine (e.g.,
labyrinthitis or Mnires) or VIIIth nerve dysfunction
(vestibular neuritis). Rotational vertigo in the torsional
plane (clockwise or counterclockwise direction) is due
to anterior and posterior SCC dysfunction on one side
from a central lesion in the dorsal medulla. Tilt lateral
translation or lateropulsionis due to utricle dysfunction, which can be caused by lesions in the labyrinth
or VIIIth nerve, but more commonly occurs from central
defects. Lesions in central vestibular pathways may cause
nystagmus, skew eye deviation, and lateropulsion but
rarely cause rotational vertigo.
Circumstance
The clinician must determine the circumstances in which
the patients dizziness occurs. Dizziness may be provoked only by certain movements, such as standing up
after lying down for at least 10 minutes (orthostatic
hypotension) or vertical or oblique head movements
(lying down, turning over in bed, or sitting up, BPPV). If
eye movements of the head cause dizziness and there is
no eye movement disorder (such as ocular misalignment
or an internuclear ophthalmoparesis), the symptom is not
likely to be due to a vestibular or neurological problem.
When dizziness occurs without provocation (spontaneous) and it is vestibular in origin, it is commonly exacerbated by head movements.
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Other Helpful Elements in the History

How the Dizziness Affects the Patients Life
One of the most useful questions to ask in order to determine appropriate management is How does the dizziness affect your life? Three patients with an incomplete
peripheral vestibular loss from vestibular neuritis on one
side may give different responses. The first patient may
state that he is not affected at all by the dizziness, but he
just wants to be reassured that it is nothing seriously
wrong; this response would not require extensive evaluation and management. A second patient may state that
she has no unsteadiness while walking but can no longer
play golf or tennis because of her balance; this patient
may require only a high-level physical therapy exercise
program. A third patient may state that he is completely
devastated by the dizziness and will not leave the house,
drive, or participate in any social activities. This patient
requires extensive counseling and physical therapy by the
physician and physical therapist. He may also need medication and psychological counseling to better cope with
the symptom.
Medications
The clinician must make sure to obtain a complete list of
all of a patients prescription and over-the-counter medications. A number of drugs cause dizziness, some of
which are used to treat dizziness (see Chapter 11). Some
over-the-counter medications, such as diphenhydramine
and meclizine, also cause dizziness.
What the Patient Believes is Causing the Dizziness
Another overlooked question that should be asked of a
patient with dizziness is What do you think is causing
your dizziness? Sometimes the patient has a specific
concern that may not be addressed by the health care
provider. Unless this concern is addressed, the patient
may leave the clinic unsatisfied with the visit.
Elements that Lead to Goals for

Management, Including Physical Therapy
Sensations
Two components of the history and examination are helpful in developing treatment goals. The first is obtaining a
list of the patients subjective complaints. One method of
doing so is to present a written list of symptoms that the
patient can simply check off (see Item 1 of the Patient
Questionnaire in the Appendix). The second is to use a
Visual Analogue Scale (VAS) to quantify the intensity of
specific symptoms. An example would be the head movement VAS shown in Figure 7.1. It consists of a 10-cm line
Place a mark on the line below corresponding to how dizzy

you feel while you are sitting here
As bad as it can be
No dizziness
Figure 7.1 Head movement Visual Analogue Scale (VAS).
The patient is instructed to place a mark on the line corresponding to how dizzy he or she feels while sitting and then while
performing a task. For this scale, test-retest reliability is r
0.59, based on a separate sample of patients with unilateral
and bilateral vestibular loss (n 25).
anchored with words on both ends. The person rates the

symptom intensity while sitting quietly and then while
actually performing a task. The results are expressed
as the difference between the baseline measure and the
measure after performing the task. In the example
(Fig. 7.1), the results are the intensity of dizziness, as
measured on a 10-cm line, while sitting quietly and then
after 1 minute of horizontal head movements at a 1-Hz
frequency. Separate papers containing the line are used
for each measure.
Impact on Functional Activities

The effect of dizziness on the patients functional activities can be determined from Section A of the Multidimensional Dizziness Inventory found on the last page of
the Patient Questionnaire (see Appendix A, page 483).
Perceived Disability
The perceived disability caused by a patients dizziness
can be determined from the Disability Scale, shown in
Box 7-1.7 In this scale, the patient picks the best statement out of six that best fits how he or she feels. The
clinician must remember that this is perceived disability
or handicap. The scale has been validated for degree of
perceived disability in patients with unilateral vestibular
loss (UVL) and bilateral visual loss (BVL). A score of 4
or higher is correlated with poor outcome of vestibular
rehabilitation; that is, the dizziness is unlikely to change
with rehabilitation. This scale has high test-retest reliability (r 0.97).8
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Box 7-1
DISABILITY SCALE*
For the following, please pick the one statement
that best describes how you feel:
______ Negligible symptoms
(0)
______ Bothersome symptoms
(1)
______ Performs usual work duties but
symptoms interfere with outside activities
(2)
______ Symptoms disrupt performance of
both usual work duties and outside activities (3)
______ Currently on medical leave or had to
change jobs because of symptoms
(4)
______ Unable to work for over one year or
established permanent disability with compensation payments
(5)
*Numbers in parentheses are individual scores for scale. A score of 4 or
higher is correlated with poor outcome from vestibular rehabilitation,
i.e., that patients condition is unlikely to change with rehabilitation.
From Shepard et al, 1990.7
Fall History
In the fall history, the clinician should obtain a description of any falls (where, when, lighting, what was the
patient thinking about), the frequency of falls, the last
occurrence, and whether any injuries occurred with the
falls. It is also important to obtain information about
near fallsthose events in which patients would have
fallen if they had not caught themselves by gripping furniture or some other object or if someone else had not
caught them.
Confidence in Balance
The patients confidence in balance can be obtained with
the Activities-Specific Balance Confidence Scale (ABC)
developed by Powell and Myers.9 This scale can be selfadministered or done through interview. Each item is
rated 0 to 100%. The lower the score, the greater the
patients fear of falling. There is a moderately strong negative correlation (r.64) between the Dizziness
Handicap Inventory and the ABC in patients with complaints of dizziness.10
Interference with Daily Activities

Interference with daily activities includes basic activities
of daily living (ADLs) such as dressing, bathing, getting
113
on and off a toilet, preparing a simple meal, and performing light housekeeping, whether driving is restricted
or altered, and whether the patients employment is
affected by dizziness.
Problems that May Interfere with Recovery

Several features of a patients status may interfere with
recovery from dizziness: medications, a list of which can
be obtained from item 10 of the Patient Questionnaire
(see Appendix); anxiety or depression, presence of which
can be obtained from item 12B of the Appendix (Positive
Affect, Negative Affect scale (PANAS)); the patients
support system at home or work; and whether the patient
would have secondary gains from being ill.
Physical Examination
Table 7-3 lists the portions of the physical examination
that should be performed on every patient with dizziness
to facilitate diagnosis. Visual fixation reduces or suppresses horizontal and vertical nystagmus generated by
peripheral vestibular defects. Therefore, some portions
of the examination are optimally done with either Frenzel
lenses or a video infrared camera to block fixation
(Table 7-4).
Spontaneous Nystagmus
Peripheral Vestibular Disorders
Selective lesions in the peripheral vestibular pathways
result in spontaneous nystagmus due to the unopposed
higher spontaneous neural activity in the intact vestibular
pathways (Fig. 7.2). For example, vestibular neuritis on
one side results in peripheral vestibular nystagmus
because of the unopposed activity of the lateral and anterior SCC activity on the intact side.11 The lateral and
anterior SCCs project to the ocular motor nuclei via the
medial vestibular nucleus. Peripheral vestibular nystagmus after acute loss of vestibular function on one side is
a static defect, because it occurs even with the head still.
Static defects from peripheral vestibular loss resolve
spontaneously in 1 to 2 weeks, without any intervention.
Simultaneous bilateral vestibular loss does not cause
spontaneous nystagmus because there is no asymmetry
between the two sides.
Three features of spontaneous nystagmus can be
used to separate peripheral (inner ear or VIIIth cranial
nerve) vestibular orders from central vestibular disorders
(Table 7-5). First, nystagmus that is caused by peripheral
disturbances can be decreased with fixation, but nystag-
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Table 7-3 PHYSICAL FINDINGS FOR DIAGNOSIS OF DIZZINESS

Physical Finding
Pathology
Spontaneous nystagmus present
Acute unilateral vestibular loss, or brainstem/cerebellum abnormality
Skew eye deviation (vertical eye misalignment)
Disruption of peripheral or central utricle pathway
Decreased vestibulo-ocular reflex
Chronic vestibular hypofunction
Eye movements and vertigo elicited only

during maneuvers
Usually, inner ear debris from benign paroxysmal positional vertigo

Rarely, central positional vertigo or nystagmus, perilymphatic fistula,
hypermobile stapes, Mnires disease, superior semicircular canal
dehiscence
Visual tracking impaired
Brainstem abnormality
Imbalance while standing or walking
Any listed in table
mus resulting from brainstem and cerebellum lesions usually cannot. The clinician can easily test this feature by
examining one eye with an ophthalmoscope while having
the patient fixate on a target with the other eye.13 Then the
clinician covers the fixating eye with a hand to determine
whether the nystagmus increases. Other ways to check for
the effect of fixation on spontaneous nystagmus are listed
Table 7-4 WHEN TO USE FRENZEL

LENSES OR VIDEO
INFRARED CAMERA
DURING TESTING TO
BLOCK FIXATION
Part of Physical
Examination
Use Frenzel Lenses

or Video IR?
Look for spontaneous nystagmus
Yes
Assess vestibulo-ocular reflex

(VOR):
Dynamic visual acuity
Head thrust test
Head-shaking nystagmus test
No
No
Yes
Look for skew eye deviation
No
Examine visual tracking and

saccades
No
Look for eye movements elicited

during maneuvers
Yes
Examine stance and gait
No
Figure 7.2 Peripheral vestibular loss on the left side from

vestibular neuritis. This disorder disrupts the portion of the
vestibular nerve from the horizontal semicircular canal (HSC)
and anterior semicircular canal (ASC) (X). The ASC and HSC
project to the superior vestibular nucleus (SVN) and the medial
vestibular nucleus (MVN). The SVN in turn projects to the oculomotor nucleus (III) via the brachium conjunctivum (BC) and
the ventral tegmental track (VTT). The MVN projects to the
abducens nucleus (VO) and the III nucleus vial the medial longitudinal fasciculus (MLF). The VI nucleus projects to the lateral
rectus muscle (LR). The III nucleus projects to the superior rectus (SR), medial rectus (MR), and inferior oblique (IO) muscles.
(Adapted from Tusa, 1998.12)
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Table 7-5 FEATURES THAT DISTINGUISH PERIPHERAL FROM

CENTRAL VESTIBULAR NYSTAGMUS
Feature
Peripheral Vestibular Nystagmus
Central Vestibular Nystagmus
Effect of fixation
Nystagmus decreases
Nystagmus either does not change or it

increases
Direction of gaze
Usually mixed plane (horizontal and

torsional)
Usually single-plane horizontal (torsional or

vertical)
Effect of gaze
Nystagmus increases with gaze toward

direction of quick phase
Nystagmus either does not change or reverses

direction
in Table 7-6. Second, the direction of jerk nystagmus in

peripheral causes is primarily horizontal, and torsional to
a small degree. The slow phases of the horizontal and the
torsional component move the eyes toward the involved
ear (Fig. 7.3). One must remember that nystagmus is
defined by the direction of the quick phases, so a left
vestibular neuritis causes right-beating and right torsional nystagmus. Third, nystagmus from peripheral vestibular disorders varies in amplitude and velocity according to
eye position in the orbit (gaze dependency). On the first
day of a peripheral vestibular disorder, the nystagmus is
found when the eyes are gazing center, or toward or away
from the side of the lesion (third-degree nystagmus), but
the nystagmus is most brisk during gaze away from the
side of the lesion. Within a few days, nystagmus may be
found only during gaze center and gaze away from the
side of the lesion (second-degree nystagmus). Within 1
week, nystagmus may be present only during gaze away

from the side of the lesion (first-degree nystagmus).
Central Vestibular Disorders

Figure 7.4 illustrates the structures and pathways that
mediate central vestibular nystagmus, and Table 7-7
describes the neural mechanisms.
Table 7-6 USEFUL METHODS OF

OBSERVING NYSTAGMUS
WITH FIXATION BLOCKED
Tool
Technique
Ophthalmoscope
View optic nerve of one eye

while covering the other eye
Ganzfeld
Have patient stare at blank

wall or blank sheet of paper
Video infrared camera
View eyes with infrared camera inserted in blackout

goggles
Frenzel lenses
View eyes while patient is

wearing 20-diopter lenses
inserted into face mask
Figure 7.3 Peripheral vestibular nystagmus. This figure

depicts disruption of the left superior division of the VIIIth nerve
from vestibular neuritis (X). Top, Mild right-beating and right
torsional nystagmus when fixation is present. Middle, Vigorous
nystagmus when fixation is suppressed in a subject wearing
Frenzel goggles. Nystagmus is labeled according to the direction of the quick phases. Eye movement trace is shown below
the face. By convention, eye position to the right is up, and eye
position to the left is down. Bottom, The effect of horizontal eye
position on nystagmus. The intensity of nystagmus increases
when the patient looks in the direction of the quick phases.
(Adapted from Brandt, 1991.14)
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Skew Eye Deviation
Figure 7.4 Central vestibular pathways and lesion location

for central vestibular nystagmus. Downbeat nystagmus occurs
whenever the tone within the central pathways from the anterior
semicircular canals (ASCs) is relatively higher than the tone
within the posterior semicircular canals (PSCs). This can occur
from lesions of the cerebellar flocculus (FLO) on both sides due
to disinhibition of the superior vestibular nucleus (SVN). It can
also occur from bilateral lesions of the medial longitudinal
fasciculus (MLF), which caries input from the PSC to the IIIrd
nerve (IIIN) nuclei. The IIIN nuclei includes the superior rectus
nucleus (S), inferior rectus nucleus (I), medial rectus nucleus
(M), and inferior oblique nucleus (O). Upbeat nystagmus
occurs whenever the tone within the central pathways from the
PSC is relatively higher than the tone within the ASC. This can
occur from lesions of the ventral tegmental tract (VTT) or the
brachium conjunctivum (BC), both of which carry input from the
ASC to the IIIrd nerve nuclei. Torsional nystagmus occurs when
both ASC and PSC central nuclei are lesioned on one side, as
in dorsolateral medullary lesions (Wallenbergs syndrome).
Periodic alternating nystagmus is characterized by velocity-constant jerk nystagmus directed to the right for 12 minutes and
then nystagmus to the left for 12 minutes, with a nystagmusfree interval in between. It occurs whenever the MVN is disinhibited from the cerebellar nodulus (NOD). Seesaw nystagmus
occurs from unilateral inactivation of the interstitial nucleus of
Cajal. (Adapted from Tusa, 1998.12)
Skew eye deviation is a vertical misalignment of the eyes

due to a peripheral or central otolith defect. It is part of
the ocular tilt response. Each otolith innervates four eye
muscles via a three-neuron arc. The central connections
of the utricle on one side are shown in Figure 7.5.15 The
projection to the ocular motor nuclei causes the vertical
eye deviation and torsion during head tilt. The projections in the lateral and medial vestibular spinal tracts
mediate the head tilt during the ocular tilt reflex. Acute
loss of function of the utricle on one side from VIIIth
nerve section or vestibular neuritis causes a pathologic
ocular tilt response because of the unopposed excitation
of the intact utricle.16
Figure 7.6 depicts the findings in a left-sided lesion
(leftward pathologic ocular tilt response [OTR]).
Excitation of the right superior rectus and oblique muscles causes elevation and intorsion of that eye, and excitation of the left inferior rectus and oblique muscles
causes depression and extorsion of that eye. This combination causes a skew eye deviation. Excitation of the neck
muscles innervated by the intact vestibulospinal tracts
causes a left head tilt. Leftward pathologic OTR can be
due to destructive lesions along the pathway extending
from the utricle on the left side, such as in the left utricle
(labyrinthitis), left vestibular nerve (vestibular neuritis),
left vestibular nucleus (Wallenbergs syndrome), right
medial longitudinal fasciculus (left internuclear ophthalmoparesis [INO]), right rostral interstitial nucleus of the
medial longitudinal fasciculus, and right interstitial
nucleus of Cajal.
Vestibular-Ocular Reflex
When vestibular function is lost on one side, two types of
abnormalities emerge within the VOR. The first abnormality is a static imbalance due to a difference in the
tonic discharge rate between the vestibular nuclei on the
two sides of the brainstem. The tonic resting firing rates
of most or all of primary afferents on the lesioned side are
lost.17 Resting firing rates of type I nuclei neurons on the
lesioned side are acutely absent. In comparison, the resting firing rates of the neurons on the normal side double
owing to inactivation of the inhibitory commissural path.
This imbalance results in a spontaneous nystagmus. Even
though the primary afferents may not recover, the relative
resting firing rates are readjusted centrally within several
days after onset (loss of spontaneous nystagmus). About
a week after vestibular neuritis occurs, spontaneous
nystagmus can be completely suppressed in the light. On
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Table 7-7 VESTIBULAR NYSTAGMUS DUE TO CENTRAL LESIONS

Nystagmus
Pathology
Possible Mechanism
Torsional nystagmus
Dorsolateral medulla lesion
Decreased tonic neural activity to the INC from

anterior and posterior SCC on one side
Downbeat nystagmus
Lesion of cerebellar flocculus or

floor of fourth ventricle
Decreased tonic neural activity to the INC from

posterior SCC on both sides
Upbeat nystagmus
Lesion of brachium conjunctivum

or dorsal upper medulla
Decreased tonic neural activity to INC from

central anterior SCC on both sides
Seesaw nystagmus
Unilateral lesion of INC
Unilateral inactivation of INC on one side
Periodic alternating
nystagmus
Cerebellar nodulus lesions
Unstable (high gain) neural activity in the MVN
Latent nystagmus
Loss of cortical binocular visual

input to the NOT usually from
congenital esotropia
Decreased tonic neural activity to MVN from the

NOT on one side when one eye is covered. (NOT
provides all of the visual input into the MVN)
INC interstitial nucleus of Cajal; MVN medial vestibular nucleus; NOT nucleus optic tract; SCC semicircular canal.
average, though, the relative resting firing rates are less

than in control animals. The second abnormality is the
loss of dynamic sensitivity during head rotation because
of the loss of half of the push-pull combination. This
results in a decreased gain (eye velocity/head velocity) of
the VOR.
The following three bedside tests examine the
changes in the dynamic sensitivity of the VOR (Table
7-8). The results of all three VOR bedside tests are useful
for patients with unilateral or bilateral loss of vestibular
function (such as vestibular neuritis or ototoxicity).
Results of the dynamic visual acuity and head-thrust tests
are strongly positive in patients with bilateral vestibular
loss, but the head-shaking nystagmus test result is not
positive in this group.
Head-Thrust Test
The clinician asks the patient to fixate on a target and then
grasps the patients head to perform passive horizontal
and vertical head thrusts, observing the eyes during the
thrusts. After a head thrust, the observation of a refixation
saccade indicates decreased VOR.18 It is important that
the patients be tested while they are wearing their usual
glasses, because the VOR is calibrated for visual inputs
through those glasses. Table 7-9 shows the sensitivity and
specificity of the head-thrust test with respect to the
caloric test for UVL. For complete UVL due to nerve section, the sensitivity and specificity are 100%; for a variety
of types of UVL, the overall sensitivity is 36%, but the
specificity is 97%. Sensitivity of testing can be improved
by (1) pitching the head down 30 degrees to place the horizontal SCC in the plane of movement and (2) making the
head thrust unpredictable.19 Table 7-10 shows how the
head thrust test results vary with the severity of UVL.23
For example, for moderate paresis of the caloric test
(5075% weakness), 19 patients had a negative head
thrust test (90% of the total tested) and 2 patients had a
positive test (10% of the total tested).
Head-Shaking Nystagmus Test

While wearing Frenzel or IR goggles, the patient is asked
to close the eyes, pitch the head down 30 degrees, and
then oscillate the head 20 times horizontally. After the
head oscillation, the patient opens the eyes, which the clinician observes for nystagmus. The presence of nystagmus immediately after this procedure indicates a
vestibular imbalance.24 This sign may persist indefinitely
after a peripheral or central unilateral vestibular lesion.
Table 7-11 shows the sensitivity and specificity of the
head-shaking nystagmus test with respect to the caloric
test for UVL. For a variety of types of UVL, the overall
sensitivity is 46%, and the specificity is 75%. Table 7-12
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X
Figure 7.6 Pathologic ocular tilt response from left-sided
peripheral vestibular defect. This defect causes the head to tilt
to the left, the eyes to have a static torsional component to the
left, and a skew eye deviation resulting in a right hypertropia. In
the light during bedside examination, the only finding that may
be readily appreciated is the skew eye deviation.
Figure 7.5 Otolith pathway from the left utricle. This figure
depicts disruption of the left utricular division of the VIIIth nerve
from vestibular neuritis. The utricle projects to the lateral (L) and
medial (M) divisions of the vestibular nucleus. These portions of
the vestibular nucleus project to the medial vestibular spinal
tract (MVST) and lateral vestibular spinal tract (LVST). In addition, the medial division of the vestibular nucleus projects to the
trochlear (IV) and oculomotor (III) nuclei via the medial longitudinal fasciculus (MLF). The IV projects to the superior oblique
eye muscle (SO), and the III projects to the superior rectus
(SR), inferior rectus (IR), and inferior oblique (IO) eye muscles.
INC interstitial nucleus of Cajal; VI abducens nucleus;
S superior vestibular nucleus. (Adapted from Tusa, 1998.12)
shows how the sensitivity and specificity vary with the

severity of UVL.28
Clinical Vestibular Dynamic

Visual Acuity Test
The clinical vestibular dynamic visual acuity test compares visual acuity with the head still to visual acuity
with the head moving. Visual acuity with the head still is
measured first using a visual acuity chart. The patient is
then asked to read the smallest possible line on the chart
while the examiner manually oscillates the patients head
horizontally at 2 Hz so the face moves 1 or 2 inches in

either directionabove the frequency at which pursuit
eye movements can track the target. If the VOR is normal, the patients eyes will move smoothly in the opposite direction of the head movement so that ocular
fixation is always maintained. The patient should be able
to read either the same line as when their head was still
(initial static visual acuity) or the next line above it,
which has larger letters. If the patient can read only lines
more than 3 lines above the initial static visual acuity
line, he or she likely has a vestibular defect (Fig. 7.7).
After vestibular adaptation exercises, dynamic visual
acuity improves, possibly because of the development of
preprogrammed or anticipatory eye movements.29,30
Maneuver-Induced Vertigo
and Eye Movements
If there is a mechanical problem (e.g., BPPV), nystagmus
can be elicited by certain maneuvers. Therefore, in addition to looking for spontaneous nystagmus, the clinician
should perform certain maneuvers that may evoke nystagmus (Table 7-13).
Position Testing
The Hallpike-Dix test result is positive in patients with
BPPV (Fig. 7.8). Nystagmus from BPPV should begin
within 30 seconds and last less than 30 seconds. If nystagmus persists while the patient is in this position and is
not present when the patient is sitting, it is likely due to a
central disorder (central positional vertigo). The only
exception to this statement is BPPV due to cupulolithiasis. In this condition, otoconia are attached to the cupula of the SCC, so the Hallpike-Dix test will result in
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Table 7-8 BEDSIDE TESTS OF THE VESTIBULAR-OCULAR REFLEX (VOR)

Test
Procedure
Result
Vestibular dynamic
visual acuity (DVA)
Static, distant visual acuity is determined with the head still

Dynamic visual acuity is then determined while the patients head is
oscillated manually at 2 Hz
A dynamic visual acuity of 3 or more lines

above static visual acuity indicates a vestibular
defect
Head thrust
The patient fixates a distant visual

target, and eye position is observed
immediately after a small thrust of
the head to the left and right
A refixation saccade after the head thrust indicates decreased VOR

If the head thrust elicits a refixation saccade
when the patient is fixating a target at near, the
test should be repeated with the patient looking at a distant target in order to clearly have a
positive result, especially in older patients
Head-shaking nystagmus
Clinician pitches the patients head

down 30 degrees and oscillates the
head horizontally 20 times
Elicitation of jerk nystagmus during this procedure indicates a vestibular imbalance
persistent nystagmus and vertigo (see Chapter 17 for further details). Positional nystagmus may also be seen in
patients with a variety of other mechanical problems of
the inner ear, but the characteristics of the nystagmus are
usually not classic for BPPV. These other disorders are
central positional vertigo, central positional nystagmus
without vertigo, and perilymphatic fistula (a hole
between the endolymph and perilymph or between the
perilymph and middle ear).
Pressure Testing, Tullio Phenomenon,

and Tragus Movement
Nystagmus or drift of the eyes should also be assessed
after positive and negative pressure directed to the external auditory canal (Henneberts sign), Valsalva, or loud
noise (Tullio phenomenon). A positive response is found
in patients with perilymphatic fistula, hypermobile
stapes, and, occasionally, Mnires disease or hydrops.
Table 7-9 HEAD-THRUST TEST COMPARED WITH CALORIC TEST

FOR UNILATERAL VESTIBULAR LOSS (UVL)*
Type or Cause of UVL
Sensitivity (%)*
Specificity (%)*
No. of Patients
Study
Complete UVL due

to nerve section
100
100
20
Halmagyi & Curthoys (1988)18
Complete UVL due

to nerve section
100
100
12
Foster et al (1994)25
Various
39
97
112
Harvey & Wood (1996)26
Various
35
95
105
Harvey et al (1997)27a
Various
34
Average: 36
100
Average: 97
150
Beynon et al (1998)23
Various
70
81
77
Grine et al (2000)19
*Caloric test used as the standard.
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Table 7-10 HEAD-THRUST TEST

(HT) AS A FUNCTION
OF CANAL PARESIS
Canal
Paresis
No. of
Patients
Table 7-12 HEAD-SHAKING

NYSTAGMUS TEST
(HSN) AS A FUNCTION
OF CANAL PARESIS
Negative
HT Result
Positive
HT
Result
Normal (025)
76
76 (100%)
0 (0%)
Mild paresis
(2550)
23
23 (100%)
0 (0%)
Moderate paresis
(5075)
21
Severe paresis
(75100)
30
19 (90%)
2 (10%)
Canal Paresis
Positive HSN Result
Normal (020)
22%
Mild paresis (2125)
24%
Moderate paresis (2550)
28%
Severe paresis (50)
62%
Adapted from Asawavichianginda et al, 1997.28
7 (23%)
23 (77%)
Visual Tracking
Smooth Pursuit Eye Movements and
Cancellation of the Vestibulo-Ocular Reflex
Table 7-11 HEAD-SHAKING
NYSTAGMUS TEST
COMPARED WITH
CALORIC TEST*
Sensitivity
(%)*
Specificity
(%)*
No. of
Patients
40
60
108
Wei et al
(1989)27b
95
62
85
Takahashi et al
(1990)28
27
85
116
Jacobson et al
(1990)29
44
65
105
Burgio et al
(1991)30
42
85
197
Goebel and
Garcia (1992)31
35
92
105
Harvey et al
(1997)27a
38
79
290
Asawavichianginda et al
(1997)28
Average:
46
Average:
75
*Caloric test used as the standard.
Study
Both smooth pursuit eye movements and VOR cancellation are slow tracking movements that maintain images
of small moving targets on the fovea. During smooth pursuit eye movements, the head is kept still. During VOR
cancellation, the head is moving synchronously with the
target. This movement is referred to as VOR cancellation
because the VOR must be suppressed during the head
movement; otherwise, the image of the target could not
be maintained on the fovea. The patient is asked to track
a small target that is moving slowly (20 degrees per second [deg/sec]) both horizontally and vertically, with the
head still (smooth pursuit). VOR cancellation can be
measured by having the patient fixate on a small target
that moves synchronously with the head movement. The
easiest way to do this is for the clinician to grasp the
patients head with both hands and gently move it back
and forth at 1 Hz. The clinician moves his or her own
head synchronously with the patients head and asks the
patient to follow the clinicians nose.
A unilateral peripheral vestibular lesion does not
impair either smooth pursuit or VOR cancellation unless
the spontaneous nystagmus from the lesion is so high that
it prevents the eye tracking systems from functioning
normally. In contrast, a lesion in the parieto-occipital
frontal cortex, frontal cortex, pontine nuclei, cerebellar
vermis, or cerebellar flocculus does cause deficits in
smooth pursuit and VOR cancellation for targets moving
toward the side of the lesion. During smooth pursuit for
target motion toward the side of the lesion, there are
catch-up saccades because of decreased pursuit gain
(gain slow phase eye velocity target velocity); this
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Figure 7.7 Dynamic visual acuity (DVA) scores in patients with vestibular hypofunction and normal controls. On the ordinate is the number of letters (optotypes) missed on a standardized visual
acuity (SVA) chart called the ETDRS chart (used in the Early Treatment Diabetic Retinopathy Study).
This chart has 5 letters on each line. On the abscissa are the rankings of individual subjects from the
best visual acuity (to the left) to the more impaired (to the right). Gray bars represent controls or
subjects seen in the clinic for dizziness who did not have a vestibular defect according to bithermal
water caloric testing. White bars represent subjects with unilateral vestibular loss (25% or greater
asymmetry). Black bars represent subjects with bilateral vestibular loss according to caloric testing
(20 degrees of peak slow-phase velocity on 4 irrigations) and rotary chair test (gain 0.1).
process is sometimes referred to as saccadic pursuit.

During VOR cancellation toward the side of the lesion, a
horizontal jerk nystagmus occurs. An example of saccadic pursuit in a right-sided lesion is shown in Figure
7.9. In patients with cerebellar degeneration or other
bilateral disorders, smooth pursuit and VOR cancellation
are impaired in both directions.
Table 7-13 MANEUVER-INDUCED

VERTIGO AND EYE
MOVEMENTS FROM
MECHANICAL PROBLEMS
IN THE INNER EAR
Positive Result of:
Disorder(s)
Position testing
Benign paroxysmal positional

vertigo
Central positional nystagmus
Central positional vertigo
Dehiscence of superior
semicircular canal
Perilymphatic fistula
Pressure testing, tragus

movement, or Tullio
phenomenon
Dehiscence of superior
semicircular canal
Mnires disease
Figure 7.8 Hallpike-Dix test for benign paroxysmal positional

vertigo (BPPV). (A) In this test, the patient sits on the examination table and the examiner turns the head 45 degrees horizontally. (B) The examiner then quickly brings the head and trunk
straight back en bloc so that the head is hanging over the
edge of the examination table by 20 degrees. Nystagmus is
sought, and the patient is asked whether he or she has vertigo.
Although not shown in the figure, the examiner then brings
patient up slowly to a sitting position with the head still turned
45 degrees, and looks for nystagmus again. The test is repeated
with the head turned 45 degrees in the other direction. This figure also shows movement of debris in the right posterior semicircular canal (black arrows) during the test. In this example, the
patient would have nystagmus and vertigo when the test is performed on the right side, but not when the test is performed on
the left side. (Modified from Tusa and Herdman 1998 [see
Chapter 17 for reference].)
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Target Position
R10degEye Position
L10deg0
500
1000
1500
2000
2500
TIME (msec)
Saccadic Eye Movements

Saccadic eye movements are very fast changes in eye
position. These eye movements can be tested by having
the patient follow a target that rapidly changes position.
Having the patient fixate on the clinicians nose assesses
steady fixation. Having the patient look between the clinicians nose and a finger held approximately 20 degrees
eccentrically assesses voluntary saccades; this evaluation
is repeated several times to the left, to the right, up, and
down. During this test, the clinician should determine
whether the saccades have normal amplitude and velocity. For saccades to eccentric targets, the amplitude
should be normal or not more than 10% hypometric,
and never hypermetric; for saccades back to center, the
amplitude should be normal or no more than 10% hypometric or hypermetric. Saccade velocity should be brisk
and equal in the two eyes. The patient should also be told
to follow an optokinetic drum or tape to assess quick
phases of nystagmus.
Peripheral vestibular defects do not impair saccades.
In contrast, unilateral lesions of the cerebellum or its
afferent and efferent connections can cause hypermetria
in one direction and hypometria in the other direction.
A unilateral lesion involving the cerebellar vermis from a
superior cerebellar artery infarction results in contralateral hypermetria and ipsilateral hypometria (Table 7-14).
Infarction of the lateral medulla (Wallenbergs syndrome) also results in ipsilateral hypermetria and
contralateral hypometria, presumably because of deafferentation of the fastigial nucleus from infarction of the
inferior cerebellar peduncle.
Cerebellar vermal lesions result in hypometric saccades to the right and to the left. Slow saccades can be due
to a number of different disorders, including a decrease in
the number of burst cells in the paramedian pontine reticular formation (PPRF) and rostral interstitial nucleus of
the medial longitudinal fasiculus (RiMLF). Generally,
lesions involving the midbrain cause vertical saccade
slowing, whereas lesions involving the pons cause horizontal saccade slowing. Slow saccades can be due also to
Figure 7.9 Impaired smooth pursuit to

the right. The light line represents target
trajectory. The dark line represents eye
position. R10deg and L10deg represent
eye positions (right and left 10 degrees,
respectively) within the orbit.
an internuclear ophthalmoparesis (INO). An INO occurs

when the pathway between the VIth and IIIrd nerve nuclei
is disrupted. In an INO, saccades in the eye moving
toward the nose (adducting) are slower or limited compared with those in the eye moving away from the nose
(abducting). Slow saccades can also occur because of
problems in the neuromuscular junction (e.g., myasthenia
gravis, Miller-Fisher syndrome). Finally, slow saccades
may occur because of eye muscle problems (thyroid eye
disease, progressive external ophthalmoplegia).
Stance and Gait

The Romberg test, Sharpened Romberg (heel-to-toe
tandem stance) test, Fukudas Stepping Test, and
Table 7-14 SACCADIC EYE

MOVEMENT DEFICITS
Saccade
Parameter
Definition
Lesion
Location
Latency
Time from target

step to beginning of saccade
Increased latency
seen primarily with
lesions in cerebral
cortex (visual attention defects) or
brainstem (defects
in initiation)
Velocity
Peak speed of
saccade
Decreased velocity
seen primarily from
lesions in the pons
(burst cells)
Accuracy
How close amplitude of saccade

matches amplitude of target
step
Decreased or
increased amplitude
primarily determined by cerebellar
vermis and pathways to brainstem
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retropulsion test should be performed to evaluate stance,

and gait and tandem gait should be examined.
In the Romberg tests, the patient is asked to stand
with feet slightly apart and arms folded across the chest
with eyes open for 30 seconds and then with eyes closed
for 30 seconds. A positive Romberg test result is one in
which the patient is stable with eyes open but loses balance with eyes closed. A positive Romberg result occurs
in patients with severe proprioceptive defects from a
peripheral neuropathy and may be found in patients with
acute vestibular defects. The Romberg test is also useful
in identifying a functional component, suggested when
the patient rocks backward on the heels yet remarkably
does not fall or have an exaggerated sway during the test.
In the Sharpened Romberg test, the patient is asked to
stand with feet in heel-to-toe position, first with eyes
open and then with eyes closed. A positive Sharpened
Romberg test result is found in patients with the same
disorders that cause a positive Romberg result as well as
in those with chronic vestibular defects and in some normal individuals older than 65 years.
For the Fukudas Stepping Test, the subject steps in
place for 50 steps with arms extended and eyes closed.20
Progressive turning toward one side of more than
30 degrees is abnormal. A positive Fukudas Stepping
Test result is frequently found in patients with a unilateral vestibular defect but it is also seen in patients with a
leg-length discrepancy or other structural abnormalities
of the legs.
In the retropulsion test, the patient stands with the
feet slightly spread apart and is instructed to just take one
step backward if pulled backward at the hips by a mild
force. The result is positive if the patient must take three
or more steps backward or falls backward like a log. The
retropulsion test has a positive result in patients with
basal ganglia disorders (progressive supranuclear palsy,
Parkinsons disease) and disorders that disrupt frontal
lobebasal ganglia projections (normal-pressure hydrocephalus, leukoareosis).
Normal gait and tandem gait should be examined for
cerebellar ataxia, decreased head-on-body movements
during turns (vestibular hypofunction), and shuffling gait
in Parkinsons disease. Other features of gait help identify a functional component, including knee buckling
without fall, small-amplitude steps, uneconomical posture and movement, excessive slowness in gait, and fluctuations in levels of impairment.21,22
References
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4. Kuritzky A, Ziegler DK, Hassanein R: Vertigo, motion
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7. Shepard NT, Telian SA, Smith-Wheelock M: Habituation
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9. Powell LE, Myers AM. The Activities-specific Balance
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10. Whitney SL, Hudak MT, Marchetti GF. The activitiesspecific balance confidence scale and the dizziness handicap inventory: a comparison. J Vestib Res 1999;9:
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11. Fetter M, Dichgans J: Vestibular neuritis spares the
inferior division of the vestibular nerve. Brain 1996;119:
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12. Tusa RJ: The dizzy patient: disturbances of the vestibular
system. In: Tasman WL, Jaeger, EA eds. Duanes Clinical
Ophthalmology, Vol 2. Philadelphia: Lippincott-Raven;
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13. Zee DS: Ophthalmoscopy in examination of patients
with vestibular disorders. Ann Neurol 1978;3:373374.
14. Brandt T: Vertigo: Its Multisensory Syndrome. London:
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15. Uchino Y, Sasaki M, Sato H, et al: Utriculoocular reflex
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16. Halmagyi GM, Gresty MA, Gibson WPR: Ocular tilt
reaction with peripheral vestibular lesion. Ann Neurol
1979:6;8083.
17. Smith PF, Curthoys IS: Neuronal activity in the contralateral (and ipsilateral) medial vestibular nucleus of the
guinea pig following unilateral labyrinthectomy. Brain
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18. Halmagyi GM, Curthoys IS: A clinical sign of canal
paresis. Arch Neurol 1988;45:737739.
19. Grine EL, Herdman SJ, Tusa RJ: Sensitivity and specificity of the head thrust test for peripheral vestibular
patients. Neurol Rep 2000;24:177.
20. Fukuda T: The stepping test: Two phases of the
labyrinthine reflex. Acta Otolaryngol [Stockh]
1959;50:95108.
21. Keane JR: Hysterical gait disorders: 60 cases. Neurology
1989;39:586589.
22. Lempert T, Brandt T, Dieterich M, Huppert D: How to
identify psychogenic disorders of stance and gait. J
Neurol 1991;238:140146.
23. Beynon GJ, Jani P, Baguley DM: A clinical evaluation
of head impulse testing. Clin Otolaryngol 1998;23:
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24. Hain TC, Fetter M, Zee DS: Head-shaking nystagmus in

patients with unilateral peripheral vestibular lesions. Am
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25. Foster CA, Foster BD, Spindler J, Harris JP: Functional loss of the horizontal dolls eye reflex following
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26. Harvey SA, Wood DJ: The oculocephalic response in
the evaluation of the dizzy patient. Laryngoscope 1996;
106:69.
27a. Harvey SA, Wood DJ, Feroah TR: Relationship of the
head impulse test and head-shake nystagmus in reference
to caloric testing. Am J Otol 1997;18: 207213.
27b. Wei D, Hain TC, Proctor LR: Head shaking nystagmus:
associations with canal paresis and hearing loss. Acta
28a. Asawavichianginda S, Fujimoto M, Mai M, Rutka J:
Prevalence of head-shaking nystagmus in patients according to their diagnostic classification in a dizziness unit. J
Otolaryngol 1997;26;2025.
28. Takahashi S, Fetter M, Koenig E, Dichgans J: The clinical significance of head-shaking nystagmus in the dizzy
patient. Acta Otolaryngol (Stockh) 1990;109:814.
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CHAPTER
Vestibular
Function Tests
Laboratory testing serves several purposes. It (1) confirms what one already suspects from the history and clinical examination (i.e., unilateral or bilateral vestibular
loss versus no vestibular loss), (2) quantifies the extent of
loss (complete labyrinthine loss innervated by superior
and inferior vestibular loss versus incomplete loss), (3)
shows evidence of central compensation after physical
therapy, and (4) shows evidence of an aphysiological
component. Each of these points is discussed in this chapter. The discussion is divided into tests that are specific
for different portions of the labyrinthine and vestibular
nerve (Fig. 8.1) and tests that assess function but are not
specific to labyrinth and vestibular nerve (Table 8-1).
Tests that Specifically Assess

Labyrinth or Vestibular Nerve
Caloric Test
The caloric test is the best method of determining whether
a unilateral vestibular defect is peripheral or central and
also of identifying the side of the defect. This test is usually not well tolerated in children younger than 8 years.
The caloric test is usually part of a battery of tests included in electronystagmography (ENG) (or electrooculography [EOG]), or videography (VOG). The battery of tests
consists of spontaneous eye movements, position testing,
Figure 8.1 Labyrinth and vestibular

nerve. The superior vestibular nerve
innervates the anterior semicircular
canal (SCC), horizontal SCC, and
utricle. The inferior vestibular nerve
innervates the posterior SCC and the
saccule (Adapted from Schuknecht,
1974.1)
125
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Table 8-1 TYPES OF TESTS USED

TO ASSESS PATIENTS
WITH DIZZINESS
Tests that assess
the function of
the labyrinth and
vestibular nerve
Functional tests
that do not evaluate
peripheral vestibular
function
Caloric test appropriate

for horizontal SCC and
portion of the superior
vestibular nerve.
Spontaneous and positional tracking, smooth pursuit, OKN and saccadic

eye movements
Rotary chair test approComputerized dynamic

priate for horizontal SCC
posturography
and portion of the superior
vestibular nerve
Each ear canal is irrigated for 40 seconds, with a

constant flow rate of water at two temperatures (30C and
44C). Eye movements are recorded for 2 minutes after
each irrigation. During the test, the patient is supine, but
the head is tilted up 30 degrees, placing the horizontal
SCC in a vertical plane. When cold water (30C) or iced
water is flowing into external auditory canal, endolymph
fluid in the horizontal SCC sinks. This movement of
endolymph causes the cupula to depress away from the
utricle (Fig. 8-2). Movement of the cupula away from the
utricle inhibits the spontaneous activity in the vestibular
nerve (Fig. 8.3), resulting in nystagmus with slow phases
directed toward the side of irrigation (Fig. 8.4). When
Cupula movement toward utricle

Ampulla
Middle
ear
Quantified DVA test

appropriate for horizontal
SCC and portion of the
superior vestibular nerve
VEMP testappropriate
for saccule and portion
of the inferior vestibular
nerve
Subjective visual vertical
test appropriate for utricle and portion of the
superior vestibular nerve
visual tracking, and vestibular testing (caloric testing or

rotary chair tests). These tests are objective and quantitative and ideally are performed in all patients in whom a
vestibular defect is detected by clinical examination. ENG
and EOG record eye movements by means of small electroencephalography (EEG) electrodes placed on either
side of the eye to record small voltage differences
between the cornea and retina of the eye. VOG records
eye movements by means of a video camera and software
that track the pupil of the eye.
Before the caloric test is performed, the internal
auditory canal is examined with an otoscope, and any
wax or debris that blocks the canal is removed. If there is
a tympanic membrane perforation, different temperatures
of air instead of water should be used as the stimulus. The
caloric test uses a nonphysiological stimulus (water) to
induce endolymphatic flow in the semicircular canal
(SCC) by creating a temperature gradient within it.
Utricle
HSCC
Crista
44C
irrigation
External
auditory
canal
30C
irrigation
External
auditory
canal
Note direction
of endolymph movement
Cupula movement away from utricle

Ampulla
Middle
ear
Utricle
HSCC
Crista
Note direction
of endolymph movement
Figure 8.2 Diagram illustrating how irrigation of external

auditory canal with water of different temperatures sets up convection currents in different directions in the endolymph of the
horizontal semicircular canal. This results in deflection of the
cupula in different directions, with an end result of either excitation or inhibition of the vestibular neurons. In this illustration, the
subject has been positioned supine with the head elevated 30
degrees, placing the horizontal semicircular canal (HSCC) in a
vertical alignment. (Modified from Baloh and Honrubia,19902)
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Chapter 8 VESTIBULAR FUNCTION TESTS
127
Figure 8.3 Schematic diagram of caloric test in right ear. Iced water irrigation will cause
endolymph to sink within the horizontal semicircular canal (HCC), resulting in decreased spontaneous neural activity in the medial vestibular nucleus (MVN). Asymmetric firing of the MVN on each
side leads to nystagmus. In this figure, a left-beating nystagmus would occur (slow phases to the
right and quick phases to the left), mediated by the lateral rectus muscle (LR), medial rectus muscle
(MR), VIth nerve nucleus (VI), oculomotor nucleus (III) and connection between VI and III, called
the medial longitudinal fasciculus (MLF). Quick phases are generated by the parapontine reticular
formation (PPRF). PAUSE cells suppress cells in the PPRF.
warm water (44C) is flowing into external auditory canal,

the opposite response occurs. At the end of this period, the
ear is emptied of any remaining water, and sufficient time
is allowed for the nystagmus to stop before the next irrigation is begun (usually 5 minutes).
The results of caloric testing, and the determination
whether there is a meaningful asymmetry in the responses, can be quantified using Jongkees formula, as follows:
(LC LW) (RC RW)
100
(LC LW) (RC RW)
where the values are the velocity of the slow-component
eye moments to cool-water irrigation of the left ear (LC),
warm-water irrigation of the left ear (LW), cool-water
irrigation of the right ear (RC), and warm-water irrigation
of the right ear (RW).
The comparison of responses from the irrigation of
the right and left ears also can be depicted graphically
(Fig. 8.5).
Strengths of Test
The caloric test is the best test for determining whether a
vestibular defect is peripheral or central and for identifying the side of the defect. It is inexpensive relative to
rotary chair testing. See the discussion of rotary chair
testing for sensitivity and specificity information.
Weaknesses of Test
The caloric test assesses only the horizontal SCC or the
portion of the superior vestibular nerve that innervates
this canal. Because it compares the response from one ear
with that from the other ear, it cannot be used to assess
bilateral vestibular loss. The test also cannot be used to
determine central compensation.
Rotary Chair Testing

Rotary chair testing is a physiological test that can be
used to assess the horizontal SCC or the superior vestibu-
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Figure 8.4 Caloric nystagmus in a patient with left

vestibular hypofunction. Note that irrigation of the right
ear with warm water (C) results in a right-beating nystagmus and that irrigation with cool water results in a
left-beating nystagmus (D). In contrast, there is no
response from the left ear to either cool water (A) or
warm water (B).
Figure 8.5 Graphic illustration of

the caloric asymmetry in the patient
represented in Figure 8.4.
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129
VOR 240 deg/sec CW

6
Eye Position (degs)
4
2
0
-2
-4
-6
-8
-10
10
12
Time (secs)
Figure 8.7 Vestibular nystagmus from rotary chair test (constant velocity chair rotation at 240 deg/sec). With rotation in a
clockwise direction (patients right), a slow-component eye
velocity is generated to the left. In the depiction here, eye movements to the right are positive or up, and eye movements to the
left are negative or down. Note the gradual decrease in the
slope of the slow-component eye movement trace with time,
which indicates that the eye movement velocity is slowing.
Figure 8.6 Rotary chair testing: Rotation of the patient generates a response that reflects stimulation of both inner ears
simultaneously. Eye movements are recorded using electrooculography (EOG) or infra-red video-oculography.
lar nerve that innervates it (Fig. 8.6). Eye movements

are measured by EOG or VOG. After calibration, peak
slow-phase eye velocity is measured during either sinusoidal chair rotations or constant-velocity step rotations
in the dark, to assess vestibulo-ocular reflex (VOR) gain
(eye velocity chair velocity), time constant during constant velocity steps (rate of decay of slow-phase eye
velocity), and phase during sinusoidal rotation (offset
between time of peak eye velocity and time of peak chair
velocity). VOR gain is normally near 1.0 at birth and
decreases in adults.3 In my laboratory, gain for VOR step
rotation less than 0.3 is abnormal and indicates vestibular
hypofunction.
If head rotation is sustained in one direction (e.g.,
spinning around at a constant speed), the slow-phase eye
movements of the VOR drive the eyes into extreme contraversive deviation in the orbit. Moving the eyes in this
extreme position during the VOR triggers a quick phase
(type of saccade) in the opposite direction, which brings
the eyes back into the working ocular motor range. A sustained sequence of slow and quick phases is called nystagmus (Fig. 8.7).
The sensory stimulus for the VOR is head acceleration, and yet, during head rotation at a constant velocity,
slow-phase eye velocity still matches head velocity fairly
well, at least for the first several seconds after head acceleration has stopped. This function is mediated by the
velocity storage system located in the brainstem, a system capable of storing the head velocity signal for a limited portion of the time. During a sustained, constant
velocity rotation, slow-phase eye velocity decreases in an
exponential manner (Fig. 8.7). The time constant of the
decay (time to decay to 37% of initial value) is 10 to 30
seconds. This decay can be graphically illustrated by
plotting the velocity of each slow-component eye movement against time (Fig. 8.8). Another form of rotary chair
testing uses sinusoidal chair movements rather than step
rotations at a constant velocity. In sinusoidal rotary chair
testing, the chair rotations are performed at 0.0125, 0.05,
0.2, 0.4, and 0.8 Hz. The gain and phase of the slowcomponent eye velocities are plotted for each frequency
of rotation (Fig. 8.9).
Strengths of Test
Rotary chair testing is one of the most physiological
tests to assess vestibular function and can be performed
even in children of any age, although calibrations are
usually obtainable only in infants 6 months or older
(by using a happy face or similar stimulus). Children
younger than 4 years can sit in a parents lap. The test
is not susceptible to mechanical problems of the ear, so
it can be done in individuals with such problems, includ-
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Eye velocity
50
Rotation 240deg/sec
240
Eye velocity
Eye velocity
80
Rotation 60deg/sec
80
Rotation 60deg/sec
50
0
100
0
-240
-80
10
20
30
10
20
30
Time, sec
Time, sec
VOR DATA: at 60 degrees per second

Gain:
Time Constant:
Rot. to L = 0.679
L = 10.0
GAIN DP = 29.6
TC DP = 27.1
Rot. to R = 0.369
R = 17.5
VOR DATA: at 240 degrees per second
-80
0
10
20
30
Time, sec
Figure 8.8 Slow-phase eye velocity decay during 60
deg/sec, constant velocity rotary chair test. Vestibulo-ocular
reflex (VOR) gain (peak slow-phase eye velocity peak chair
[or head] velocity) can be measured; in this example, it is 30
60 0.5. VOR time constant (time it takes for eye velocity to
decrease to 37% of peak value) can be measured; in this example it is 14 seconds.
ing perforated tympanic membrane. It is superior to

caloric test in patients with bilateral vestibular weakness.
Some patients with central vestibular defects have
increased VOR gain (some forms of spinocerebellar atrophy), which is not detected with caloric tests but is with
rotary chair testing. This test can be used to help determine central compensation from vestibular rehabilitation
(Fig. 8.10).
The sensitivity of bithermal caloric test for identifying vestibular hypofunction ranges from 31% to 90%,
and its specificity is 86%.4,5 The sensitivity of rotary
Bode plot Gain
1.4
50
1.2
GAIN DP = 36.0
TC DP = 27.1
Rot. to R = 0.392
R = 17.5
Figure 8.10 In individuals with uncompensated unilateral vestibular hypofunction, gain is reduced for rotation to the side of the lesion in both 60 deg/sec and 240
deg/sec chair rotations. The patient represented by this
figure has an uncompensated defect on the right side. In
individuals with compensated defects, the vestibulo-ocular reflex (VOR) gain at low chair velocities (60 deg/sec)
would begin to return to normal.
chair testing for identifying vestibular hypofunction

ranges from 66% to 71%, and its specificity is 54%.4,5
One reason for this large range in sensitivity is that there
is no gold standard for identifying vestibular hypofunction other than when it occurs surgically (vestibular
nerve section).
Weaknesses of Test
Rotary chair testing can assess the horizontal only
SCC or the portion of the superior vestibular nerve
that innervates it. Because rotation affects vestibular
Bode plotPhase
30
0.8
VOR Phase
VOR Gain
Rot. to L = 0.832
L = 10.0
40
0.6
0.4
20
10
0
0.2
-10
0
10
Gain:
Time Constant:
-2
10
-1
Frequency
10
10
-2
10
-1
Frequency
10
Figure 8.9 Bode plot of gain and

phase of slow-component eye movements during sinusoidal rotation in the
dark. Phase is analogous to the time
constant obtained during step rotations.
The three solid lines in each plot indicate
the mean and standard deviation for a
normal response. The responses depicted in this figure are for the patient represented in Figures 8.4 and 8.5, who has a
left vestibular hypofunction.
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Figure 8.11 Setup for quantified dynamic visual

acuity test. See text for explanation.
function on both sides, it can be more difficult to identify a small lesion on one side with this test than with
the caloric test. The rotary chair test equipment is
very expensive and requires yearly calibration and
maintenance.
manually or actively. During the test, the subject is asked

to tell the operator the direction that the optotype is pointing (letter E in the computerized test my colleagues and I
use6). The optotype comes on only during head velocities
of 120 to 180 degrees per second (deg/sec) as determined
by a velocity rate sensor (Fig. 8.11). The results, DVA, are
expressed as the difference between acuity measured with
the head stationary and acuity measured with the head
moving. We usually measure visual dynamic visual acuity as the logarithm of the minimal angle of resolution
(LogMAR), one of the best ways to measure change in
visual acuity.
Dynamic visual acuity decreases as vestibular
loss increases. Figure 8.12 ranks patients according to the
Quantified Dynamic Visual Acuity

Quantified dynamic visual acuity (DVA) is one of the best
functional tests in patients with unilateral and bilateral
vestibular hypofunction.6 It measures visual acuity while
the head is moving. In this test, the static, distant visual
acuity is first determined with the head still. Visual acuity
is then determined while the patients head is oscillated
1.00
0.90
0.80
DVA (LogMAR)
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
1
11
16
21
26
31
36
41
46
51
56
61
66
NL
71
76 81
86
UVL
91
96 101 106
11 116 121 126 131 136 141 146 151 156
BVL
Figure 8.12 Variability in dynamic visual acuity (DVA) among patients with dizziness without
vestibular loss (NL), with unilateral vestibular loss (UVL), and with bilateral vestibular loss (BVL).
DVA is measured as the logarithm of the minimal angle of resolution (LogMAR), where LogMAR
0.000 is equivalent to a visual acuity of 20/20, and LogMAR 1.00 is equivalent to one of 20/200.
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degree of vestibular loss based on caloric test result

and LogMAR score. There is good reliability in any
single patient, but great variability among patients
with specific vestibular defects. One reason for this variability is that the test is age-dependent, older patients
having higher (worse) LogMAR scores. Therefore, the
test should not be used to diagnose unilateral or bilateral
vestibular loss.
DVA is best used to identify change in a patient
undergoing a 5-week course of vestibular adaptation
exercises (see Chapter 20) (Fig. 8.13). Note that not all
patients show an improvement in DVA after such a
course of exercises.
sides, DVA may not identify a problem in patients

with small lesions on one side. Ocular motor defects (eye
muscle weakness, strabismus, central nystagmus) and
glasses with high refractive changes (bifocals and progressive lenses) can decrease DVA; therefore, the test
should not be used to diagnose unilateral or bilateral
vestibular loss.
Vestibular Evoked
Myogenic Potential Test
The vestibular evoked myogenic potential (VEMP) test
assesses the saccule and its central projections, including
the inferior vestibular nerve.8,9 VEMPs evaluate the sacculemedial vestibular spinal projectionXIth central
nerve circuit. The test assesses the function of the saccule
by presenting tones in the ears while recording the
evoked responses from the sternocleidomastoid muscle
(SCM). Subjects are positioned supine in a dimly lit
room. Surface electrodes are placed over the belly of each
SCM with a ground electrode placed on the forehead. The
subject is asked to flex the neck while a series of tones is
presented in each ear individually. The stimulus can be
tones or clicks. The intensity of the stimulus ranges
between 60 and 94 dB, normalized hearing level (nHL).
The rate of the stimulus is typically 5.0 per second, and
128 trials are averaged. The response to the stimulus is an
inhibitory response of SCM tone detected by a surface
Strengths of Test
DVA is one of the most useful tests for following functional VOR in patients with unilateral and bilateral
vestibular deficits. It can be used to help identify central
compensation. DVA is a highly reliable test in patients
with vestibular hypofunction (r 0.84), and normal values by age are available.6
Weaknesses of Test
This test can assess only the horizontal SCC or the
portion of the superior vestibular nerve that innervates
it. Because rotation affects vestibular function on both
0.80
0.70
0.60
0.50
0.40
0.30
DVA
(LogMAR)
0.20
0.10
LogMAR pre-tx
LogMAR post-tx
13
17
21
25
29
33
37
41
45
49
53
57
0.00
Figure 8.13 Change in dynamic visual acuity (DVA) in individual patients with
unilateral vestibular hypofunction after 4
to 6 weeks of vestibular rehabilitation.
Approximately 22% of the patients did
not show an improvement in DVA,
defined as a change greater than the
mean plus 2 SD of the test-retest variability. (From Herdman et al, 2003.7)
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It is difficult to determine partial defects on the basis of

the amplitude of the response, because the amplitude
varies according to the muscle tone of the SCM. One way
around this problem is to record from both muscles
simultaneously with the subject lifting the head up while
supine. This test cannot be used to determine central
compensation. It can be done in individuals with sensorineural hearing loss, but not in individuals with conduction hearing defects (e.g., otosclerosis). There is some
evidence that the VEMP can reappear in approximately
17% of patients in whom it previously was absent.10
degree of ocular torsion present after unilateral lesions in

these pathways. Subjects sit in a dark room and orient a
projected image of a tilted line until it looks vertical to
them. They are given at least 10 trials before the mean
and standard deviation of the offset from true vertical are
determined. Usually, 2 degrees of tilt or less is considered
a normal response. Ocular torsion for peripheral problems is ipsilateral; that is, with a right utricular or superior vestibular nerve defect, the offset is to the right.
The degree of offset depends on the completeness of
the lesion and the age of the defect. Studies show that
people with unilateral vestibular loss in which the utricle
is damaged shift their perception of vertical orientation in
a way that reflects the asymmetry in utricular input.12,13
This phenomenon occurs only when there are no visual
cues to aid in orientation, which is why the test is performed in complete darkness (a light-tight room). In a
study of patients who had undergone unilateral vestibular
nerve section, the mean offset was 12 degrees at 1 week
after surgery, 6 degrees at 1 month, and 4.5 degrees at 1
year.11 The mean deviation of the line (to the right or left)
is compared with values for healthy individuals that we
have established in the literature11 (deviation from true
vertical 2.0 degrees is the criterion for abnormal
response).
Subjective Visual Vertical Test
Strength of Test
The subjective visual vertical (SVV) test assesses utricular function and its central connections, including the
superior vestibular nerve.11 It is a subjective test of the
The SVV test is the easiest means available for assessing

utricular function, the other means of directly assessing
degree of ocular torsion being with retinal photographs.
electromyography (EMG) recording. Amplitude of the

response depends on tone intensity and baseline muscle
contraction. The response is a positive and negative wave
(Fig. 8.14). The evoked responses in the SCMs are
recorded (total of 750 trials for each ear) and summed for
each ear. Absence of the evoked myogenic response
reflects damage to the saccule on that side.
Strength of Test
The VEMP test is the only test for assessment of the saccule and inferior vestibular nerve.
Weaknesses of Test
Figure 8.14 Vestibular evoked myogenic potential (VEMP) test results. Normal P13, N 23
VEMP values in the right ear with absence of response from the left ear.
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Because the SVV response changes with time, it can be

used to assess central compensation of a static defect, but
only by looking at changes in the same individual.
Weaknesses of Test
The SVV test must be done in a completely dark room.
It will not detect bilateral utricular defects.
Tests That Do Not Specifically

Assess Labyrinth
or Vestibular Nerve
Visual Tracking
Smooth Pursuit Eye Movements and
Vestibulo-Ocular Reflex Cancellation
Smooth pursuit eye movements and VOR cancellation
are slow tracking movements that maintain images of
small moving targets on the fovea. During smooth pursuit
eye movements, the head is kept still. During VOR cancellation, the head is moving synchronously with the target. This movement is referred to as VOR cancellation
because the VOR must be suppressed during the head
movement; otherwise the image of the target could not be
maintained on the fovea. With quantitative testing, unlike
the clinical exam, the patient is asked to track a small,
slowly moving target (20 degrees/second) and the eye
movement is recorded. Thus the gain (eye velocity/target
velocity) of smooth pursuit can be calculated. This is

especially important because smooth pursuit eye movements degrade with age and the decision as to whether or
not the eye movements are normal can be made more
accurately if the eye movements are quantified. See
Chapter 7 for further discussion.
Saccadic Eye Movements

Saccadic eye movements are very rapid changes in eye
position. The advantage of measuring saccadic eye
movements using a tracking system is that the gain,
amplitude, accuracy and latency to onset of the saccades
can be measured and compared to normal values. See
Chapter 7 for further discussion.
Computerized Dynamic Posturography

Postural sway is quantified with dynamic posturography,
which measures sway in conditions in which visual
and somatosensory cues are absent or altered (Fig. 8.15).
Automatic postural responses can also be measured
in response to perturbations of the support platform.
Deficits in a variety of different neural systems can
be identified, including cerebral cortex, anterior cerebellum, and the spinal cord. The test is not specific for
vestibular disorders, although patients with uncompensated or severe vestibular deficits typically have difficulty maintaining their balance when both visual and
somatosensory cues are altered. This test is also very
Figure 8.15 Computerized

dynamic posturography. The
patient stands on a force platform. Sensors are oriented to
detect vertical pressure changes
and shear forces. In some
equipment, as shown here, both
the support surface (force platform) and the visual surround
can move. (With permission
from NeuroCom International
Inc, Clackamas, OR).
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useful in demonstrating objective signs of a functional

component.
The advent of computerized posturography as part of
balance assessment has extended the ability of clinicians
and researchers to identify subtleties in postural control,
specific system impairments, and functional limitations.
Postural control involves the interplay among the sensory,
central nervous, and musculoskeletal systems. To meet
the constantly changing demands of maintaining balance,
body position and movement must be detected by the
visual, somatosensory, and vestibular systems. The central nervous system then must integrate this information
and select an appropriate response. Finally, the response
must be performed by the musculoskeletal system within
the appropriate timeframe and with adequate force.
Research has demonstrated that interventions targeted at
improving specific deficits are successful in improving
postural control and in reducing the risk for falls.14
Computerized posturography can be used to quantify many aspects of postural control, such as the ability to
maintain quiet stance and to shift weight voluntarily, as
well as to assess automatic postural reactions. Computerized posturography has now been expanded to include
the assessment of activities such as moving from sitting
to standing and turning while walking.
135
Balance under Different

Sensory Conditions
Postural sway can be measured under conditions in which
visual and somatosensory feedback is altered (Table 8-2).
Such manipulation of feedback is called the sensory
organization test (SOT). In one commercially available
apparatus (NeuroCom International, Inc., Clackamas,
OR), the change in sway angle is used to move either a
visual surround or the support surface. At low frequencies
of sway (0.3 Hz), the visual surround or support surface
moves in synchrony with the individuals sway, and visual and somatosensory cues are minimized.
At higher frequencies of sway, the mechanics of the
system cannot move the surround or surface at the same
frequencies as body sway, so the sensory feedback is simply altered in a way that is novel to the subject.
Movement of the visual surround alters the visual cues
normally used for postural stability. For example, in quiet
stance, humans normally have a small amount of anterior
and posterior (AP) sway. As humans sway, a number of
visual cues influence postural stability, including stereopsis, contrast sensitivity, and retinal disparity.1517 If the
visual world around a person (visual surround) moves in
parallel with the body as he or she sways, the usual visu-
Table 8-2 SENSORY ORGANIZATION TESTS IN COMPUTERIZED

DYNAMIC POSTUROGRAPHY
Sensory Organization
Test Conditions
Sensory Cues
Cues Available for Stablity
Condition 1 (C1)
Eyes open
Visual surround and platform stable
Normal visual, somatosensory, and vestibular cues
Condition 2 (C2)
Eyes closed
Visual surround and platform stable
No visual cues
Normal somatosensory and vestibular cues
Condition 3 (C3)
Eyes open
Moving visual surround
Platform stable
Normal somatosensory and vestibular cues

Altered visual feedback
Normal visual and vestibular cues
Condition 4 (C4)
Eyes open
Visual surround stable
Platform moving
Altered somatosensory feedback

Normal vestibular cues
No visual cues
Condition 5 (C5)
Eyes closed
Platform moving
Altered somatosensory feedback

Normal vestibular cues
Condition 6 (C6)
Eyes open
Visual surround and platform moving
Altered visual and somatosensory feedback
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al cues are reduced or inaccurate and so cannot be used

effectively to maintain postural stability. Similarly, when
the support surface moves in parallel with body sway, the
alteration in somatosensory feedback is less effective as a
signal in the maintenance of upright posture. Other systems (e.g., Balance System, Biodex Medical Systems,
Shirley, NY; Balance Quest, Micromedical Technologies,
Chatham, IL; the Modified-Clinical Test of Sensory
Interaction in Balance [M-CTSIB] test, NeuroCom
International, Inc.) alter vision by having the subject
close the eyes or by projecting an optokinetic stimulus
and alter the somatosensory feedback by having the subject stand on dense foam or an unstable surface.
Automatic Postural Responses

Tests of reactive balance involve sudden, brief displacement of the support surface in order to assess the automatic postural responses used in the recovery of balance.
These tests are important because people must be able to
react to external disturbances in balance if they are to
move safely in a challenging environment, such as when
a train suddenly starts moving. Tests of the automatic
postural responses typically use forward and backward
translations of the support surface or pitch movements of
the support surface (toes-up or toes-down). During the
translational perturbations of the support surface, the relative distribution of weight on each leg, the latency of
onset of force development used to regain postural stability, and the amplitude or strength of the response are
recorded. The larger the perturbation of the support surface, the greater the response needed to regain balance.
Normal subjects and patients with bilateral vestibular
deficits exhibit a relative increase in the response (initial
rate of change of torque developed) as the amplitude of
surface displacement increases. In contrast, patients with
cerebellar disorders fail to modify their automatic postural responses as measured by surface reactive force.18
The shift in the center of gravity alignment that
occurs with pitch perturbations of the support surface
destabilizes the individual. Measurements of the magnitudes of response to five identical toes-up or toesdown perturbations are used to assess motor learning or
adaptation. As equal perturbations are repeated, there
should be a decrease in the amplitude of the force developed to maintain postural stability. Normal individuals
quickly learn to maintain their balance during this paradigm, and loss of balance is unusual except during the
initial trial in younger subjects.19 In older subjects ( 70
years), there is an increased likelihood of loss of balance
on all trials of toes-up perturbations even though adaptation still occurs.
The addition of surface electrode EMG during toesup perturbations allows the clinician to measure muscle
activitythe postural evoked response. The toes-up
movement of the platform elicits both a short-latency
response and a middle-latency response in the gastrocnemius-soleus muscle group (Fig. 8.16B and D). The
short-latency response is equivalent to the monosynaptic
stretch reflex, and the middle-latency response is a
multisegmental spinal reflex.20 This is followed by a
long-latency response in the anterior tibialis muscle,
which acts to restore postural stability by shifting the
center of gravity alignment forward (Fig. 8.16C and E).
The long-latency response is believed to encompass a
transcortical pathway.20 The presence, absence, or delay
of any of the reflex responses has been correlated with
site of neurological lesion (Table 8-3). Note, however,
that the measurement of postural evoked responses with
surface electrode EMG is not a typical component of the
evaluation of patients with vestibulopathy.
Application to Patient Management

It is important to recognize that dynamic posturography
is not a diagnostic test and cannot be used to identify
vestibular deficits. Dynamic posturography measures the
output of multiple balance systems, not just the vestibulospinal system. Thus, during posturography testing,
vestibular deficits may be masked by other, functioning
balance systems.
Although dynamic posturography should not be
used as a diagnostic tool, the results of studies in patients
with different problems show performance patterns that
are useful as guides to expectations for certain diagnoses
(Table 8-4). The overlap in findings among diagnoses can
be clearly seen; therefore, difficulty on test conditions 5
and 6 (see Table 8-2) cannot be interpreted as indicating
a vestibular deficit. For instance, it is well documented
that patients with severe bilateral vestibular loss are
unable to maintain balance under conditions in which
both visual and somatosensory cues are altered.21
However, patients with other balance problems, as
diverse as Huntingtons disease and fear of falling, also
may lose their balance under these same conditions.22,23
It is probably most appropriate to interpret the
results of the SOT in terms of the functional implications
of the test performance. Several common patterns in test
performance have been identified and ascribed to difficulties using different sensory cues (Table 8-5) rather
than diagnoses. It is important to remember that although
this test provides reliable data, test performance can be
strongly influenced by subjective factors, including
patient effort, fear, and cognition.
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Figure 8.16 Postural evoked responses as measured by surface electrode electromyography

(EMG) in a normal subject. (A) Tracings are averaged from a series of 20 pitch (toes-up) perturbations of the support surface. The ramped line indicates the perturbation of the support surface, with
the thick arrow indicating the initiation of the perturbation. (B and D) Short-latency (SL) and middlelatency (ML) responses elicited in the left (L) and right (R) gastrocnemius/soleus muscles. (C and E)
The long-latency response (LL) occurs in the left (L) and right (R) anterior tibialis muscles and acts
to correct for the sudden posterior shift in the center of mass.
Identification of Aphysiological
Test Performance
An aphysiological or nonorganic basis of balance test
performance can be characterized by specific patterns
of performance on the SOT and motor test (Table 8-6).37
Cevette and colleagues35 examined patients who
had symptoms unrelated to organic findings. They found
that these patients had erratic performances within
each condition (i.e., greater intertrial variability) and

relatively better performance on the more difficult
conditions than on the easier conditions of the SOT
(Fig. 8.17). Additionally, they noted a discrepancy
between the patients abnormal performance on dynamic
posturography and their normal or near-normal ability
to walk.
Goebel and colleagues34 identified two additional
criteria from the motor control testsexaggerated
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Table 8-3 SHORT-, MIDDLE-, AND LONG-LATENCY POSTURAL

RESPONSES AND SITE OF LESION
Condition
Short-Latency Response
Middle-Latency Response
Long-Latency Response
Normal (mean 1 SD)
43.5 4.2 msec
89.5 10 msec; absent in

25% of subjects
125.3 17.8 msec;

duration 76 19 msec
Normal (mean 2 SD)
51.9 msec
Latency 109.5 msec
Latency 160.9 msec;

duration 114
Peripheral neuropathy
Delayed
Delayed
Delayed
Anterior lobe cerebellar

atrophy; diffuse
cerebellar disease
Delayed due to concomitant peripheral neuropathy
Normal
Increased duration in
66% of subjects
Friedreichs ataxia
Absent in 66% of subjects
Absent in 66% of subjects; when present, is

delayed
Prolonged rate of rise

( 50 msec); delayed
(225 msec)
Cerebellar hemispheric
lesion
Normal
Normal
Delayed (146 msec)
Parkinsons disease
Normal latency; normal

integral
Normal latency;
greatly increased
integral
Normal latency; normal

integral
Spinal cord lesion
Normal
Absent in 50% of subjects
Delayed (164 36.5

msec)
Intracranial lesions
Normal latency
Normal latency
Delayed latency
From Diener and Dichgans, 1986.20
responses to small translational perturbations and inconsistent responses to small and large perturbations of the
support surfacethat had a high specificity for identifying persons who were deliberately feigning instability.
These researchers also found that a combination of SOT
and motor control test criteria reduced to zero the likelihood of identifying a problem where there is no organic
cause.34 The criteria for identifying an aphysiological test
performance were validated in a study by Gianoli and
associates,36 who found that 76% of patients who would
benefit from an abnormal test (secondary gain) had exaggerated test results, compared with only 8% of patients
without secondary gain.
One concern about the use of computerized posturography in identifying malingerers or patients with other
nonorganic problems is that individuals may learn to
manipulate their results. That is, people who deliberately
malingering may learn how to produce results that mimic
real disorders rather than producing results that are clear-
ly identifiable as aphysiological patterns. Fortunately,

Morgan and colleagues38 showed that an individuals
ability to manipulate the results does not improve when
he or she has additional information about dynamic posturography.
Treatment
Dynamic posturography is useful in establishing treatment and in monitoring patient recovery, especially as
part of the rehabilitation process. For example, patients
may use different sensory cues to maintain postural stability. Figure 8.18 illustrates the results of the sensory
organization test in three patients with bilateral vestibular
loss secondary to aminoglycoside ototoxicity. None of
the patients can maintain balance when both visual and
somatosensory cues are altered (conditions 5 and 6), a
finding consistent with the findings of numerous studies
in patients with bilateral vestibular loss.24,25,27 The first
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Table 8-4 PATTERNS SEEN ON POSTUROGRAPHY WITH VESTIBULAR DEFECTS

Diagnosis
Posturography Performance Pattern*
Peripheral vestibular deficits24,25
Abnormal sensory organization test results

Rare motor test abnormality ( 2%)
Severe bilateral vestibular loss24,25,27
Loss of balance on C5, C6; may or may not have increased

sway on C3, C4
Correlation of sensory organization test results with severity
of deficit (VOR Tc)
Incomplete bilateral vestibular deficit
Increased # of falls on C3, C5, and C6, but not necessarily on

all trials
Acute unilateral vestibular deficit28
Increased sway or loss of balance especially on C5 and C6

Can be normal within few days after onset
Compensated unilateral vestibular deficit29,30
Normal sensory organization test results but evidence of

decrement in performance several months out
Benign paroxysmal positional vertigo3133
Increased sway on C3 and C6 in BPPV plus head injury

Increased sway on C5 and C6 in BPPV with no head injury
Increased sway on all tests pre-treatment; improved with
remission of symptoms post treatment
Central deficits26
90% of subjects have abnormal results of motor tests (especially latencies) as well as sensory organization tests
*C1 through C6 are sensory conditions; for definitions, see Table 8-2.
Table 8-5 INTERPRETATION OF FUNCTIONAL DEFECTS SEEN ON POSTUROGRAPHY

Functional Defect(s)
Possible Interpretations(s)
Loss of balance or increased sway:

On C2, C3, C5, and C6
Visual dependency
On C4, C5, and C6
Somatosensory dependency
On C5 and C6
Reflects increased difficulty of these conditions,

vestibular deficit, or severe bilateral vestibular loss
Generally increased sway

Stopping test by putting hands out to touch wall
Verbalized expression of concern or fear
Fear of falling
Increased sway or loss of balance occurring on later

trials only, with normal performance on initial trials
of same condition
Fatigue
Loss of balance or increased sway on initial trial of

each sensory condition
Inability to handle novel postural challenges
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Table 8-6 CRITERIA USED FOR

APHYSIOLOGICAL
PERFORMANCE ON
POSTUROGRAPHY TESTS
A
100
75
50
Study
FF
AA
LL
LL
25
FALL
1
F
A
L
L
F
A
L
L
Sensory Test Condition
Goebel et al,
199734
Substandard performance on C1
Score No. of points below norm for
the best trial of C1
Exaggerated motor responses to small
translations
Score average number of degrees of
sway in all trials for small forward
and backward translations (should be
2 degrees)
Inconsistent motor responses to small
and large translations
Score No. of tests with at least 2 of
3 concordant trials per test (max 4)
Cevette et al,
199535
Lower scores on C1 and 2, higher

scores on C5 and 6
Score [(C1 norm1) (C2
norm2)] [(C5 norm5) (C6
norm6)]
Highest score on the following 3 equations:
Aphysiological 158.2 (1.94
C1) (1.09 C2) (1.37 C4)
(0.15 C6)
Normal 238.14 (2.24 C1)
(1.45 C2) (1.70 C4) (0.13
C6)
Vestibular 251.21 (2.31 C1)
1.54 (C2) (1.89 C4)
(0.58 C6)
Gianoli et al,
200036
Substandard performance on C1
and C2
Large-amplitude anterior-posterior
(AP) sway without falls
Score average number of AP sways
5 degrees on C4, C5, and C6 without falls
Large amplitude lateral sway
Score average number of lateral
sways 1.25 degrees on C4, C5, and
C6 without falls
Excessive intertrial variability (no score
calculated)
Circular sway (no score calculated)
Composite
38
B
Trial 1
Trial 2
Trial 3
1
shear
AP sway
5 degrees; 35lb Force

20 seconds
Figure 8.17 (A) Performance on the sensory organization

test by patients with aphysiological balance problems is characterized by inconsistent performance on different trials of the
same condition and by better performance on more difficult
conditions than on easier conditions (compare condition C3
with C1 and C5 with C2). (B) Inspection of the anterior-posterior sway trace often reveals a regular periodicity to the sway.
patient (Fig. 8.18A), however, has no difficulty with the

other tests. In contrast, the second patient may rely on
somatosensory cues for stability and therefore lose his
balance when somatosensory feedback is altered (test
condition 4) but not when visual cues are altered (test
conditions 2 and 3) (Fig. 8.18B). Similarly, other patients
may be reliant on visual cues and so have difficulty in
test conditions 2 and 3 but not test condition 4 (Fig.
8.18C). Identification of reliance on a particular sensory
Criteria for Aphysiological Performance
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100
75
75
50
50
25
25
stop
stop
stop
stop
stop
stop
100
0
1
stop
stop
stop
stop
stop
stop
stop
stop
stop
0
1
cue can then be used to establish specific exercises for

the patient.
Computerized dynamic posturography results can
be used as an outcome measure for vestibular rehabilitation.25,3941 Improved postural stability has been docu-
100
75
50
stop
stop
stop
stop
stop
stop
stop
stop
25
stop
Figure 8.18 Performance of three patients with

bilateral vestibular loss secondary to aminoglycoside ototoxicity on the sensory organization test demonstrates
the variability in test performance that can occur even
within the same diagnostic groups. (A) One subject
loses his balance only when both visual and somatosensory cues are altered (conditions 5 and 6). The other
two subjects have additional difficulty (B) when
somatosensory feedback is altered (condition 4) or
(C) when visual feedback is altered (conditions 2 and 3).
Equilibrium scores (higher number indicates more stability) for three trials of each condition are shown.
Stop loss of balance.

mented in patients with acute and chronic unilateral
vestibular hypofunction,39,42 benign paroxysmal positional vertigo,3133 and bilateral vestibular loss,43 although
patients may continue to demonstrate significant physical
impairments.
Table 8-7 OVERVIEW OF TESTS FOR VESTIBULAR FUNCTION

Problem
Helpful Bedside Test(s)
Helpful Laboratory Test(s)
Acute unilateral vestibular

loss (vestibular neuritis,
labyrinthitis, vestibular
nerve section)
Head-thrust
Skew eye deviation
Electronystagmography (ENG) (spontaneous nystagmus and caloric)

Rotary chair
Chronic unilateral vestibular

loss (same causes as above)
Head-thrust
Head-shaking nystagmus
Dynamic visual acuity
ENG (caloric)
Rotary chair
Mechanical problems (benign

paroxysmal positional vertigo)
Position testing
ENG (position testing)
Central problems (stroke,

multiple sclerosis, trauma)
Smooth pursuit
Saccades
ENG (spontaneous nystagmus, visual

tracking)
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There is also some evidence that dynamic posturography can be used to predict the outcome of vestibular
rehabilitation. Poor pre-rehabilitation disability, including spontaneous and/or continuous symptoms in conjunction with motion sensitivity and abnormalities in four
or more of the SOT test conditions, predicts poorer outcomes of a course of rehabilitation.30,44,45 Although computerized posturography is reliable test and therefore is
appropriate as an outcome measure, the relationship
between posturography results and functional activities is
still not clear.
14.
15.
16.
17.
18.
Summary
Laboratory testing should be used in conjunction with the
history and clinical examination to identify the cause of a
patients dizziness and extent of the defect. Table 8-7 lists
the bedside tests that best correlate with laboratory tests
for particular problems.
References
1. Schuknecht HF: Pathology of the Ear. Cambridge:
Harvard University Press; 1974.
2. Baloh RW, Honrubia H: Clinical Neurophysiology of the
Vestibular System, 2nd ed. Philadelphia: FA Davis; 1990.
3. Weissman BM, DiScenna AO, Leigh RJ: Maturation of
the vestibulo-ocular reflex in normal infants during the
first 2 months of life. Neurology 1989;39:534538.
4. Arriaga MA, Chen DA, Cenci KA: Rotational chair
(ROTO) instead of electronystagmography (ENG) as the
primary vestibular test. Otolaryngol Head Neck Surg
2005;133:329333.
5. Shepard NT: Rotational chair testing. In: Goebel JA, ed:
Practical Management of the Dizzy Patient. Philadelphia:
Lippincott Williams & Wilkins; 2001;129141.
6. Herdman SJ, et al: Computerized dynamic visual acuity
test in the assessment of vestibular deficits. Am J Otol
1998;19:790796.
7. Herdman SJ, et al: Recovery of dynamic visual acuity in
unilateral vestibular hypofunction. Arch Otolaryngol Head
Neck Surg 2003;129:819824.
8. Clarke AH, Schonfeld U, Helling K: Unilateral examination of utricle and saccule function. J Vestib Res 2003;13:
215225.
9. Magliulo G, et al: Vestibular evoked myogenic potentials
and glycerol testing. Laryngoscope 2004;114:338343.
10. Piciotti PM, et al: VEMPs and dynamic posturography
after intratympanic gentamicin in Menieres disease. J
Vestib Res 2005;15:161168.
11. Curthoys IS, Dai MJ, Halmagyi GM: Human ocular torsion position before and after unilateral vestibular neurectomy. Exp Brain Res 1991;85:218225.
12. Clarke AH, et al: Measuring unilateral otolith function via
the otolith-ocular response and the subjective visual vertical. Acta Otolaryngol Suppl 2001;545:8487.
13. Goto F, et al: Compensatory changes in static and dynamic subjective visual vertical in patients following vestibu-
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2003;30:2933.
Rikli RE, Jones CJ: Assessing physical performance in
independent older adults: issues and guidelines. J Aging
Phys Act 1997;5:244261.
Fox CR: Some visual influences on human postural equilibrium: binocular versus monocular fixation. Percept
Psychophys 1990;47:409422.
Lord SR, Menz HB: Visual contributions to postural stability in older adults. Gerontology 2000;46:306310.
Paulus WM, Straube A, Brandt T: Visual stabilization of
posture: physiological stimulus characteristics and clinical
aspects. Brain 1984;107:11431163.
Horak FB: Comparison of cerebellar and vestibular loss
on scaling of postural responses. In: Brandt T, Paulus W,
Dietrich S, et al, eds. Disorders of Posture and Gait. New
York: Georg Thieme; 1990.
Wolfson L, et al: A dynamic posturography study of balance in healthy elderly. Neurology 1992;42:20692075.
Diener HC, Dichgans J: Long loop reflexes and posture.
In: Bles W, Brandt T, eds. Disorders of Posture and Gait.
Black FO, et al: Outcome analysis of individualized
vestibular rehabilitation protocols. Am J Otol
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Baloh RW, et al: Balance disorders in older persons:
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Neck Surg 1998;119:8992.
Tian JR, et al: Postural control in Huntingtons disease
(HD). Acta Otolaryngol Suppl 1991;481:333336.
Horak FB, Nashner LM, Diener HC: Postural strategies
associated with somatosensory and vestibular loss,. Exp
Brain Res 1990;82:167177.
Herdman SJ, et al: Characteristics of postural stability in
patients with aminoglycoside toxicity. J Vestib Res
1994;4:7180.
Voorhees RL: Dynamic posturography findings in central
nervous system disorder. Otolaryngol Head Neck Surg
1990;103:96101.
Black FO, Nashner LM: Vestibulo-spinal control
differs in patients with reduced versus distorted vestibular function. Acta Otolaryngol Suppl (Stockh) 1984;406:
110114.
Hamid MA, Hughes GB, Kinney SE: Specificity and sensitivity of dynamic posturography, Acta Otolaryngol
Suppl (Stockh) 1991;481:586600.
Fetter M, Diener HC, Dichgans J: Recovery of postural
control after an acute unilateral vestibular lesion in
humans. J Vestib Res 1990-1991;1:373383.
Cass SP, Kartush JM, Graham MD: Clinical assessment of
postural stability following vestibular nerve section.
Laryngoscope 1991;101:10561059.
Black FO, Nashner LM: Postural disturbances in patients
with benign paroxysmal positional nystagmus. Ann Otol
Rhinol Laryngol 1984;93:595599.
Blatt PJ, et al: The effect of the canalith repositioning
maneuver on resolving postural instability in patients with
benign paroxysmal positional vertigo, Am J Otol 2000;
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Di Girolamo S, et al: Postural control in benign paroxysmal positional vertigo before and after recovery. Acta
Otolaryngol 1998;118:289293.
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34. Goebel JA, et al: Posturographic evidence of nonorganic

sway patterns in normal subjects, patients, and suspected
malingerers. Otolaryngol Head Neck Surg 1997;117:
293302.
35. Cevette MJ, et al: Aphysiologic performance on dynamic
posturography. Otolaryngol Head Neck Surg 1995;112:
767688.
36. Gianoli G, et al: Posturographic performance in patients
with the potential for secondary gain. Otolaryngol Head
Neck Surg 2000;122:1118.
37. Uimonen S, et al: Does posturography differentiate malingerers from vertiginous patients? J Vestib Res 1995;5:
117124.
38. Morgan SS, Beck WG, Dobie RA: Can posturography
identify informed malingerers? Otol Neurotol 2002;
23:214217.
39. Herdman SJ, et al: Vestibular adaptation exercises and
recovery: acute stage after acoustic neuroma resection.
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40. Shepard N, Telian SA, Smith-Wheelock M: Habituation

Neurol Clin 1990;8:459475.
41. Szturm T, Ireland DJ, Lessing-Turner M: Comparison
of different exercise programs in the rehabilitation of
patients with chronic peripheral vestibular dysfunction.
J Vestib Res 1994;4:461479.
42. Horak FB, et al: Effects of vestibular rehabilitation on
dizziness and imbalance. Otolaryngol Head Neck Surg
1992;106:175180.
43. Brown, KE, et al: Physical therapy outcomes for persons
with bilateral vestibular loss. Laryngoscope 2001;111:
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44. Shepard N, Telian SA: Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg 1995;112:
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9
Otolith
Function Tests
The peripheral vestibular system is sensitive to both linear

and angular accelerations: The semicircular canals
(SCCs) sense angular acceleration whereas the otoliths
the saccule and the utriclesense linear accelerations.
Many different ways of testing otolith function have been
proposed, including the measurement of horizontal, vertical, and torsional eye movements as well as psychophysical settings in response to linear accelerations produced
on swings,1 sleds,2 centrifuges,3 tilt-chairs,4 and barbeque
spits.5 For an otolith function test to be clinically useful, it
must be safe, practical, robust, and reproducible. The test
also needs to be specific for, and sensitive to, otolith dysfunction, particularly unilateral otolith hypofunction. In
our view, only two teststhe subjective visual horizontal
and the vestibular evoked myogenic potentialscome
near to fulfilling these requirements. Both have been regularly used in our clinical laboratories for several years,
and what follows is in part a distillation of our own experience with these tests and of their scientific basis. Before
considering these tests, however, one must have some
familiarity with the structure and function of the otoliths.
The balance organs in the inner earthe vestibular
sensory regions are the gyros of the human body, and
unnoticed, they function continuously in an almost perfect fashion, providing the brain with information about
head position and head movement. Until these organs
fail, no one really appreciates their significance in daily
life, and anyone who has experienced an attack of vertigo will readily verify their importance. These biological
144
gyros detect forces: the forces imposed by gravity and the

forces generated when we move. They are constructed in
such a way that different regions detect rotational forces
and linear forces in any direction. The brain synthesizes
the information from these separate force detectors to
provide a global integrated summary of where a person is
and how the person is moving. This realization is of clinical importance, because it implies that disease affecting
only one isolated region of the inner ear could have consequences for the overall integration of all of the vestibular sensory input. In this chapter, we deal only with the
otoliths, the structures that sense linear forces, such as the
force of gravity or the straight line acceleration experienced in a vehicle accelerating from a stop.
Otolith Structure
The basic element of all vestibular transducers is the
receptor hair cell, which is similar in both the angular and
the linear force-sensing systems (Fig. 9.1). The SCCs and
the otoliths detect these two different forces, not so much
because of any differences in the intrinsic properties of
the hair cells themselves but because of the way the structures that surround the hair cells are affected by the stimulating force. Each receptor cell has several fine, hairlike
cilia projecting from the cell body into a gelatinous
overlying mass, the otolithic membrane. The longest
cilium is called the kinocilium; it is located at one side of
the receptor cell and has a specialized cross-sectional
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Chapter 9 OTOLITH FUNCTION TESTS
145
Figure 9.1 The structure and function of the otolithic system. (a and b) Schematic representation
of the approximate orientation of the utricular and saccular maculae in the head. Reids line is a standard reference line joining the center of the external ear and the lower edge of the bony orbit. (c)
Three drawings show how different linear force stimuli affect the utricular receptor hair cells. The top
diagram (1) shows the back view of a person at rest with the cilia upright. Head tilts to the right (2)
cause the cilia to be deflected to the right; similarly, a linear acceleration to the left (3, arrow) causes
a deflection of the cilia to the right. (d) Schematic top-down view of a single receptor hair cell to
show the polarization pattern. The kinocilium is located at one extreme of the upper surface of the
cell. If the stereocilia are bent toward the kinocilium, as shown at the right, the receptor cell activity
increases. (e) Schematic illustration of the organization of a macular surface. The crystals of calcium
carbonate (the otoliths) are embedded in one side of the gelatinous otolithic membrane, and the tips
of the cilia project into the other side of this membrane. Forces cause the membrane to slide so that
the cilia are bent, thus stimulating the receptor cells.
structure. The remaining cilia, the stereocilia, are of uniform cross-sectional structure and are arranged in a series
of increasing height as they approach the kinocilium.
Forces cause the otolithic membrane to slide so that the
cilia of the receptor hair cells are bent.
Each labyrinth consists of endolymph-filled tubes
and sacs containing receptor structures. The two specialized sacs are the utricular sac and the saccular sac.
Contained within each of these sacs is a plate of specialized receptor hair cells and connective tissue, the macula. Each macula takes its name from the sac in which it is
located, so that in each inner ear there is an utricular macula and a saccular macula. The terms utricle and saccule
are often used to refer to the utricular and saccular maculae, although strictly speaking, utricle and saccule refer
to the membranous sacs that contain the maculae.
The two maculae have similar gross features.
Embedded on the outer (free) surface of the otolithic
membrane are dense crystals of calcium carbonate, the
otoconia. On the inner surface of this membrane, the cilia
of the hair cells project into the membrane. The density of
the otolithic membrane itself is similar to that of the surrounding endolymph, at 1.0 g/cm3, but the density of the
otoconia is almost three times greater, at 2.7 g/cm3. These
two receptor structures are together called the otoliths,
because their construction is similar and because both
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Section TWO MEDICAL ASSESSMENT AND VESTIBULAR FUNCTION
detect forces according to the same physical principle

namely, that an imposed linear force displaces the relatively dense otoliths embedded in the otolithic membrane.
The otolithic membrane then tends to slide across the surface of the macula, displacing the cilia of the receptor hair
cells and producing a change in hair cell resting membrane potential. The displacements of the otolithic membrane generated in this way by natural head movements in
a 1-g environment are in the order of one micron.
The utricular and saccular maculae are almost perpendicular to each other. With the head erect, the utricular macula is tilted by about 30 degrees (open anterior)
with respect to the horizontal plane of the head, whereas
the saccular macula is almost vertical. These different
orientations mean that the receptors on each macula
respond maximally to forces in different directions. The
surface area of the human utricular and saccular maculae
is only about 4.2 mm2 and 2.2 mm2, respectively. There
are about 33,000 receptor hair cells in the utricular macula and about 19,000 in the saccular macula. As in other
sensory systems, there is convergence of receptors to primary afferent nerves, so that only about 6000 primary
afferent nerve fibers supply the utricle, and only about
4000 supply the saccule.
Otolith Function
Intracellular recordings from single isolated otolithic
receptor hair cells subjected to controlled forces in
precisely defined directions have shown that each receptor hair cell is polarized; that is, (1) it responds most
strongly to forces in one direction and (2) as the direction
of the force deviates from that optimal direction, so the
response of the receptor declines. This optimum direction
is referred to as the cells polarization vector. This physiological polarization corresponds to a morphological
polarization, in that receptor cells respond optimally
when the imposed force shears the stereocilia toward the
kinocilium. Receptor hair cells are arranged in a regular
fashion across each macula so that the direction of the
kinocilium of each cell shifts in direction by only a small
amount relative to its neighbors, with the result that there
is a highly ordered arrangement of polarization vectors
across each macula.
Primary afferent neurons synapse on a number of
adjacent receptor hair cells so that some of the precision
of tuning of the individual receptors is lost: Afferent
fibers respond to forces over a greater range of directions
than the individual receptors. Each afferent fiber exhibits
a preference for forces in a particular direction, presumably reflecting the preferred orientation of the receptor
hair cells on which the fiber synapses. For afferent fibers,
just as for receptors, as the force direction deviates from
the optimal direction, the fibers firing frequency

declines. Utricular afferents in general show a preference
for forces directed across the plane of the maculain
other words, for laterally directed forcesand similarly,
saccular afferents show a preference for forces directed
vertically across the plane of the macula.
Primary Otolithic Afferents

Recordings from primary otolithic afferent neurons in the
vestibular nerve of experimental animals show a number
of important characteristics (for a review see Goldberg &
Fernandez6). 1. Primary otolithic afferents have a resting
discharge rate. They fire at about 50 spikes per second
even when there is no imposed force stimulus. 2. They
have a functional polarization vector. This means that linear accelerations oriented in one particular direction will
most effectively activate the afferent neuron. As the direction of the imposed force is deviated from this optimum
direction, so the response of the afferent neuron declines.
If the stimulus is directed exactly opposite to the preferred direction, then the firing of the cell is maximally
suppressed. 3. The afferents show a marked asymmetry in
bidirectional sensitivity. This characteristic results in an
increase in firing rate for forces in the excitatory direction
that is larger than the decrease in firing rate for the same
magnitude of force in the opposite, disfacilitatory direction. 4. The spatial distribution of the directional preferences of all otolithic afferents is not uniform. In the
squirrel monkey, for example, there is a directional preponderance so that more otolith afferents prefer ipsilaterally directed forces to contralaterally directed forces.
There is 3:1 preponderance of utricular afferents preferring ipsilateral force, whereas there is about a 1:1 distribution of saccular afferents preferring up-and-down
force. 5. At rest, some otolithic afferents have a regular
interspike interval, and others show an irregular pattern
of firing. The dynamic response characteristics of these
two groups of neurons are quite different. Regular neurons show little adaptation to maintained forces, whereas
the irregular neurons show a transient mode of responding: They fire vigorously during the change in the stimulus but adapt rapidly for a maintained stimulus. This
means that even at the level of the afferent neurons leaving the macula, functional specialization has already
taken place, in that different aspects of the force stimulus
are being signaled by these different parallel pathways.
Central Projections
Primary otolithic afferent neurons project to secondary
vestibular neurons mainly in the lateral, medial, and
descending vestibular nuclei. In some regions these
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otolithic projections show considerable overlap with the

projections of horizontal SCC afferents. The predominant response of lateral vestibular nucleus neurons is an
increase in firing rate in response to ipsilateral tilts. Just
as horizontal SCC neurons in the medial vestibular
nucleus are interconnected to the contralateral medial
vestibular nucleus via commissural fibers, which play a
major role in the neural operation of the system, so
otolith-responsive neurons are interconnected to similar
neurons in the opposite vestibular nucleus. However, the
interconnections in the otolithic system are indirect, and
the functional mode of the bilateral interconnections is
predominantly excitatory rather than inhibitory, as is the
case with the horizontal SCC system.
Some cells in each vestibular nucleus can be activated both by SCC stimulation and by otolithic stimulation.
These convergent neurons integrate linear and angular
acceleration input and thus help maintain posture and
equilibrium. The pathways from the otolithic regions of
the vestibular nuclei to the ocular motor nuclei are poorly
understood. Trochlear motoneurons can be disynaptically
activated by electrical stimulation of the utricular nerve,
and increasing attention is being paid to two midbrain
regions close to the oculomotor nucleithe interstitial
nucleus of Cajal and the rostral interstitial nucleus of the
medial longitudinal fasciculusthat integrate inputs for
torsional and vertical eye movement responses produced
by otolithic stimulation. In particular, it seems that the
interstitial nucleus of Cajal has a major role in integrating
otolithic input for coordinated eye and head responses to
the linear forces detected by the otoliths. The neural substrate for the compensatory postural movements required
by a linear acceleration are mediated by otolith-spinal
projections, the lateral vestibulospinal tract arising in the
lateral vestibular nucleus and the medial vestibulospinal
tract arising in the medial vestibular nucleus.
Function of Otolithic Input

Electrical stimulation of the utricular nerve in the cat
causes a distinct pattern of eye movement: a torsion of
both eyes so that the upper poles of the eyes roll away
from the side being stimulated.7 Complementing that
finding are studies that have shown that unilateral section
of the vestibular nerve causes a torsion of both eyes
toward the operated side.3,8 In natural movements, the
otoliths are activated and generate compensatory eye and
postural responses. For example, tilting the head toward
one shoulder causes the gravity vector to activate particular regions of the utricular and saccular maculae, and as
a consequence, the eyeball torts (or rolls) around the
visual axis in a compensatory direction. At the same time,
there is a complex pattern of activation of neck and trunk
147
muscles acting to oppose this challenge to the equilibrium of the head. The degree of this countertorsion or ocular counter-rolling is only about 10% of the head tilt, but
it does depend on otolith function because subjects without otoliths do not show such counter-rolling.4
Subjective Visual Horizontal or

Vertical Testing of Otolith Function
Peripheral Vestibular Lesions
A normal subject sitting upright in a totally darkened
room can accurately set a dimly illuminated bar to within
1 degree of the true gravitational vertical or horizontal.3
Friedmann9,10 was the first to show that patients with various unilateral vestibular lesions set such a bar so that it
was no longer aligned with the gravitational vector but
was consistently tilted toward the side of the lesion. We
studied the ability of patients with Mnires disease to
set such a light-bar to the visual horizontal before and
after uVD.3,8 Before uVD, the patients settings were
within the normal range. After uVD, patients invariably
set the gravitationally horizontal bar so that it was actually tilted toward the lesioned side, by 15 degrees or more;
they did this because they actually saw the gravitationally
horizontal bar as being tilted toward the intact side.
Although their settings of the bar gradually returned
toward the true or gravitational horizontal, the settings
were still tilted by a mean of 4 degrees 6 months or more
after uVD, so that a slight ipsilesional tilt or offset of the
subjective visual horizontal (SVH) was a permanent legacy of a uVD procedure for treatment of Mnires disease.
These findings have been confirmed by others.1116
After uVD for vestibular schwannoma, some patients
have permanent tilt or offset of the SVH of 15 degrees or
more, values similar to that found acutely after uVD. In
other words, the SVH appears not to be compensated for,
even though in other respects compensation has occurred
normally.17 The explanation for this difference in the
SVH long after uVD for Mnires disease and vestibular
schwannoma is not clear but might have to do with
involvement of the brainstem or cerebellum during
removal of large schwannomas. The ipsilesional offset of
the SVH after uVD is enhanced by vibration over the
ipsilesional mastoid bone or sternomastoid muscle.18
What could be the cause of this perceptual error? Is
it an offset of the internal representation of the gravitational vertical as a result of the profound asymmetry in
otolithic input to the vestibular nuclei that must occur
after uVD? Arguing against this mechanism is the observation that despite the uVD, the patients do not feel that
their own bodies are tilted, but on the contrary, feel themselves to be normally upright, even in the dark. In other
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words, although they tilt the bar toward the uVD side, it
is not in order to null a perceived tilt of the bar with the
body, toward the intact side.
Another possible mechanism of the SVH offset is a
torsional deviation of the eyes as a part of the ocular tilt
reaction. The ocular tilt reaction is a postural synkinesis
consisting of head tilt, conjugate ocular torsion, and
skew deviation, all toward the same side. Some patients
demonstrate a florid, temporary, ipsilesional tonic ocular
tilt reaction after a unilateral peripheral vestibular

lesion,19,20 and others just a partial one with ocular torsion
and skew deviation.2023 We measured torsional ocular
position as well as SVH before and after uVD8 and found
that after uVD, there was invariably an ipsilesional deviation of torsional ocular position so that the 12 oclock
meridian of each eye was invariably rotated toward the
side of the uVD (Fig. 9.2). One week after uVD, there
was up to 15 degrees of ipsilesional ocular torsion and a
Figure 9.2 Ocular torsional position before and after unilateral vestibular deafferentation (uVD).
Fundus photographs of the left and right eyes of a patient before (top row) and one week after
(bottom row) right vestibular neurectomy. After operation, there is tonic rightward torsion of the
12 oclock meridian of each eye toward the patients right side. The torsion measures 17 degrees in
the right eye and 15 degrees in the left eye. When the patient was asked to set a luminous bar to the
perceived visual horizontal in an otherwise darkened room, he set the bar tilted down on his right
side by 14.2 degrees when viewing with the right eye, and 15.1 degrees when viewing with the left.
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149
labyrinth recovers. It should be noted that offsets of torsional ocular position and of the SVH can also occur with
SCC stimulationthat is, together with horizontal or
torsional nystagmus.25,26 Nonetheless, ocular torsion in
the absence of spontaneous nystagmus is likely to be
otolithic, a conclusion based on the proposition that ocular torsion represents a tonic offset of the dynamic ocular
counter-rolling mechanism, which appears to be under
utricular control (Fig. 9.4).4,27

and Settings of the
Subjective Visual Vertical
Figure 9.3 The relationship between ocular torsional position and the subjective visual horizontal. The average value
1 week after unilateral vestibular deafferentation of the change
in ocular torsional position was calculated for each patient and
correlated with that patients average change in the visual horizontal. The correlation (0.95) is statistically significant. (From
Dai et al, 1989.3)
close correlation (r 0.95) between the magnitude of the

ocular torsion and the offset of the SVH (Fig. 9.3).
Furthermore, the ocular torsion gradually resolved with a
temporal pattern identical to that of deviation of the SVH.
One month after uVD, both the ocular torsion and the tilting of the SVH were at half the 1-week value. A slight but
significant ipsilesional ocular torsion of 4 to 5 degrees is
a permanent legacy of uVD for Mnires disease.8 It is
of interest that after acute uVD in frogs there is head torsion, which follows the same time course as conjugate
eye torsion in humans and has been used to monitor drug
effects on vestibular compensation.24
The offset of the SVH appears to be due to ocular
torsion, but the mechanism of the ocular torsion itself is
speculative. The conjugate ocular torsion is part of the
ocular tilt reaction, which could be considered the equivalent in the otolithic system of the spontaneous nystagmus in the SCC system. Torsional ocular position and,
therefore, the setting of the SVH depend on relative resting activity in the left and right vestibular nuclei, so as the
brainstem compensates for the uVD, the SVH returns
toward normal, although a small offset of the SVH
appears to be a permanent stigma of uVD.8 Therefore, in
analogy with spontaneous nystagmus, a return of the
SVH toward normal is inevitable whether or not the
Patients with acute brainstem2831 or cerebellar32,33 lesions

can show offsets of torsional eye position and of the SVH
or subjective visual vertical (SVV). Patients with lower
brainstem lesions involving the vestibular nucleus (e.g.,
lateral medullary infarcts) offset the SVV toward the side
of the lesion, whereas patients with upper brainstem
lesions involving the interstitial nucleus (paramedian thalamic infarcts) or with cerebellar lesions involving the
nodulus have offsets of torsional eye position and of the
SVV away from the side of the lesion. In most patients,
there is a deviation of torsional ocular position (also
called cyclotorsion) in the same direction as the offset of
the SVV. The relationship between the SVV and ocular
torsion is not as tight as with peripheral lesions but is
nonetheless present. In patients with peripheral vestibular
lesions, the ocular torsion and the consequent setting of
the SVV are almost the same in each eye; in contrast,
there can be significant left eyeright eye differences in
both ocular torsion and the SVV in patients with central
vestibular lesions. For example, in patients with lateral
medullary infarcts, the excyclotorsion of the ipsilesional
eye can be much larger than the incyclotorsion of the contralesional eye.
Clinical Significance
Standardized measurement of the SVH, with use of a dim
light-bar in an otherwise totally darkened room, can give
valuable diagnostic information. In some laboratories,
patients are asked to set a bar to the SVV, but we find that
most patients have a better intuitive understanding of the
horizontal than of the vertical and that the settings of
the vertical might not be the same as those of the horizontal.34 In any case, in order for the test to be valid,
either the room must be totally dark apart from the light
bar or there must be some other way, such as with a
Ganzfeld stimulator or a rotating dome, to exclude all
visual cues.29
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Figure 9.4 Explanation of the changes in torsional eye position after unilateral vestibular deafferentation
(uVD). Normally, second-order afferents from the vestibular nucleus send excitatory projections to the contralateral inferior oblique and ipsilateral superior oblique muscles, as well as to the contralateral inferior rectus and ipsilateral superior rectus muscles (not shown). Left uVD, as shown here, produces reduced tonic
activity in the contralateral inferior oblique (and inferior rectus, not shown) muscles, so that the contralateral
eye intorts, and reduced activity in the ipsilateral superior oblique (and superior oblique, not shown) muscles, so that the ipsilateral eye extorts. One presumes that, through commissural disinhibition, the left uVD
increases tonic activity in the contralateral, right vestibular nucleus, and therefore increases tonic activity of
the contralateral superior oblique muscle, which also produces intorsion of the contralateral eye. IV
trochlear nucleus; MLF medial longitudinal fasciculus. (Courtesy of Ms. Agatha Brizuela.)
A significant offset of the SVH or the SVV indicates

acute vestibular hypofunction, possibly otolithic. It indicates a lesion either at the level of the end-organ, vestibular nerve, or vestibular nucleus on the side to which the
patient offsets the bar or at a level above the vestibular
nucleus on the side opposite to which the patient rotates
the bar. Although the greater the deviation of the SVH or
SVV, the more acute as well as the more extensive the
lesion, a small permanent deviation of the SVV might
be a permanent legacy of both central and peripheral vestibular lesions. The SVH test is the single most
useful investigation in the acute phase of suspected
vestibular neuritis: There is a deviation of the SVH,
sometimes by more than 20 degrees, always toward the
side of the lesion.14,15 SVH testing can also be used to follow the progress of vestibular loss and compensation
after intratympanic gentamicin treatment for Mnires
disease.13
Vestibular Evoked
Myogenic Potential
Testing of Otolith Function
Physiological Background
Brief (0.1 msec) loud (95 db above normal hearing
level [nHL]) monaural clicks35,36 or short tone-bursts37,38
produce a large (60300 V), short-latency (8 msec)
inhibitory potential in the tonically contracting ipsilateral sternocleidomastoid muscle. The initial positivenegative potential, which has peaks at 13 msec (p13) and
at 23 msec (n23), is abolished by selective vestibular
neurectomy but not by profound sensorineural hearing
loss. In other words, even if the patient cannot hear the
clicks, there can be normal p13-n23 responses. Later
components of the evoked response do not share the
properties of the p13-n23 potential and probably do not
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depend on vestibular afferents. Failure to distinguish

between these early and late components could explain
why earlier work along similar lines was inconclusive.
For the preceding reasons, we called the p13-n23
response the vestibular evoked myogenic potential
(VEMP). Unlike a neural evoked potential such as the
brainstem auditory evoked potential, which is generated
by the synchronous discharge of nerve cells, the VEMP
is generated by synchronous discharges of muscle cells
or, rather, motor units. Being a myogenic potential, the
VEMP can be 500 to 1000 times larger than a brainstem
potential,39 for example, 200 V rather than less than
1 V. Single motor unit recordings in the tonically contracting sternocleidomastoid muscle show a decreased
firing rate synchronous with the surface VEMP.40
The amplitude of the VEMP is linearly related to the
intensity of the click and to the intensity of sternomastoid
muscle activation during the period of averaging, as
measured by the mean rectified electromyography
(EMG) value.36,41 Inadequate sternomastoid contraction
produces spurious results by reducing the amplitude of
the VEMP (see, for example, Ferber-Viart et al.42). A
conductive hearing loss abolishes the response by attenuating the intensity of the stimulus (see Halmagyi et al.,43
Figure 9.5 Explanation of the pathways for the click-evoked vestibular myogenic potential (VEMP). The loud click
moves the stapes to activate receptors in
the underlying saccular macula, which
thereby causes, via the vestibulospinal
tract, disynaptic activation of ipsilateral C2
segment anterior horn cells supplying the
sternomastoid muscle. LVN lateral
vestibular nucleus.
151
Fig. 9). In such cases, the VEMP can be elicited by a tap

to the forehead,44 by a bone vibrator,4547 or by a direct
current applied to the mastoid bone.48
There are two main reasons to suppose that the
VEMP arises from stimulation of the saccule. First, the
saccule is the most sound-sensitive of the vestibular endorgans,49,50 possibly because it lies just under the stapes
footplate,51,52 in an ideal position to receive the full
impact of a loud click delivered to the tympanic membrane. Second, not only do click-sensitive neurons in the
vestibular nerve respond to tilts,53,54 most originate in the
saccular macula54,55 and project to the lateral and
descending vestibular nuclei as well as to other structures
(Fig. 9.5).56,57 The VEMP measures vestibular function
through what appears to be a disynaptic vestibulocollic
reflex, originating in the saccule and transmitted via the
ipsilateral medial vestibulospinal tract to sternomastoid
motoneurons.58
Method
Any equipment suitable for recording brainstem auditory
potentials will also record VEMPs. Because the amplitude
of the VEMP is linearly related to the intensity of both the
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click and of sternomastoid activation during the period of

averaging, it is essential to ensure that the sound source is
correctly calibrated and that the background level of
rectified sternomastoid EMG activation is measured. Two
reasons why the VEMPs could be absent or less than
50 V in amplitude are a conductive hearing loss and
inadequate contraction of the sternomastoid muscles.
For clinical testing, three superimposed runs of 128
averages for each ear in response to clicks of 100-dB
intensity are usually sufficient. The test cannot be done
on uncooperative or unconscious patients. The patient
lies down and activates the sternomastoid muscles for the
averaging period by keeping the head raised from a pillow. An alternative methoduseful, for example, in
patients with painful neck problemsis to ask the patient
to turn the head, which continues to rest on the pillow, to
one side. It is then possible to measure the VEMP in the
sternomastoid muscle on the side opposite to the rotation.
The peak-to-peak amplitude of the p13-n23 potential from each side can be expressed relative to the level
of background mean-rectified EMG to create a ratio that
largely removes the effect of differences in muscle activity. More accurate but more time-consuming correction
can be made by making repeated observations with differing levels of tonic activation.36 One ear is best evaluated through comparison of the amplitude of its VEMP
with that of the VEMP from the other ear. We take asymmetry ratios of 2.5:1 to be the upper limit of normala
value similar to that obtained by others.59,60 Minor
leftright differences in latency commonly occur and

might reflect differences in electrode placement over the
muscle or differing muscle anatomy. VEMP amplitude
declines after age 60 years.61
Clinical Applications
Superior Semicircular Dehiscence
A third window into the bony labyrinth allows sound to
activate the vestibular system in animals62,63 and in
humans.6466 Patients with a bony opening or dehiscence
from the superior SCC to the middle cranial fossa (Fig.
9.6) not only have sound- and pressure-induced vestibular
nystagmus but also have abnormally large, low-threshold
VEMPs.6568 In normal subjects the VEMP, just like the
acoustic reflex, has a threshold, usually 90 to 95 dB nHL.
In patients with the superior SCC dehiscence, the VEMP
threshold is about 20 dB lower than in normals (Fig. 9.6)
and the VEMP amplitude at the usual 100- to 105-dB
stimulus level can be abnormally large ( 300 V). If a
VEMP can be consistently elicited at 70 dB nHL, the
patient has a superior SCC dehiscence. Patients with
superior SCC dehiscence also have an abnormal large,
low-threshold, click-evoked vestibulo-ocular reflex.69,70
Mnires Disease
In Mnires disease as well as in delayed endolymphatic hydrops,71,72 and unlike in acute low-tone hearing
Figure 9.6 (A) Audiogram. Following the left stapedectomy and two revisions, there is still a large
air-bone gap at 500 and 1000 Hz on the left as well as on the unoperated right side. The contralateral acoustic reflex, the sound stimulus in the operated left ear and the volume probe in the unoperated
right ear, is present at 1kHz and 2 kHz (AA ) and absent at 0.5 and 4 kHz. It is absent at all frequencies with the stimulus in the unoperated right ear and the volume probe in the thrice-operated
left ear. There is also a severe high frequency loss due to noise damage. Speech comprehension at
65 dB was 95% on the right and 85% on the left; m masked; n-r no response.
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Left SCD
Right SCD
153
Normal
Figure 9.6 (continued) (B) Vestibular evoked myogenic potentials (VEMPS). Left, Despite the
significant air-bone gap, p13-n23 VEMP responses to 110 dB clicks are still present. The VEMP from
the left ear is normal in amplitude but smaller (115 V) than from the right (307 V), indicating that
there is some conductive loss on the left (as a result of the 3 operations) as well as a conductive gain.
The response from stimulating the right ear is abnormally large and is accompanied by a contralateral
inverse response, n13-p23. Right, The VEMP threshold is normal from the left ear (with a conductive
loss, the VEMP should be absent) and abnormally low (80 dB; normal 95 dB) from the right ear.
(C) Left and center, High-resolution spiral computed tomography (CT) scan of the temporal bones,
reconstructed in the plane of each superior semicircular canal, shows a bilateral superior semicircular
canal dehiscence (SCD; [large white arrowheads]). CT scan from a normal subject is shown for comparison. The TORP device is clearly seen abutting the oval window on the left. The small white arrows
show the head of the malleus. (Courtesy of Dr. John Harding-Smith, Central Sydney Imaging).
loss,73 VEMPs can be abnormal,74 either too small75 or

too large,76 or can have altered tuning properties.77 In
some cases, glycerol dehydration can reduce theVEMPs
that are too large and enlarge the VEMPs that are too
small.7880 VEMPs can be used to monitor intratympanic
gentamicin therapy in patients with Mnires disease.81
Vestibular Neurolabyrinthitis and Benign

Paroxysmal Positional Vertigo
After an attack of vestibular neuritis, about one patient
in three experiences posterior SCC benign paroxysmal
positional vertigo (BPPV), usually within 3 months.82
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The patients who experience BPPV after vestibular neuritis have intact VEMPs, whereas those who do not show
absence of VEMP. In other words, an intact VEMP seems
to be a prerequisite for the development of postvestibular neuritis BPPV. The reason could be that in patients
who experience postvestibular neuritis BPPV, only the
superior vestibular nervewhich innervates the anterior
SCC, lateral SCC, and utricleis involved. Because the
inferior vestibular nerve innervates the posterior SCC and
the saccule, the presence of posterior canal BPPV and the
preservation of the VEMP imply that the inferior vestibular nerve must have been spared. Support for such an
explanation comes from data showing preservation of
posterior SCC impulsive vestibulo-ocular reflex in some
patients with vestibular neuritis, patients who presumably have involvement of only the superior vestibular
nerve.83,84 The galvanic currentevoked VEMPs are generally abolished in those patients with vestibular neuritis
in whom the click-evoked VEMPs are abolished, indicating that the site of lesion is truly in the vestibular nerve
rather than, or as well as, in the labyrinth.85 The VEMP
can recover in patients with vestibular neuritis.86
patients with acoustic neuromas.8890 Because the VEMP

does not depend on cochlear or lateral SCC function, it
can be abnormal in the presence of vestibular schwannomas even when caloric test results are normal or when
brainstem auditory evoked potentials cannot be measured
because the hearing loss is too severe. In patients with
bilateral vestibular schwannoma due to neurofibromatosis type 2, loss of VEMP is unrelated to tumor size.91
The VEMP can be preserved after vestibular schwannoma surgery,92 suggesting preservation of the saccular
nerve.
Vestibular Schwannoma
Initial experience with this technique suggests that the

VEMP test can provide valuable information additional
to that obtained by tests of lateral SCC function, such
as caloric or rotational tests, and by tests of utricular
function, such as the SVH test.47 We have seen patients
with symptoms of unilateral or bilateral vestibulopathy
(e.g., vertigo, ataxia) in whom SCC function test results
were normal but VEMP test results were unequivocally
abnormal. The following case study describes a typical
example.
Although most patients with vestibular schwannoma

(acoustic neuroma) present with unilateral hearing loss,
some present with vestibular ataxia. This fact is not
entirely surprising because most of these tumors arise not
from the acoustic nerve but from one of the vestibular
nerves, usually the inferior.87 The VEMP, which is transmitted via the inferior vestibular nerve, is abnormalof
low amplitude or absentin perhaps four of every five
Multiple Sclerosis
VEMPs can also be abnormal in diseases affecting central vestibular pathways,93 especially white-matter diseases such as multiple sclerosis,9497 which affect the
medial vestibulospinal tract, the continuation of the
medial longitudinal fasciculus, a site commonly involved
by demyelination.
Other Conditions
CASE STUDY 1
A 61-year-old, previously well male business executive experienced sudden intense vertigo and nausea
while driving home from work. He had to stop his
car, vomited, and called for help. He was taken by
ambulance to a hospital emergency room. On admission he was distressed by vertigo, retching, and
vomiting. He was unable to stand. There was no
spontaneous or positional nystagmus with or without
visual fixation; the head impulse test result was negative vertically as well as horizontally. A CT scan of
the brain was normal. He was admitted to the hospi-
tal with the provisional diagnosis of cerebellar

infarct. The following day he felt better and could
stand without support. At that time, he noted that
he could not hear in his left ear. Over the next 3 days
his balance continued to improve, but his hearing
did not.
Investigations at that time revealed the following:
Audiogram: Severe flat sensorineural hearing
loss left ear; slight conductive loss right ear (Fig.
9.7A).
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Electronystagmogram: Minimal left-beating

gaze-evoked nystagmus in the dark; normal
caloric test results (Fig. 9.7B).
Subjective visual horizontal: More than
6 degrees to the left (Fig. 9.7C).
Vestibular-evoked myogenic potentials: Absent
from left ear to clicks and to taps (Fig. 9.7D).
Magnetic resonance imaging with contrast showed
no abnormality, in particular neither cerebellar infarction nor contrast enhancement of the inner ear.
155
Despite the absence of pain and vesicles, the patient

was given a tapering course of prednisone and acyclovir on the chance that this episode was due to
herpes zoster. His balance continued to improve, but
even 2 weeks later, he still rotated to the left on the
Unterberger (Fukuda) test and fell on the matted
Romberg test. Within 1 month his hearing also
improved but not quite back to normal, and SVH and
VEMP values both returned to normal.
Figure 9.7 (A) Audiogram from a 61-year-old

man with left neurolabyrinthitis. There is a severe
sensorineural hearing loss on the left with absence
of acoustic reflexes and zero speech discrimination,
all findings suggestive of a retrocochlear loss. On
the right there is a slight conductive loss, which is
asymptomatic and unrelated to the present problem.
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C A S E S T U D Y 1 (continued)
Figure 9.7 (continued) (B) Electronystagmogram and caloric test from the same patient. There
is minimal left-beating gaze-evoked nystagmus in darkness (slow-phase velocity 1 deg/sec).
Bithermal caloric tests show symmetrical slow-phase velocities from each ear. These findings indicate
normal lateral semicircular canal function.
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Figure 9.7 (continued) (C) Subjective visual horizontal (SVH) from the same patient. The
patient makes 10 settings of the SVH at his own speed, with each eye open and then with both eyes
open. There is a highly significant offset of more than 5 degrees to the left (the side of the hearing
loss). Normal subjects can set the horizontal to within 2 degrees of the gravitational horizontal.
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Figure 9.7 (continued) (D) Vestibular evoked myogenic potentials (VEMPs) from the same
patient. Channels 23 and 24 show the responses to 95-dB clicks; channels 25 and 26 show the
response to forehead taps. The responses are absent from the left. The absence of tap responses
shows that the absence of click response is due not to some conductive hearing loss in the left ear
(that is being masked by the severe sensorineural loss), but due to loss of saccular function. The
VEMP response to clicks has nothing to do with the audibility of the stimulusit is present even if the
click is not heard.
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Comment
This patient had acute neurolabyrinthitis affecting the
cochlea, the saccule, and the utricle but sparing the
SCCs. In some cases of acute neurolabyrinthitis, as in
this one, the inner ear can recover most or all function.
However, even if the ear had not recovered (as would
have been indicated by persistent loss of hearing and
VEMP), the SVH would have returned to normal through
central vestibular compensation (see Chapter 5).
Summary
The subjective visual horizontal test and vestibular
evoked myogenic potential measurements are simple,
robust, reproducible, and specific tests of otolith dysfunction that can provide clinically useful diagnostic information in patients with vertigo and other balance disorders.
Although they appear to have high specificity for otolith
dysfunction, further clinical research is required to establish their sensitivity.
Acknowledgments
Work described in this chapter is supported by the National Health and Medical Research Council, the Garnett
Passe and Rodney Williams Memorial Foundation, and
the Royal Prince Alfred Hospital Neurology Department
Trustees.
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10
Auditory Examination
Many patients presenting to a clinician with a possible

vestibular disorder have underlying auditory impairment.
Because the ear houses the sensory organs for auditory as
well as vestibular input, many otologic disorders (e.g.,
Mnires disease, perilymphatic fistula, labyrinthitis,
acoustic neuroma), not surprisingly, give rise to both
auditory and vestibular symptoms. An understanding of
the clinical methods of assessment and management of
hearing loss is essential for the clinician who must diagnose and treat patients with vestibular impairment.
History and Physical Examination

A thorough assessment of a patients auditory system
requires obtaining information from a careful history and
physical examination as well as from audiological testing. A patient whose chief complaint is one of disabling
dizziness may not volunteer information about a mild
hearing difficulty, particularly one with an insidious
onset. At the time of the initial clinical assessment, the
examiner should grossly assess the hearing acuity of any
patient presenting with possible vestibular impairment,
especially if audiological testing has not yet been performed. Obtaining a formal audiological assessment in
patients with vestibular hypofunction would be a high
priority. Inquiry should be made as to whether the patient
has subjective hearing difficulties and, if so, in what environments is hearing most challenging. Information such
as whether the patient can still talk on the telephone with
162
either ear or whether he or she frequently needs to ask for

speakers to repeat themselves can be indicative of worsening hearing. For more subtle hearing losses, the patient
may report problems only in certain situations, such as
listening in church or communicating in a noisy environment such as a restaurant.
The simplest method of identifying gross hearing
impairment is for the examiner to occlude one external
canal by pressing inward on the tragus and assessing
whether the patient can hear a vibrating tuning fork, a
whisper, or the examiners fingers rubbing together near
the other ear. An asymmetric hearing loss can sometimes
be identified by the Weber tuning fork test, which entails
placing a vibrating 512-Hz tuning fork firmly on the
patients forehead or teeth and determining whether the
patient perceives the sound emanating from the midline
(Fig. 10.1A). If sound perception lateralizes to one side,
then hearing loss is present (Fig. 10.1B).
To determine which ear has the loss, the examiner
can perform a Rinne test with the fork. To do this test,
the examiner first places the vibrating fork behind the
patients ear, and when the patient can no longer hear the
tone, the tines of the vibrating fork are placed in front of
the external auditory canal of the same ear. If the patient
can still hear the tone when the fork is placed by the ear
canal, the result is normal (Fig.10.2). If the Rinne test
result is abnormal on the side where the tone perception
lateralized with the Weber test, the patient likely has a
conductive hearing loss in that ear. On the other hand, if
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Chapter 10 AUDITORY EXAMINATION
163
panic membrane perforation is suspected in a patient

being evaluated for vestibular loss, water caloric testing
should be deferred in favor of alternative tests of vestibular function. Similarly, caloric tests are contraindicated in
patients who have undergone a mastoidectomy. In the
case of a painless middle ear effusion, a caloric test may
be performed; however, if the test result is abnormal, the
test may need to be repeated after the effusion has resolved, to accurately interpret the situation.
Figure 10.1 The Weber tuning fork test. The sound of the
vibrating tuning fork is perceived (A) in the ear with a conductive hearing loss or (B) in the ear contralateral to the ear with a
sensorineural loss.
the Weber test result is abnormal and the Rinne test yields
a normal result, the patient probably has a sensorineural
hearing loss (SNHL) in the nonlateralized ear. The Weber
and Rinne tests are screens for hearing loss only. For
example, if the patient has a mixed hearing loss, these
tests can yield inconclusive results.
Otoscopic examination is frequently helpful to visualize the outer ear canal and tympanic membrane in the
evaluation of a patient presenting with dizziness. The
pinna and external auditory canal should be examined
for any signs of erythema, edema, or mass, and should be
free of any foreign bodies, vesicles, or discharge. If the
canal is totally occluded with material such as wax or a
foreign body, a conductive hearing loss will result in that
ear.
Next, the tympanic membrane should be inspected
for any signs of perforation, bulging, retraction, or evidence of underlying fluid in the middle ear cavity that
could contribute to a conductive hearing loss. Pneumatic
otoscopy should be performed by insufflating the ear
canal while otoscopically examining the tympanic membrane for normal mobility. Visualization of normal drum
mobility confirms the absence of a perforation and makes
the presence of a middle ear effusion less likely.
Otoscopy should always be performed before a
caloric test is performed for vestibular function. If a tym-
Figure 10.2 The Rinne test. See text for explanation.
Audiological Evaluation
and Management
Evaluative Procedures
Tests for Hearing Sensitivity
The most common screen for hearing acuity is the measurement of auditory thresholds to pure-tone stimulation
across frequencies from 250 Hz to 8 KHz. An auditory
threshold corresponds to the lowest intensity of a sound
stimulus that is detectable in 50% of presentations.1 The
intensity of the presented sound is typically measured in
units of decibels of hearing level (dB HL), in which 0 dB
HL is calibrated to the sound pressures that represent
hearing sensitivity of young adults with normal hearing
when tested in a reasonably quiet environment.2 Audiometric thresholds of hearing sensitivity across a specified
frequency range are typically plotted as an individuals
audiogram (Fig. 10.3). The abscissa of the audiogram is
in units of dB HL of the presented sound stimulus, and
the ordinate corresponds to the frequency of the tone
presented.
An audiogram typically shows an individuals hearing thresholds to pure-tone stimuli presented via air conduction (AC). Air-conducted sounds are presented by
means of either binaural earphones or a loudspeaker, and
thus, the energy is transmitted through all parts of the
ear. For this reason, measuring auditory thresholds to airconducted sounds alone may be sufficient for diagnosing
a hearing loss but provides insufficient information for
determining from which part of the ear the impairment
originates. In contrast, hearing thresholds to tones presented via bone conduction (BC) are obtained by measuring hearing sensitivity to pure tones presented with an
oscillator placed on a skull bony prominence, typically
the mastoid process behind the auricle. The boneconducted sounds are transmitted directly to the boneencased cochlea and, thus, bypass transmission through
the outer and middle ear. Thus, if a hearing loss is identified by bone conduction audiometry, it is secondary to a
cochlear or retrocochlear problem.
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Figure 10.3 Types of audiograms. Case 1, normal hearing; case 2, conductive hearing loss;
case 3, sensorineural hearing loss; case 4, mixed type hearing loss. o air conduction; bone
conduction.
Pure-Tone Audiogram Interpretation

and Types of Hearing Loss
When AC thresholds are consistent with a hearing loss,
but BC thresholds are normal, an air-bone gap is present,
as shown in the audiogram depicted in case 2 of Fig.
10.3. The presence of an air-bone gap indicates that the
hearing loss may be due to a problem in either the outer
or middle ear. Such a hearing loss is called a conductive
loss. Causes of conductive losses include fluid in the
middle ear, disruption or diminished mobility of the
ossicular chain, and abnormal tympanic membrane compliance due to a perforation or excessive scarring. A conductive hearing loss can be caused by anything that
occludes the ear canal, such as a mass, impacted wax or
debris, or even a finger! Disorders that may cause a conductive hearing loss include otitis media, otosclerosis,
ossicular chain disruption from trauma or chronic otitis
media, cholesteatoma, hemotympanum (blood in the
middle ear cavity), neoplasm in the outer or middle ear,
superior semicircular canal (SCC) dehiscence, and barotrauma.
On the other hand, if AC thresholds indicate a hearing loss and the BC thresholds are the same as those
obtained by AC, no air-bone gap is present, and the loss is
of sensorineural origin (Fig. 10.3, case 3). A sensorineural loss (SNHL) is therefore due to a problem either in the
cochlea, or further proximal in the auditory nerve or central nervous system. Common causes of SNHLs are presbycusis, ototoxic drugs, congenital losses, labyrinthitis,
ischemia, acoustic neuroma, temporal bone fracture. and
Mnires disease. Some metabolic or infectious disorders also can cause sensorineural loss, including meningitis, congenital syphilis, toxoplasmosis, cytomegalovirus,
rubella, and herpes. Birth complications such as hypoxia,
prolonged mechanical ventilation, and low birth rate also
increase the risk for development of sensorineural loss.
When BC thresholds show hearing loss and AC
thresholds indicate an air-bone gap, a mixed-type loss is
present, meaning the loss has both conductive and sensorineural components (Fig. 10.3, case 4). Mixed-typed
losses may be seen in advanced otosclerosis, severe
chronic otitis media, and some genetic forms of auditory
impairment.
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In addition to classification as conductive, sensorineural, or mixed, hearing losses can also be further
classified according to severity, the frequencies predominantly affected, or the threshold shape on the audiogram.
The severity of the hearing loss may be described as
mild, moderate, moderately severe, severe, or profound
according to the amount of threshold elevation above
normal range (Table 10-1). In general, hearing thresholds
are considered normal in adults if less than 20 dB HL.
For children younger than 18 years, thresholds less than
15 dB HL are considered within normal limits. Hearing
loss is considered mild if thresholds are less than 40 dB,
moderate if between 41 and 55 dB, moderately severe
between 56 and 70 dB, severe between 71 and 90 dB, and
profound if greater than 90 dB HL.
Many SNHLs disproportionately affect higher frequencies, such as those usually associated with aging or
noise exposure, and thus may be described as being
down-sloping on the audiogram. Classically, noise
trauma leads to hearing loss in which sensitivity to 4000
Hz is most affected. This kind of hearing loss forms a
V-shape on the audiogram, or what is sometimes referred
to as a 4 KHz notch. Individuals with high-frequency
hearing loss have most difficulty with hearing highpitched consonants within words, although they may hear
the lower frequencies of vowels. Therefore, Englishspeaking patients may complain that they can hear
speech but have the most difficulty understanding what is
being said. Languages in which the words end in vowels
do not produce the same problems for people with highfrequency hearing loss.
Low-frequency SNHLs are typically seen in patients
with Mnires disease and some forms of inherited
Table 10-1 CLASSIFICATION

OF HEARING LOSS
Pure-Tone Audiogram
Result (dB)
Classification
15
Normal hearing
1625
Slight loss
2640
Mild loss
4155
Moderate loss
5670
Moderately severe loss
7190
Severe loss
91
Profound loss
165
deafness. An audiogram may also be described as being

U-shaped or cookie-bite shaped. Thresholds in this
type of audiogram form a U-shape when a hearing loss
with either the least or most severely affected frequencies
is in the mid-portion of the hearing range.
Speech Audiometry
Another component of a routine hearing evaluation is the
determination of an individuals ability to detect and recognize speech sounds. The intensity of a speech stimulus
that is detectable by a listener 50% of the time is called
the speech detection threshold (SDT). The SDT should
closely coincide with the average threshold of hearing
sensitivity to pure tones at 500, 1000, and 2000 Hz, an
average referred to as a pure-tone average. The intensity
of a speech stimulus necessary for a patient to recognize
a word is typically around 8 dB higher than the SDT. The
intensity level at which a listener can repeat 50% of the
speech material is referred to as the speech reception
threshold (SRT).
The ability to recognize words presented at a comfortable listening level is assessed by determining a
patients speech recognition score (also referred to as the
speech discrimination score in some texts). This score is
obtained by presenting a list of words well within the
patients audible range and calculating the percentage
correctly recognized. A score that is within normal limits
varies according to the number and type of words in the
list, and normative ranges are available for the particular
method used. Speech discrimination scores are more
likely to be abnormal in sensorineural losses and frequently are severely affected in retrocochlear losses. In
addition to providing information that may be helpful in
determining whether a loss is of sensorineural origin, discrimination test results provide information about the listeners ability to communicate effectively and whether
hearing aids would be effective management.
Measurements of Acoustic Immittance

A routine audiological evaluation frequently includes
measurements of acoustic impedance, or resistance to
acoustic energy transmission. The most common tests of
acoustic impedance are tympanometry and stapedial
reflex measures. Tympanometry measures the change in
the compliance of the eardrum with changes in air pressure in the external auditory canal. Compliance peaks
when air pressure in the outer ear is equivalent to that in
the middle ear. Thus, when negative pressure applied to
the ear canal gives rise to the peak compliance, it may be
inferred that negative pressure exists in the middle ear
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cavity. Such would be the case commonly with eustachian tube dysfunction. On the other hand, when a middle ear
effusion is present, changing ear canal pressure will have
no significant effect on compliance, and hence, the compliance will remain constant at all pressure levels, thereby
giving rise to a flat tympanogram (without a peak).
For routine immittance testing, there are several
types of tympanograms, as depicted in Figure 10.4. Type
A refers to normal compliance with normal middle ear
pressure. Type Adeep (or Ad) is consistent with eardrum
compliance which peaks with normal middle ear pressure, but with peak compliance greater than normal. The
Ad pattern is typical for ossicular chain disruption or for
a flaccid eardrum. The Ashallow or As pattern of tympanogram is seen when compliance peaks with normal middle
ear pressure but with a reduced peak compliance, such as
would be expected for ossicular chain fixation from otosclerosis, tympanic membrane thickening, or a middle
ear mass that dampens ossicular chain mobility. Type B
tympanograms have compliance measures that stay constant as the ear canal pressure is changed and are consistent with a middle ear effusion, tympanic membrane
perforation, or cerumen impaction. Negative middle ear
pressure gives rise to a type C tympanogram.
Another assessment of acoustic impedance is the
measurement of the acoustic reflex. The acoustic reflex is
the contraction of the stapedius muscle for approximately
10 seconds in response to loud sound stimulation, which
results in a decrease in tympanic membrane compliance
leading to a reduction in the transduction of acoustic ener-
gy across the membrane. For the reflex to occur, residual

hearing must be present in the ear being stimulated, and
the efferent fibers to the stapedius muscle must be intact.
The reflex in normal-hearing individuals typically occurs
when sound is presented 70 to 100 dB above auditory
threshold in either the ipsilateral or contralateral ear.
The acoustic reflex test battery evaluates for the
presence of an acoustic reflex and the threshold at which
it occurs. If the reflex threshold is less than 70 dB greater
than the hearing threshold, a cochlear lesion is suspected
because of the evidence of abnormal loudness growth, or
sensory recruitment.3 Practically, the presence of the
acoustic reflex at lower levels above auditory threshold
confers a reduced dynamic range of comfortable hearing,
which is useful information for the fitting of appropriate
hearing aids.
Middle ear disease will inhibit the acoustic reflex as
well, although in mild serous otitis media or in some
forms of ossicular chain disarticulation, the reflex may
remain intact. In most cases, both ipsilateral and contralateral reflexes are absent when the patient has a conductive hearing loss with an air-bone gap of 20 dB or
more in the stimulated ear.
The pattern of abnormal acoustic reflex responses to
ipsilateral and contralateral stimulation helps differentiate
impairment of the VIIth or VIIIth cranial nerve. Abnormal
elevation of the reflex threshold (i.e., more than 95 dB
above the auditory threshold) or absence of the reflex in
the presence of normal hearing threshold measurements
should raise suspicion of VIIth cranial nerve disease.
Reflex response amplitude that decays to less than half
of the original amplitude within 10 seconds for 500-Hz
and 1-kHz tones at 10 dB above reflex threshold is also
consistent with neural impairment. Finally, the absence
of contralateral reflexes in a patient whose ipsilateral
reflexes are intact may in indicate brainstem disease.
The acoustic reflex threshold should never be less
than the pure-tone threshold. Such findings, when they
occur, are most likely due to either a nonorganic hearing
loss or a technical error.
Auditory Brainstem Response
Figure 10.4 Types of tympanograms. See text

for explanation.
Measurement of the auditory brainstem response (ABR)

provides another means of assessing the integrity of the
auditory pathways from the outer ear to the level of the
midbrain. The ABR is a surface-recorded averaged
response representing the activity of the distal portion of
the auditory pathway in response to a sound stimulus.
Practical uses for ABR measurement include estimation
of auditory threshold in patients unable to participate in
routine audiometric testing, such as infants or the cogni-
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tively impaired, and documentation of an audiological

threshold in those feigning hearing loss. Information
about the site of a lesion along the auditory pathway may
be inferred from the ABR, because waveform morphology may be selectively abnormal at the site of lesion. ABR
monitoring is also useful intraoperatively when surgery is
performed that otherwise could put the auditory nerve at
risk, such as during the resection of an acoustic neuroma.
To elicit the ABR, both clicks and brief frequencyspecific tonal stimuli may be used. Electrodes are placed
on the vertex, forehead, and behind each earlobe. The
electrode on the earlobe ipsilateral to the ear stimulated is
used as a reference electrode, and the other as a ground
electrode. The first five positive polarity peaks within 10
msec are routinely analyzed. Typically, waveforms of
1000 to 3000 sweeps are averaged to obtain the ABR.
The morphology of the ABR is shown in Figure
10.5A. Wave I originates from the portion of the auditory
nerve within the internal auditory canal. Wave II is from
the cochlear nucleus and proximal portion of the VIIIth
Figure 10.5 (A) Basic morphology of auditory

brainstem response (ABR). Wave I corresponds to
the cochlea, acoustic nerve; wave II to the
acoustic nerve, cochlear nucleus; wave III to the
superior olivary complex; wave IV to the lateral
lemniscus; and wave V to the inferior colliculus.
(B) ABRs obtained from a 46-year old patient with
a surgically confirmed acoustic neuroma on the left
side. She had a moderate sensorineural hearing
loss in the left ear. Repeated ABR testing on the
left side at 70 dB and 80 dB normalized hearing
level showed no discernible responses, but clear
responses were obtained when the right ear was
stimulated.
167
nerve in the cerebellopontine angle (CPA); wave III is

from the superior olivary complex; wave IV is from the
lateral lemniscus; and wave V is from the inferior colliculus. Of note, waves III through V have bilateral crossed
inputs and no longer represent solely an ipsilateral
response. Response latencies normally increase as stimulus amplitude decreases, but interwave intervals remain
relatively constant regardless of stimulus intensity; hence,
wave IV and IIIV intervals are routinely measured.
Norms are available for waveform response latencies, and abnormally long latencies or widened interwave
intervals may be seen with lesions of the auditory nerve
or brainstem. An example of abnormal ABR waveform
from a patient with a left-sided acoustic neuroma is
shown in Figure 10.5B.
Otoacoustic Emissions
Otoacoustic emissions (OAEs) are sounds that are generated from healthy cochlear outer hair cells. Outer hair
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cells are motile and are thought to function as an amplifier of cochlear partition displacement during acoustic
stimulation and, in so doing, generate acoustic byproducts, or cochlear echoes. OAEs are obtainable from
essentially all patients with normal hearing but may be
reduced or absent in ears with mild hearing loss.
Intrasubject variability is minimal in OAEs, and emissions remain stable over several years for any one ear.
OAE measurements are highly useful in screening for
hearing loss in neonates, because the test is quick, noninvasive, and highly sensitive.
Otoacoustic emissions may be divided into spontaneous emissions (SOAEs), which occur without acoustic
stimulation of the ear, and evoked otoacoustic emissions
(EOAEs), which represent a response to an acoustic stimulus. Evoked otoacoustic emissions may be further subdivided into transient evoked otoacoustic emissions,
elicited by transient, brief stimulus such as a click or a
brief tone burst; stimulus-frequency otoacoustic emissions, elicited by a pure tone; and distortion-product
otoacoustic emissions, generated by pure tones separated
by a specific frequency difference.
Otoacoustic emissions are recorded by inserting a
probe tip containing both a miniature loudspeaker and a
sensitive microphone into the ear canal. The loudspeaker
delivers the stimulus for eliciting evoked OAEs, and the
microphone samples the emission for approximately 20
msec. Recorded emissions are then signal-averaged and

subsequently delivered to a sophisticated signal processor. The transient EOAEs correspond to a delayed echo
of the stimulus and span a frequency range of 0.4 to 6
kHz with a latency of 5 to 20 msec in humans. Emission
amplitude typically decreases as frequency increases.
Distortion-product OAEs are elicited by two stimulus tones delivered at a 55- to 85-dB sound pressure level,
separated by a particular frequency interval. The most
prominent distortion-product otoacoustic emission
occurs at the cubic difference frequency described by the
expression 2f1 f2, in which f1 represents the lowerfrequency stimulus, and f2 the higher-frequency primary
tone. The resultant emission typically has an amplitude
that is 60 dB lower than the primary tones.
Electrocochleography
Electrocochleography refers to the measurement of neuroelectric events generated by the cochlea and auditory
nerve in response to acoustic stimulation. The electrocochlear response consists of the cochlear microphonic,
the summating potential (SP), and the whole-nerve action
potential generated by the auditory nerve (AP) (Fig.
10.6). The cochlear microphonic mimics the waveform
of the sound stimulus, and the shift in its baseline (or
direct current [DC]) is called the summating potential.
Figure 10.6 Electrocochleograms from the normal ear.
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The AP corresponds to wave I of the ABR. Ideally, electrocochleography is recorded with an electrode placed as
close as possible to the round window of the cochlea. A
transtympanic needle electrode referenced to another
electrode placed on the forehead or tragus may be used,
or an electrode may be placed on the surface of the tympanic membrane or in the ear canal.
The electrocochleogram is particularly useful in
identifying abnormal cochlear function and has been
used extensively to evaluate for possible endolymphatic
hydrops or Mnires disease. Endolymphatic hydrops
changes the elasticity of the basilar membrane, causing
an increase in amplitude of the SP relative to that of the
AP. The SP-to-AP ratio normally ranges from 10% to
50%, with higher ratios in many patients with Mnires
disease.
Audiological Management
Hearing Aids
The majority of individuals with hearing loss are treated
with hearing aids (Fig. 10.7). Selection of proper amplification systems for hearing loss depends on many factors,
including type and extent of the loss and whether it is
bilateral and symmetric. In addition, personal and practical factors, such as patient age, cognitive and physical
health status, auditory needs, and cosmetic concerns, also
can play a role. Most hearing aid devices are worn either
in the ear (ITE) or behind the ear (BTE). Developments
in hearing aids have allowed high-powered aids for more
severe hearing losses to be smaller and less conspicuous.
The smallest hearing aids are worn entirely in the ear
canal (ITC), so that they are minimally visible at all, but
these are typically not powerful enough to amplify for
severe hearing loss.
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Some individuals with severe to profound hearing

loss use body aids. A body aid consists of a microphone
and power supply within a small box connected to the
earmold with a lead. The power supply may be worn in a
shirt pocket. Because their power supply may be larger,
body aids can be quite powerful. These aids are not as
popular now as they were in the past, but they are still
useful in some patients with severe loss or in patients
with vision or dexterity limitations that otherwise make it
difficult to use a conventional hearing aid.
For patients with conductive hearing loss, bone conduction hearing aids may be of benefit. These hearing
aids utilize an oscillator that contacts skin overlying the
mastoid bone, leading to transmission of sound via bone
conduction and bypassing the middle and outer ear. They
may be worn either attached to a headband or eyeglasses
or like a behind-the-ear hearing aid. An alternative to traditional bone conduction aids is an implanted boneanchored hearing aid (BAHA). The BAHA consists of a
permanent titanium fixture or implant that is surgically
inserted into mastoid bone. It has a separate directional
microphone and detachable external sound processor.
Lastly, some hearing aids are specifically manufactured to benefit those with unilateral hearing losses. The
CROS (contralateral routing of signal) hearing aid delivers sound from an ear with normal hearing to the contralateral ear with hearing loss. For those with marked
asymmetric bilateral hearing loss, a biCROS hearing aid
may be more appropriate. The biCROS amplifies sounds
from both sides and delivers it to the ear with the better
hearing.
Traditional hearing aids receive sounds and convert
them either into electrical signals, which are then amplified (analog conversion), or to digital signals. Digital
hearing aids are more expensive but have the advantage of
Figure 10.7 Types of hearing aids. Left, In-the-ear; center, behind the ear; right, in-the-canal.
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being able to selectively amplify certain frequencies to

suit an individuals needs and hearing loss characteristics.
Aural Rehabilitation
Aural rehabilitation involves the administration of services to help people adjust to their hearing loss and make
the best use of hearing aids. Exploring possible assistive
devices and providing education about ways to optimally
manage conversations and enhance communication skills
may also be included in aural rehabilitation. Sometimes
spouses or other family members can participate in aural
rehabilitation to gain information about hearing loss and
the attendant issues of communication. In some aural
rehabilitation programs, patients are assisted in learning
lip-reading skills.
Medical Testing in the

Evaluation of Hearing Loss
The majority of hearing losses may be attributed to genetics, may be age-related, or both, and may be optimally
treated with conventional audiological evaluation and
management. However, with some clinical presentations,
a closer evaluation to uncover other potential etiologies
for the hearing loss may be necessary. The clinician must
be able to recognize common medical causes underlying
hearing impairment and, in addition, may need to maintain a low threshold of suspicion for uncommon, yet
potentially treatable, causes of hearing loss.
Laboratory Testing
Some systemic disorders manifest as hearing loss, such as
autoimmune or infectious disease. For patients presenting
with SNHL, either the fluorescent treponemal antibody
absorption test (FTA-ABS) or the microhemagglutination
test for Treponema pallidum (MHA-TP) should be performed, particularly because hearing loss related to
syphilis is potentially treatable. Routine screening for
autoimmune disorders is not routinely warranted, however, unless disease is suggested by information obtained
from the history and physical examination. In particular,
if other cranial neuropathies are present, lumbar puncture
is warranted to perform the Venereal Disease Research
Laboratory (VDRL) test for neurosyphilis, and also to
evaluate cerebrospinal fluid (CSF) for cytology, cell
count, and levels of glucose and protein, as well as to
perform cultures. In endemic geographic areas, serum
Lyme antibody titers should be checked. If the history or
physical findings are otherwise suggestive of systemic
disorders, serological tests for possible autoimmune

causes, such as erythrocyte sedimentation rate measurement and tests for angiotensin-converting enzyme (ACE)
level and presence of rheumatoid factor, cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA), perinuclear
ANCA (p-ANCA), and antinuclear antibody (ANA), may
be helpful.
Radiological Imaging
Radiography is warranted in selected patients with hearing loss. Magnetic resonance imaging (MRI) with
gadolinium enhancement is currently the gold standard
for evaluation of hearing losses of possible retrocochlear
origin and particularly in making the diagnosis of a tumor
of the VIIIth cranial nerve or in the cerebello-pontine
angle (CPA) region. Computed tomography (CT) is useful in patients with suspected labyrinthine congenital
anomalies, such as large vestibular aqueduct syndrome
and Mondini dysplasia. CT also is useful in cases with
suspected labyrinthine fistula or temporal bone fractures.
Clinical Presentations
of Auditory Impairment
Sudden Sensorineural Hearing Loss
The cause of sudden sensorineural hearing loss (SSNHL)
is not completely understood and has been hypothesized
to be due to a variety of causes: hypoxia, intralabyrinthine membrane rupture, and viral, vascular, inflammatory, or metabolic disorders, among others. SSNHL is
considered an otologic emergency because accepted
guidelines for treatment are to institute pharmacological
therapy within 2 weeks to achieve maximum benefit.
Many physicians use as criteria for SSNHL minimum
loss of 30 dB in three contiguous frequencies measured
in routine audiometric evaluation over a period of 3 days
or less. The rate of spontaneous resolution is relatively
high, at about 65%, but variables such as severity of loss,
flat or downsloping audiogram, age extreme, elevated
erythrocyte sedimentation rate, time from onset to diagnosis, and the presence of vertigo, all portend a poorer
prognosis. In general, patients with lower-frequency
hearing loss have a better chance for recovery (reviewed
in reference 4).
Oral corticosteroids have been shown to be effective
in some cases,5 and a 2005 study recommends giving
prednisone 60 mg/day for 14 days.6 A review of the literature concluded that intratympanic corticosteroid treatment for patients in whom oral steroid therapy fails can
be only weakly recommended.7 Addition of an antiviral
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agent to steroid treatment did not improve hearing outcome in one study,8 but whether other combinations of
agents may be more effective remains unclear and is an
area of ongoing research.
advancing age in association with an age-related decrease

in cellular immune response to herpes zoster virus.9
Hearing Loss from Infectious Disease

Labyrinthitis
The incidence of hearing loss is as high as 80% in cases

of symptomatic neurosyphilis, and 29% patients with
asymptomatic neurosyphilis.10 The mechanism of hearing loss in syphilis is either a meningolabyrinthitis or an
osteitis of the temporal bone with secondary involvement
of the labyrinth. Pathologically, a resorptive osteitis is
seen in the temporal bone, with endolymphatic hydrops
noted within the labyrinth. Clinically, hearing loss due to
syphilis is frequently indistinguishable from that in
Mnires disease, because it may fluctuate and may be
associated with tinnitus, aural fullness, or episodic vertigo. Henneberts sign and Tullio phenomenon may be
seen in otosyphilis. Treatment consists of antibiotics and
corticosteroids.
An infectious or inflammatory process within the

labyrinth can take two forms pathologically, serous or
suppurative. Serous labyrinthitis is defined as an abnormal process within the labyrinth caused by the degradation of the tissue-fluid environment within the inner ear
by either bacterial toxins or contamination of perilymph
with blood, products of tissue injury, or air at surgery. The
principal abnormal finding in serous labyrinthitis is
endolymphatic hydrops, with temporary or permanent
hearing loss and vestibular dysfunction. Commonly,
labyrinthitis is diagnosed clinically when patients present
with a relatively sudden onset of SNHL and acute vertigo.
Most commonly, serous labyrinthitis is of viral origin.
Suppurative labyrinthitis is caused by bacterial invasion of the inner ear and is manifested by profound hearing loss and acute vertigo. The route of invasion can be
from otitis media, via a fistula between the middle ear
and the labyrinth. Alternatively, the route of invasion can
be meningogenic, through the cochlear aqueduct or internal auditory canal. Suppurative labyrinthitis is the most
common cause of deafness associated with meningitis.
Measles and mumps rarely cause hearing and
vestibular loss in developed countries because of widespread vaccination against these diseases. The hearing
loss in measles is usually bilateral and moderate to profound, and vestibular function is similarly affected. In
contrast, mumps typically causes a unilateral hearing
loss. Cytomegalovirus (CMV) may cause hearing loss as
well, but this condition is typically seen in an immunocompromised patient, such as one with AIDS.
Ramsay Hunt Syndrome

If skin vesicles are noted on the pinna or external auditory canal of an ear with new-onset hearing or vestibular
loss, herpes zoster infection should be suspected. If such
vesicles are accompanied by an ipsilateral facial weakness, the condition is referred to as Ramsay Hunt syndrome, which is caused by a herpes virus. Facial paralysis
is most commonly seen, but hearing loss and vertigo can
occur alone or in combination as well. The infection
probably represents the reactivation of a latent virus, such
that after the primary infection, the virus travels to the
dorsal root ganglion of a cranial nerve, where it remains
dormant until reactivated. Incidence and severity rise with
Syphilis
Rocky Mountain Spotted Fever

Rapidly progressive SNHL has been associated with
Rocky Mountain spotted fever (RMSF), which is thought
to be secondary to a vasculitis involving the auditory system. The hearing loss may be transient. RMSF is caused
by the tick-borne pathogen Rickettsia rickettsii. Diagnosis is made on the basis of presentation and is confirmed
by serologic titers. Treatment is with broad-spectrum
antibiotics.
Lyme Disease
Lyme disease is caused by the tickborne spirochete
Borrelia burgdorferi. Most commonly, it gives rise to
facial paralysis, but it can cause hearing or vestibular loss
and should be considered as a possible cause in endemic
areas. Recommended antimicrobial therapy for Lyme
disease with neurological manifestations is with thirdgeneration cephalosporins, as long as the patient is not
allergic to these agents.
Pharmacological Toxicity
Like the vestibular system, the auditory system is vulnerable to the toxic effects of a number of pharmacological
agents. Other than removing the offending agent, no reliable treatment is known for hearing loss due to ototoxic
drug therapy.
Aminoglycoside
Probably the most common ototoxic agents encountered
in clinical practice are the aminoglycoside antibiotics,
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which are lethal to hair cells in the inner ear. Kanamycin,

tobramycin, amikacin, neomycin, and dihydrostreptomycin are more cochleotoxic than vestibulotoxic, whereas gentamycin and streptomycin cause disproportionately
more vestibular damage than cochlear damage.11 Hearing
loss may be asymmetric and may progress even after cessation of the therapy. Some auditory recovery may occur
weeks to months after treatment. Risk factors for aminoglycoside ototoxicity include renal impairment, longer
duration or high doses of drug treatment, advanced age,
and combined administration of other ototoxic drugs,
particularly loop diuretics.12
Aspirin
Aspirin toxicity may manifest as tinnitus and reversible
SNHL, and the toxic effects are typically dose-dependent.
The mechanism of injury is most likely alteration of the
turgidity and motility of the outer hair cells, with resultant
loss of OAEs and reduction in cochlear action potentials.13 Caloric responses can also be reduced by salicylates.14 Nonsteroidal antiinflammatory drugs (NSAIDs),
such as naproxen, ketorolac, and piroxicam, have been
known to cause reversible SNHL, but this side effect
occurs far less commonly than that seen with salicylates.
Chemotherapeutic Agents
Numerous cancer chemotherapeutic agents have been
associated with ototoxicity. Cisplatin (cis-diamminedichloroplatinum) is associated with irreversible bilateral
high-frequency hearing loss. If ultra-high frequencies are
tested, virtually all patients who have received cisplatin
probably will be found to have at least some degree of
ototoxicity.15 Occasionally the hearing loss is accompanied by vertigo or tinnitus. Other chemotherapeutic
agents known to cause ototoxicity are the vinca alkaloids
vincristine and to a lesser extent, vinblastine.
Ototopical Medications
Ototopical preparations containing neomycin, gentamicin, and tobramycin are widely used for the treatment of
otitis externa and chronic otitis media. However, in experimental animals and patients, these drugs are now known
to cause auditory and vestibular loss when they are
instilled in the middle ear cavities of normal healthy ears.
The toxic effect of gentamycin administered transtympanically is the mechanism of action of chemical
labyrinthectomies performed to treat patients with refractory Mnires disease.16 Thus, the use of aminoglycoside-containing topical preparations in uninflamed ears
with tympanic membrane perforations should be avoided.
Other ingredients in ototopical preparations that have ototoxic potential are polymyxin B, propylene glycol, acetic
acid, and antifungal agents.17,18
Other Drugs
Other drugs that have been reported to cause hearing loss
are deferoxamine, an iron-chelating agent, and eflornithine, used for the treatment of Pneumocystis carinii
pneumonia, trypanosomiasis, cryptosporidiosis, leishmaniasis, and malaria. Quinine has long been known to
cause SNHL, tinnitus, and visual disturbances.12 Loop
diuretics alone can cause reversible hearing loss, which is
usually bilateral and symmetric.
Surgical Management
of Hearing Loss
Although a thorough review of this topic is beyond the
scope of this chapter, many forms of ear disease can give
rise to hearing loss amenable to surgical treatment. Most
often, surgical approaches are used to treat conductive
hearing loss, because frequently the loss is secondary
to a structural problem in the middle or outer ear. When
sound transduction cannot take place because either
disease or trauma has disrupted the ossicular chain,
for example, this problem can frequently be surgically
corrected by clearing the middle ear cavity of the structural disease, by replacement of the ossicles with a
prosthetic device, or both. Disruptions in the tympanic
membrane can also be treated with a tympanoplasty
procedure. Rarely do causes of conductive hearing loss
without a sensorineural component give rise to vestibular
symptoms.
In contrast to management for conductive hearing
loss, surgical treatment for SNHL is considerably less
common, but notable approaches include cochlear
implants and interventions for CPA tumors, SCC dehiscence, and other perilymphatic fistulas (PLFs). CPA
tumors and PLFs commonly give rise to vestibular symptoms, and patients with cochlear implants may have
vestibular as well as hearing loss; thus, clinicians managing vestibular disorders may not infrequently encounter
patients with these lesions.
Cochlear Implants
Cochlear implants are an option for a growing number of
hearing-impaired patients. Although the first attempt to
electrically stimulate the auditory system occurred nearly
two centuries ago, the development of a cochlear prosthesis to restore hearing to patients with SNHL took place
only in the past four decades. A deafened auditory nerve
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was first electrically stimulated by Djourno and colleagues19 in 1957, but it was not until 1972 that a commercial device was developed for this purpose. Traditional
criteria for implantation include bilateral profound-tototal SNHL, inability to benefit from conventional hearing
aids, good physical and mental health, and the motivation
and patience to complete a rehabilitation program.20 More
recently, cochlear implants have been advocated as treatment for hearing loss associated with enlarged vestibular
aqueduct syndrome.21,22 Implantation criteria continue to
173
broaden as studies are now under way exploring simultaneous usage of acoustic hearing aids with short-electrode
cochlear implants in the same ear.23
All cochlear implants have several elements in common (Fig. 10.8A). A microphone, usually at ear level,
detects acoustic energy, which is encoded into an electrical signal by the external sound processor. The electrical
stimulus is transmitted to the implanted electrode array
either in the middle ear or inner ear through some form
of signal coupler (Fig. 10.8B). The most commonly used
Figure 10.8 (A) A multichannel cochlear implant processor, microphone, and magnet coil. (B)
Cochlear implant internal device electrode array and ear-level cochlear implant. (Photographs courtesy of Cochlear Corporation.)
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commercially available implants in the United States are

those with 22 active electrodes.
The technology of the cochlear implant continues to
improve, particularly in the area of speech processors,
with increasingly more sophisticated coding strategies.
Patient selection criteria have continued to broaden as
growing numbers of patients are found to benefit from
the procedure. The rehabilitation process is still lengthy,
however, because it involves adjustments of the speech
processor and extensive aural training.
Cerebellopontine Angle Tumors

Although the acoustic neuroma (acoustic neurinoma,
vestibular schwannoma, acoustic neurilemoma) is the
most common lesion seen in the CPA, a variety of other
benign and malignant lesions may be found in this region.
Patients with such lesions may also present with vertigo,
unsteadiness, headache, twitching, and weakness or
numbness of the face. Unilateral progressive SNHL is the
most common first symptom, and predominantly highfrequency SNHL with poor word discrimination ability is
characteristic, although other hearing loss patterns have
been described. Little relationship exists between the size
of the tumor and the audiometric results.24
Brainstem evoked response audiometry is the single
most reliable audiometric diagnostic procedure in the
diagnosis of CPA lesions. Specificity and sensitivity of
the ABR range from 92% to 96% in the diagnosis of
acoustic neuromas approximately 1 cm in diameter.25
Vestibular hypofunction is demonstrated in 82% to 96%
of patients with CPA lesions,26 and positional nystagmus
is a very common finding.27 MRI of the brain with
gadolinium contrast enhancement provides a reliable
method of diagnosing acoustic neurinomas, which may
be purely within the internal auditory canal, and is particularly useful for monitoring tumor growth and postoperative recurrence.
The acoustic neuroma arises most commonly from
the superior division of the vestibular nerve, and next
most commonly from the inferior division. In rare cases
it arises from the cochlear nerve. Acoustic neuromas are
a feature of neurofibromatosis type 2 (NF2). A partial
deletion in the long arm of chromosome 22 has been
found in patients with NF2.
Clinically symptomatic acoustic neuromas are seen
in 1.5 per 100,000 population, which constitute only
0.2% of the acoustic neuromas found in postmortem
studies of temporal bones. Because the growth rate of
these tumors is generally slow and malignant transformation is rare, the most appropriate management in patients
who are otherwise poor operative candidates may consist
of merely monitoring the lesion. Patients with service-
able hearing who have unilateral tumors less than 2.0 cm

in diameter may be offered either surgical removal with
an attempt to save hearing or radiographic monitoring,
surgery being reserved for an enlarging tumor. For small
tumors in patients with poor or no hearing, either surgical removal or radiographic follow-up may be considered. For larger tumors in healthy young and middle-aged
adults, surgical removal is generally recommended,
because the morbidity of surgical removal is directly correlated with the size of the tumor and enlargement in
healthy patients younger than 65 years is likely. For large
tumors in older patients without evidence of brainstem
compression, radiographic monitoring is recommended,
with surgery reserved for enlarging tumors and progressive symptoms. In patients with NF2 and bilateral
tumors, the goal is to avoid bilateral deafness and
vestibular hypofunction, so if hearing is good in both
ears, one should proceed with surgical excision of one
tumor in the attempt to preserve hearing.28

SCC dehiscence is caused by a disruption in the bony capsule of the temporal bone overlying the superior SCC that
renders the vestibular labyrinth sensitive to loud sounds
or pressure changes. The condition is probably congenital
because it is frequently bilateral, but it is sometimes
asymptomatic. Diagnosis can be made through demonstration of characteristic torsional nystagmus induced by
application or positive or negative ear canal pressure or by
presentation of loud sound.
Frequently, patients with SCC dehiscence first
present with a conductive hearing loss. Moreover, such
patients may actually be hypersensitive to bone-conducted sounds, resulting in measurements of audiometric airbone gaps in which BC thresholds are lower than normal
0 dB hearing level and AC thresholds are within normal
threshold range. This hypersensitivity to bone-conducted
sounds may generate patient complaints of hearing their
own pulse or eye movements. Treatment is surgical and
may involve blocking the affected superior SCC.29,30
PLFs are associated with a number of conditions, including barotrauma, head injury, heavy lifting or straining,
invasive cochlear procedures, stapedectomies, congenital
defects of the middle ear, and labyrinthine erosion from
mastoiditis or chronic granulomatous disease. The existence of PLFs of the oval and round windows is controversial, although some clinicians believe PLFs may occur
spontaneously as well.31 The onset of PLF commonly
manifests as sudden onset of hearing loss, vertigo, or
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both. Unsteadiness or dizziness is present in most cases,

and the dizziness is usually positional in nature. Seventyfive percent of patients with PLFs complain of tinnitus,
regardless of hearing status. Hearing loss in present in
53% of patients and usually does not fluctuate. Moreover,
patients do not typically present with episodic vertigo,
tinnitus, or aural fullness, features that would be more
consistent with Mnires disease. Hearing loss with PLF
is usually sensorineural but may be predominantly conductive in the case of a stapes abnormality.
Physical findings of PLF are not always present, and
identification of the involved ear may not be straightforward if no hearing loss is present. When present, physical findings include positional nystagmus occurring in
several head positions, but especially with the suspect ear
down. Henneberts signa few beats of nystagmus or
ocular deviation induced with application of negative or
positive pressure to the external auditory canal of the
involved ear with an intact tympanic membranemay be
present with PLF. This sign may be secondary to stimulation of the utricular macula as a result of deformation
of the utricular wall by the pressure change.
No specialized audiometric or electronystagmography result, including caloric testing, has been of any
value in identifying PLF or the side of the lesion. Black
and coworkers32 reported posturography as being a highly specific and sensitive test for PLF, but this finding has
not been corroborated well by others.33 Other than rarely
documenting intralabyrinthine air in association of perilymphatic leakage, neither CT nor MRI can positively
identify a PLF.
In animals, it has been shown that most PLFs heal
spontaneously, and some physicians choose nonoperative
management for at least several days, allowing time for
complete evaluation as well as possible spontaneous
recovery. Conservative management comprises bedrest
with the head of bed elevated to 30 to 40 degrees and use
of a stool softener. Lifting, stooping, nose blowing, and
any kind of activity that could elevate cerebral or middle
ear pressure is not permitted. Hearing loss is monitored
with interval audiograms. In cases of sudden hearing
loss, worsening hearing, or dizziness, or if hearing fails
to improve, surgery may be recommended. Of note, however, is that unlike PLF secondary to superior SCC dehiscence, which may be more readily diagnosed, PLF of the
oval or round window may not always be identified, even
intraoperatively, unless an obvious anatomical malformation is present.
175
Other Causes of Hearing Loss

Many other disorders may exhibit hearing loss as a symptom (Table 10-1), although rarely are auditory symptoms
the sole manifestation of the disorder. For example,
ischemic stroke and multiple sclerosis may give rise to
hearing loss, as may almost any intracranial process that
disrupts the central auditory pathways. Pagets disease
(osteitis deformans), although a rare disorder of bone,
commonly manifests as hearing loss and can be treated
with calcitonin or etidronate disodium.34 Rarely, hearing
loss may accompany blood dyscrasias, AIDS, autoimmune disease, or paraneoplastic disease.
Summary
This chapter provides an introduction to the evaluation
and management strategies for auditory disorders.
Components of the history and physical examination
which are pertinent in the evaluation of this patient population are discussed, and standard audiological testing
procedures and their indications are reviewed. The clinical presentations of the more common etiologies of hearing loss are outlined because of their relevance to the
clinician who assesses and treats patients with vestibular
disordersthe pathophysiology underlying vestibular
disease also frequently gives rise to auditory symptoms.
Familiarization with the clinical presentation and audiological features of disorders of the auditory system
significantly assists the clinician in the formulation of
differential diagnoses in these patients, which in turn,
provides the foundation for the choice of appropriate
management and therapy.
References
1. Yantis PA: Pure-tone air-conduction testing. In: Katz J,
ed. Handbook of Clinical Audiology, 3rd ed. Baltimore:
Williams & Wilkins; 1985.
2. American National Standards Institute: Specifications for
Audiometers, ANSI S3.6 -1969. New York: ANSI; 1969.
3. Metz O: Threshold of reflex contractions of muscles of
middle ear and recruitment of loudness. AMA Arch
4. Eisenman D, Arts HE: Effectiveness of treatment for sudden sensorineural hearing loss. Arch Otolaryngol Head
Neck Surg 2000;126:1161.
5. Wilson WR: The efficacy of steroids in the treatment of
idiopathic sudden hearing loss. Arch Otolaryngol 1980;
106:772.
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6. Slattery WH, et al: Oral steroid regimens for idiopathic

sudden sensorineural hearing loss. Otolaryngol Head
Neck Surg 2005;132:5.
7. Doyle KJ, et al: Intratympanic steroid treatment: a review.
Otol Neurotol 2004;25:1034.
8. Tucci DL, et al: Treatment of sudden sensorineural hearing loss with systemic steroids and valacyclovir. Otol
Neurotol 2002;23:301.
9. Oxman MN: Immunization to reduce the frequency and
severity of herpes zoster and its complications. Neurology
1995;45(Suppl 8):S41.
10. Schuknecht HF: Pathology of the Ear, 2nd ed.
Philadelphia: Lea & Febiger; 1993.
11. Caitlin FI: Prevention of hearing impairment from
infection and ototoxic drugs. Arch Otolaryngol 1985;
111:377.
12. Arts A: Differential diagnosis of sensorineural hearing
loss. In: Cummings, Fredrickson, Harker, Krause,
Richardson, Schuller (eds.) OtolaryngologyHead and
Neck Surgery, 3rd ed. St. Louis: Mosby; 1998.
13. Boettcher FA, Salvi RJ: Salicylate ototoxicity: review and
synthesis. Am J Otolaryngol 1991;12:33.
14. Bernstein JM, Weiss AD: Further observations on salicylate ototoxicity, J Laryngol Otol 1967;81:915.
15. Kopelman J, et al: Ototoxicity of high-dose cisplatin
by bolus administration in patients with advanced
cancers and normal hearing. Laryngoscope 1988;
98:858.
16. Nedzelski JM, et al: Chemical labyrinthectomy: local
application of gentamicin for the treatment of unilateral
Menieres disease. Am J Otol 1992;13:18.
17. Marsh RR, Tom LWC: Ototoxicity of antimycotics.
18. Morizono T: Toxicity of ototopical drugs: animal modeling. Ann Otol Rhinol Laryngol Suppl 1990;148:42.
19. Djourno A, et al: Preliminary attempts of electrical
excitation of the auditory nerve in man, by permanently
inserted micro-apparatus. Bull Acad Natl Med 1957;
141:481.
20. Luxford WM: Cochlear implant indications. Am J Otol
1989;10:95.
21. Bent JP 3rd, et al: Cochlear implantation in children

with enlarged vestibular aqueducts. Laryngoscope 1999;
109:1019.
22. Miyamoto RT, et al: Cochlear implantation with large
vestibular aqueduct syndrome. Laryngoscope 2002;
112:1178.
23. Gantz BJ, Turner C: Combining acoustic and electrical
speech processing: Iowa/Nucleus hybrid implant. Acta
24. Nadol JB, et al: Correlation of hearing loss and radiologic
dimensions of vestibular schwannomas (acoustic neuromas). Am J Otol 1996;17:312.
25. Turner RG, Shepard NT, Frazier G: Clinical performance
of audiological and related diagnostic tests. Ear Hear
984;51:187.
26. Ojemann RG, et al: Evaluation and surgical treatment of
acoustic neuroma. N Engl J Med 1972;287:895.
27. Okada Y, et al: Electronystagmographic findings in 147
patients with acoustic neuroma. Acta Otolaryngol Suppl
1991;487:150.
28. Nadol JB: Cerebellopontine angle tumors. In: Nadol JB,
McKenna MJ, eds. Surgery of the Ear and Temporal
Bone. New York: Raven Press; 1993.
29. Minor LB, Solomon D, Zinreich JS, Zee DS: Soundand/or pressure-induced vertigo due to bone dehiscence
of the superior semicircular canal. Arch Otolaryngol
Head Neck Surg. 1998;124:249.
30. Baloh RW: Superior semicircular canal dehiscence syndrome: leaks and squeaks can make you dizzy. Neurology
2004;62:684.
31. Stroud M, Calcaterra T: Spontaneous perilymphatic fistulas. Laryngoscope 1970;80:479.
32. Black FO, et al: The dynamic posturographic pressure test
for the presumptive diagnosis of perilymph fistulas.
Neurol Clin 1990;8:361.
33. Shepard NT, Telian SA, Niparko JK, et al: Platform pressure test in identification of perilymphatic fistula.
American J Otol 1992;13:49.
34. Lando M, et al: Stabilization of hearing loss in Pagets
disease with calcitonin and etidronate. Arch Otolaryngol
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THREE
Medical
and Surgical
Management
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11
Pharmacological and
Optical Methods of
Treatment for Vestibular
R. John Leigh, MD
Patients with vestibular disease may complain of vertigo,

oscillopsia, or the visual consequences of nystagmus.1
Vertigo consists of the illusion of turning and implies
vestibular imbalance. Oscillopsia consists of illusory, toand-fro movements of the seen environment; when it
occurs with head movements, it usually implies bilateral
loss of vestibular function. Patients with spontaneous
nystagmus, due to vestibular or other processes, may also
complain of oscillopsia when their heads are still. In this
chapter, treatments for vertigo, oscillopsia, and the visual consequences of nystagmus are reviewed, with an
attempt to base therapies on known pathophysiology.
In trying to understand and treat the symptoms
resulting from labyrinthine disorders, one must bear in
mind the nature of the demands placed on the vestibular
system during natural activities, especially locomotion.
The purpose of the vestibulo-ocular reflex (VOR) is to
maintain clear and stable vision during natural head
movements. A major threat to clear vision is the head perturbations occurring during locomotion. This fact was
first pointed out by the anonymous physician J.C.,2 who
had lost vestibular function due to aminoglycosides; he
wrote, During a walk I found too much motion in my
visual picture of the surroundings to permit recognition
of fine detail. I learned that I must stand still in order to
read the lettering on a sign.
178
Figure 11.1 summarizes the peak velocities and predominant frequencies of head rotations measured in 20
normal subjects as they walked or ran in place. Note that
although peak head velocity is generally below 150
degrees per second (deg/sec), the predominant frequencies range from 0.5 to 5 Hz.3 The latter value exceeds the
frequencies that vestibular physiologists have conventionally used to test patients with vestibular disorders,
except for the head-impulse test,4 which has gained in
popularity. Furthermore, in the design of exercises to
rehabilitate patients with vestibular disorders, strategies
should be applied to use head movements that contain
these sorts of frequencies, which mainly result from
transmitted heel-strike. Thus, in thinking about methods
to improve vestibular symptoms, one must identify the
functional goals for which the patient is aiming and so
determine the physiological demands that will be made
of the vestibular system to achieve them.
Vertigo
Pathophysiology of Vertigo
As distinct from ones perception of self-motion during
natural locomotion, vertigo is a distressing, illusory sensation of turning that is linked to impaired perception of a
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PHARMACOLOGICAL AND OPTICAL METHODS OF TREATMENT FOR VESTIBULAR DISORDERS
179
Figure 11.1 Summary of the ranges of (A) maximum velocity and (B) frequency of rotational head
perturbations that occur during walking or running in place. Distributions of data from 20 normal subjects are displayed as Tukey box graphs, which show selected percentiles of the data. All values
beyond the 10th and 90th percentiles are graphed individually as points. (From Leigh and Zee, 2006.1)
stationary environment. It is the mismatch between the

actual multisensory inputs and the expected pattern of
sensory stimulation with the head stationary that causes
vertigo.5 Although rotational vertigo connotes disturbance
of the semicircular canals or their central projections, sensations of body tilt or impulsion (e.g., lateropulsion, levitation) imply otolithic disturbance.
Vertigo should be differentiated from other causes of
dizziness, such as presyncopal faintness, loss of stable
balance, lightheadedness, and psychological disorders
(such as agoraphobia, acrophobia, and phobic vertigo
syndrome).5 Thus, accurate identification of symptoms is
essential before therapies are begun, although in practice,
diagnosis may be difficult.57 Furthermore, even when
patients do experience true vertigo, it may not be due to

organic disease. So, for example, certain individuals are
prone to experience vertigo, unsteadiness, or malaise with
motion, at height, and when assuming certain postures.5
Besides causing vertigo, sudden loss of tonic neural
input from one labyrinth or vestibular nerve causes nystagmus and unsteadiness.1,57 The nystagmus is typically
mixed horizontal-torsional with slow phases directed
toward the side of the lesion. The nystagmus is more
marked when the patient looks in the direction of the
quick phases, a phenomenon known as Alexanders law.1
Past-pointing to the side of the lesion reflects imbalance
of vestibulo-spinal reactions. Patients with rotational vertigo due to acute, peripheral vestibular lesions are often
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Section THREE MEDICAL AND SURGICAL MANAGEMENT
uncertain as to the direction of their vertiginous illusions.

This is because their vestibular sense indicates selfrotation in one direction, but their eye movements (slow
phases of vestibular nystagmus) cause visual image
movements that, when self-referred, connote self-rotation
to the opposite side. It is therefore worthwhile to evaluate
a patients vestibular sense alone by asking specifically
about the perceived direction of self-rotation with the
eyes closed, thus eliminating any possibly confounding
visual stimuli. Although most patients with acute peripheral lesions recover within a month or two, some are left
with recurrent vestibular symptoms, and others experience benign paroxysmal positional vertigo.
Neuropharmacology
of Vertigo and Nystagmus
Basic research has identified a number of neurotransmitters that appear to contribute to peripheral and central
vestibular mechanisms.812 The excitatory amino acid glutamate is the most likely neurotransmitter at the vestibular hair cellvestibular nerve afferent synapse, and also at
the synapse between the vestibular nerve and medial
vestibular nucleus (MVN). In both cases, it seems that
both kainate/AMPA (alpha-amino-3-hydroxy-5-methyl4-isoxazole-propionic acid) and NMDA (N-methyl-Daspartate) receptors are involved. There is also some
evidence that the inhibitory neurotransmitter gammaaminobutyric acid (GABA) has a role in the vestibular
labyrinth. The neurotransmitter of the vestibular efferents,
which project from brainstem to hair cells, is acetylcholine.
Both MVN and lateral vestibular nucleus (LVN)
neurons possess muscarinic and nicotinic acetylcholine
receptors. GABAA receptors on MVN type I neurons
may be the mechanisms of inhibition for projections from
MVN type II neurons that receive commissural projections, and cerebellar Purkinje cells of the cerebellar
flocculus. A general principle concerning the vestibular
projections is that inhibitory pathways to motoneurons
mediating the vertical VOR use GABA, whereas the
inhibitory pathways to motoneurons mediating the horizontal VOR utilize glycine.12 Histamine, norepinephrine,
dopamine, serotonin, and nitric oxide also appear to exert
effects on vestibular mechanisms. Thus, a large number
of neurotransmitters and neuromodulators have been
identified within vestibular and ocular motor structures,
but the functional role of most of these molecules remains
unclear.
One approach that has clarified the functional significance of these findings has been to study the behavioral
effects of pharmacological inactivation by microinjection
of agents that inactivate certain neurotransmitters. Thus,
ocular motor deficits have been induced by microinjection of the weak GABA antagonist bicuculline and the
strong GABA agonist muscimol into the vestibular and
adjacent prepositus nuclei of monkeys.13,14 Depending
on the site of injection, either agent could induced gazeevoked nystagmus (leaky neural integrator) with centripetal slow-phase drifts or centrifugal, increasing
velocity waveforms (unstable neural integrator); sometimes, nystagmus implying a vestibular imbalance was
also produced. Thus, the effects of these injections may
represent varying combinations of vestibular imbalance
and gaze-holding failure. These findings indicated that
GABA is not just an important neurotransmitter for the
vertical and horizontal VOR but is also involved in the
gaze-holding mechanism, which depends heavily on the
medial vestibular and prepositus nuclei. This finding led
to clinical trials of GABAergic agents as treatment for
forms of acquired nystagmus (described later).
There is also evidence that control of the dynamic
property of the VOR, referred to as velocity storage
(enhancement of vestibular time constant from that of the
cupula to that of the VOR) by the nodulus and uvula, is
achieved by inhibitory pathways that use GABA.15
Experimental lesions of the nodulus and uvula cause prolongation of velocity storage and periodic alternating
nystagmus (PAN).16 The GABAB agonist baclofen is able
to abolish PAN due to experimental or clinical lesions.17
Clinical evidence has also supported a role for nicotinic acetylcholinergic mechanisms in vertical eye movements that are probably mediated by the vestibular
system. First, it has been shown that nicotine can produce
upbeat nystagmus in normal subjects in darkness.18
Second, intravenous physostigmine may increase the
intensity of downbeat nystagmus.19 Third, intravenous
scopolamine suppresses downbeat nystagmus in some
patients.20
Treatment of Vertigo
The general goals in treatment are to eliminate vertigo
(illusion of motion) and accompanying neurovegetative
symptoms (nausea, vomiting, anxiety) and to promote
(or, at least, not hinder) the normal process of vestibular
compensation. In certain cases, such as vertigo due to
migraine, it may be possible to treat the underlying cause.
Usually, however, the treatment is symptomatic.
In acute vertigo due to a peripheral vestibular lesion,
functional recovery is the rule in the ensuing weeks.
There is a consensus that drugs that have a sedative
effect on the vestibular system should be used for only
the first 24 hours.5,7,21 Some drugs commonly used for
treatment of vertigo, nausea, and vomiting are summarized in Table 11-1 and are discussed more fully in
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181
Table 11-1 SOME COMMONLY USED VESTIBULAR SEDATIVES

Drug
Class
Dosage
Comments
Precautions
Dimenhydrinate
(Dramamine)
Antihistamine
Increases cAMP
Oral: 50 mg every
46 hr
IM: 50 mg; maximum of 200 mg in
24 hr
Mild sedative
Causes dryness
Moderate antiemetic
Asthma, glaucoma,
prostrate enlargement
Promethazine
(Phenergan)
Antihistamine
Anticholinergic
Phenothiazine
Oral: 25 mg, every

6 hr
Supp: 50 mg, every
12 hr
24 hr
More sedative
Moderate antiemetic
Asthma
Glaucoma
Prostate enlargement
Epilepsy
Meclizine
(Antivert, Bonine)
Antihistamine
Anticholinergic
Oral: 25 mg or 50
mg every day or
twice daily; maximum of 150 mg in
24 hr
Peak effects 8 hr
after ingestion
Less sedative
Asthma
Glaucoma
Prochlorperazine
(Compazine)
Antihistamine
Anticholinergic
Phenothiazine
Oral: 510 mg every

6 hr
Supp: 25 mg
every12 hr
IM: 510 mg every
6 hr; maximum of
60 mg in 24 hr
Sedative and
antiemetic
Can cause
extrapyramidal
reactions
Can cause liver disease when used in

combination with
CNS depressants,
propranolol,
phenytoin, anticoagulants, levodopa,
diuretics
Scopolamine
(Transderm Scop)
Anticholinergic (nonselective muscarinic)
Transdermal patch,
every 3 days; peak
effect 48 hr after
application
Less sedative
More antiemetic
Suitable for motion
sickness
Can cause confusion, mydriasis,
dependency
Asthma
Glaucoma
Ondansetron
(Zofran)
Serotonin 5hydroxytryptamine3
(5-HT3) receptor
antagonist
Oral: 48 mg every
8 hr
IV: 4 mg
Antiemetic; developed for patients

receiving cancer
chemotherapy
May be effective for
nausea due to CNS
disease
Headache
Constipation
Lorazepam (Ativan)
Benzodiazepine
0.5 mg every 12 hr
24 hr
GABA modulator
May be habitforming
Glaucoma
Additive with sedative drugs, scopolamine
CNS central nervous system; GABA, gamma-aminobutyric acid; IM, intramuscular; IV, intravenous; supp suppository.
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reviews.5,9,21 Most agents probably affect more than one

neurotransmitter system, and in intractable cases, a combination of different types of agent may be more effective
than one alone. Evidence now suggests that methylprednisolone, but not the antiviral agent valacyclovir, may
hasten recovery22; further studies are probably needed to
determine the long-term outcome.23
After the first 24 hours, drugs should be used sparingly and patients should be encouraged to get out of bed
and increase their activities, because there is evidence
that failure to do so limits recovery.21 During this period,
a course of specific vestibular exercises may be indicated
(see Chapter 14). Patients in whom enduring vestibular
symptoms develop may have an underlying central nervous system disorder, typically of the cerebellum,24 and
imaging studies are indicated. Other patients who complain of persistent symptoms may have either a phobic
disorder5 or the potential for secondary gain as a consequence of their injury.
Treatment of recurrent vertigo depends on the nature
of the underlying disorder. For example, vertigo due to
migraine (including migraine without a headache) can
usually be successfully managed medically (see Chapter
12). Recurrent vertigo due to a perilymphatic fistula or
superior canal dehiscence syndrome may recover spontaneously, but some patients require surgical repair (see
Chapter 14).
Vertigo due to Mnires disease is often difficult
to manage, although a low-salt diet and diuretics help
some patients with the disorder.25 Because the vestibular imbalance may be in a continuous state of flux, longterm use of vestibular sedatives such as meclizine is
justified in some affected patients. Treatment with
intratympanic injection of gentamicin can be beneficial
when vertigo persists, especially when it arises from a
deaf ear.25,26
Central neurological conditions, such as multiple
sclerosis, vertebrobasilar ischemia, and posterior fossa
mass lesions, may cause severe, recurrent vertigo. When
treatment of the underlying condition does not produce
improvement, vestibular sedatives are justified. Sometimes a combination of agents, such an anticholinergic
(e.g., scopolamine) and an antidopaminergic agent (e.g.,
prochlorperazine) will bring more relief than a single
agent. Ondansetron, a serotonin 5-hydroxytrytamine3 (5HT3) antagonist, helps some patients with vertigo due to
brainstem stroke.27
Benign paroxysmal positional vertigo is effectively
treated in most cases by specific vestibular exercises or
maneuvers (see Chapter 17) 21; drugs are not indicated in
this condition.
Oscillopsia
Pathogenesis
Oscillopsia brought on or accentuated by head movement
is usually of vestibular origin and reflects an inappropriate VOR gain or phase.1,2,7,28 Vision becomes blurred so
that, for example, fine print on grocery items can be read
only if the patient stands still in the store aisle.
Oscillopsia is usually caused by excessive motion of
images of stationary objects upon the retina (Box 11-1).
Excessive retinal slip not only causes oscillopsia but also
impairs vision. Oscillopsia with head movements may
also occur as result of weakness of an extraocular muscle
(e.g., abducens nerve palsy). Oscillopsia due to nystag-
Box 11-1
ETIOLOGY OF OSCILLOPSIA1
Oscillopsia with Head Movements: Abnormal
Vestibulo-Ocular Reflex
Peripheral vestibular hypofunction:
Aminoglycoside toxicity
Surgical section of VIIIth cranial nerve
Congenital ear anomalies
Hereditary vestibular areflexia
Cisplatin therapy
Idiopathic
Central vestibular dysfunction:
Decreased vestibulo-ocular reflex (VOR) gain
Increased VOR gain
Abnormal VOR phase
Oscillopsia due to Nystagmus
Acquired nystagmus (especially pendular, upbeat,
downbeat, see-saw, dissociated nystagmus)
Saccadic oscillations (psychogenic
flutter/voluntary nystagmus, ocular flutter,
microsaccadic flutter and opsoclonus)
Superior oblique myokymia (monocular
oscillopsia)
Congenital nystagmus (uncommon under
natural illumination)
Central Oscillopsia
With cerebral disorders: seizures, occipital lobe
infarction
From Leigh and Zee, 2006.1
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mus and other ocular oscillations occurs when the head is

stationary.
An abnormal VOR may lead to oscillopsia during
head movements in three possible ways: abnormal gain,
abnormal phase shift between eye and head rotations, and
a directional mismatch between the vectors of the head
rotation and eye rotation. Disease of either the vestibular
periphery or its central connections may be the cause (see
Box 11-1).
Typically, oscillopsia is worse during locomotion,
but it may be noticed during chewing food and, in the
severest cases, may occur from transmitted cardiac pulsation.2 In addition, visual acuity declines during head
movements, and the clinician can easily demonstrate this
behavior at the bedside by testing visual acuity first with
the patients head stationary and then while rotating it
from side to side at 1 to 2 cycles/second.1
Oscillopsia may also occur with disorders of the
central nervous system that change the gain or phase of
the VOR. Thus, disease of the vestibulocerebellum may
cause vestibular hyper-responsiveness, particularly in
the vertical plane. This occurs in patients with the ArnoldChiari malformation1 and, occasionally, patients with
cerebellar disorders are reported with increased gain of
both the horizontal and vertical VORs.29 In some patients
with vestibulocerebellar dysfunction, the gain of the VOR
is normal but the phase relationship between head and eye
movements is abnormal, causing retinal image slip.30
Lesions of the medial longitudinal fasciculus (internuclear ophthalmoplegia in multiple sclerosis) may cause a
low gain of the vertical VOR and produce oscillopsia with
vertical head movements.31
Treatment of Oscillopsia
With time, compensation takes place in patients with
oscillopsia due to vestibular loss. Compensation occurs
by means of a variety of factors, including potentiation of
the cervico-ocular reflex, pre-programming of compensatory eye movements, and perceptual changes.2,32,33
Thus, drugs have little to offer. Exercises (see Chapter
13) and encouragement of the patient to resume activities
such as walking are key. Rarely, oscillopsia due to a
hyperactive VOR can be treated pharmacologically.29
Paradoxically, patients who lack a VOR can read headfixed visual display during locomotion better than normal
subjects can.34 The reason is that clear vision of a headfixed display requires that vestibular eye movements be
suppressed or canceled. Because such patients have little
or no VOR, then it is easy to suppress vestibular eye
movements. The practical application of this findingin
183
the futuremight be development of head-fixed video

displays of images obtained with cameras that can compensate for head perturbations.
Newer alternative biomedical approaches to loss
over vestibular function include tactile sensory substitution methods, in which an angular accelerometer provides tactile stimulation to the patients tongue.35 With
time, the patient learns to interpret mechanically sensory
information in terms of tactile stimuli and can negotiate
the environment better. However, it remains to be determined how well elderly patients can learn to perform this
sensory substitution.
Nystagmus and its

Visual Consequences
Pathogenesis
As indicated previously, acquired nystagmus commonly
causes impaired vision and oscillopsia (illusory movement of the environment). These symptoms, which are
due to drift of images of stationary objects upon the retina, interfere with reading and watching television, and the
oscillopsia is often distressing to the patient. The relationship between retinal image velocity and visual acuity
is a direct one: For higher spatial frequencies (which correspond to Snellen optotypes), image motion in excess of
about 5 deg/sec impairs vision.36,37 On the other hand, the
relationship between retinal image velocity and the development of oscillopsia is less consistent; the magnitude of
oscillopsia is usually less than the magnitude of nystagmus. For example, in patients with downbeat nystagmus,
oscillopsia is, on average, about one third the amplitude
of the nystagmus.38 This latter finding suggests that the
brain compensates for the excessive retinal image motion
and so partly maintains visual constancy, although the
mechanism is debated. Nevertheless, if retinal image
drift, in patients with nystagmus, can be reduced to less
than about 5 deg/sec, oscillopsia is usually abolished and
vision is improved.39
Treatments
Drugs
Some of the various drugs reported to suppress nystagmus are summarized in Box 11-2. Gabapentin has been
shown, in some patients, to suppress or abolish acquired
pendular nystagmus that is associated with multiple sclerosis or follows brainstem stroke (oculopalatal tremor
syndrome).40,41 Acquired pendular nystagmus produces
perhaps the most troubling visual disturbances of all
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Box 11-2
TREATMENTS FOR NYSTAGMUS

AND ITS VISUAL
CONSEQUENCES1,17,41
Drugs
Gabapentin
Memantine
Baclofen
4-aminopyridine and 3,4-diaminopyridine
Acetazolamide
Clonazepam
Valproate
Trihexyphenidyl and benztropin
Scopolamine
Isoniazid
Carbamazepine
Barbiturates
Alcohol
Optical Devices
Base-out prisms
Spectacle lens-contact lens combination
(for retinal image stabilization)
Electro-optical devices for retinal image
stabilization
Invasive Procedures
Operative treatment of Arnold-Chiari malformation
Botulinum toxin
forms of nystagmus, and most patients who take

gabapentin experience some relief (Fig. 11.2). However,
not all such patients respond, and worsening of ataxia
may be a troublesome side effect.
Memantine, an uncompetitive N-methyl-D-aspartate (NMDA) antagonist, has also been reported to
suppress acquired pendular nystagmus in patients with
multiple sclerosis and is generally well tolerated.42 In
2004, memantine received FDA approval for treatment of memory failure in Alzheimers disease.
Physicians considering using memantine as offlabel treatment for acquired pendular nystagmus should
be aware that the required dose is up to 40 mg per day,
which is twice the recommended dose for treatment of
Alzheimers disease.
Baclofen is less effective in treating acquired pendular nystagmus than gabapentin but, as previously discussed, is usually effective in treating PAN.17 Neither
baclofen nor gabapentin is reliable for treatment of
Figure 11.2 Example of the effects of gabapentin on the

horizontal component of pendular nystagmus in a 41-year-old
woman with multiple sclerosis. Visual acuity measurements of
the recorded eye are shown in each panel. After the initial session (top panel), the patient ingested 300 mg of gabapentin,
which reduced her oscillations and improved her vision (middle
panel). The effect was sustained 2 months later (bottom panel),
when she was taking a dosage of 300 mg three times/day.
downbeat nystagmus.17,40 Other GABAergic agents,

especially clonazepam, have been reported to be useful in
the treatment of downbeat nystagmus.17,43
Anticholinergic agents may be effective in some
patients with pendular or downbeat nystagmus. In a
double-blind study, Barton and associates20 administered
scopolamine, benztropine, and glycopyrrolate (a quaternary agent devoid of central nervous system activity)
intravenously. A single dose of scopolamine effectively
reduced nystagmus and improved vision in all 5 patients
with pendular nystagmus, benztropine was less effective,
and glycopyrrolate had no significant effect. However, in
a randomized, double-blind crossover trial of oral trihexyphenidyl and tridihexethyl chloride (a quaternary
anticholinergic that does not cross the blood-brain
barrier), only 1 of 10 patients showed a decrease in nys-
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tagmus and an improvement of visual acuity with trihexyphenidyl.44 Anticholinergic side effects included dry
mouth, constipation, disturbed sleep, and tiredness.
Furthermore, transdermal scopolamine is not reliable as
treatment for acquired nystagmus and may actually make
it worse in some patients.45
Two potassium channelblocking agents, 4aminopyridine and 3,4-diaminopyridine, have both been
reported to suppress downbeat nystagmus in some
patients.46,47 Both agents have been used in the past for
symptomatic treatment in multiple sclerosis. Of the two
agents, 3,4-diaminopyridine is better tolerated and has a
longer duration of action, although epileptic seizures and
paresthesias may occur with its use. These agents may
also be effective treatment of the syndrome of episodic
ataxia type 248 although acetazolamide remains the mainstay of therapy.17
185
effect of retinal image stabilization produced by the spectacle lens. With such a system it is possible to achieve up
to about 90% stabilization of images upon the retina.
There are several limitations to the system, however. One
is that it disables all eye movements (including the VOR
and vergence), so that it is useful only while the patient is
stationary and views monocularly. Another is that some
patients with ataxia or tremor (such as those with multiple
sclerosis) have difficulty inserting the contact lens.
A newer hi-tech approach is the use of an electrooptical device that measures ocular oscillations and
moves prism devices to negate the effects of the nystagmus.53 This approach is best suited for pendular nystagmus, which can be electronically distinguished from
normal eye movements, such as voluntary saccades that
are required for clear vision. Figure 11.3 summarizes the
Optical Devices
A number of optical devices have been suggested for
treatment of nystagmus. One approach that often benefits
patients whose nystagmus dampens while they are viewing a near target is convergence prisms. An arrangement
that is often effective is 7.00 diopter base-out prisms with
1.00 diopter spheres added to compensate for accommodation.17,49 The spherical correction may not be needed in presbyopic individuals. Especially in some patients
with congenital nystagmus, the improvement of visual
acuity through nystagmus suppression due to wearing of
base-out prisms may be sufficient to qualify them for a
driving license. Some patients with acquired nystagmus
also benefit.50 Occasionally, in patients in whose nystagmus is worse during near viewing, base-in prisms help.
Theoretically, it should be possible to use prisms to
help patients whose nystagmus is quieter when the eyes
are moved into a particular position in the orbitthe
null region. Thus, in patients with congenital nystagmus, there is usually some horizontal eye position in
which nystagmus is minimized, and in patients with
downbeat nystagmus, the eyes may be quieter in upgaze.
In practice, patients use head turns to bring their eyes to
the quietest position, and only rarely are prisms that produce a conjugate shift helpful.
Another approach has been the development of an
optical system to stabilize images upon the retina during
eye movements.39,51,52 This system consists of a high-plus
spectacle lens worn in combination with a high-minus
contact lens. Stabilization can be achieved if the power of
the spectacle lens focuses the primary image close to the
center of rotation of the eye. A contact lens is then
required to extend the focus back onto the retina. Because
the contact lens moves with the eye, it does not negate the
Figure 11.3 Demonstration of how a three-lens imageshifting device can null the visual effects of ocular oscillations.
Starting with the eyes and optics in a neutral position (a), light
from a distant target is brought to the fovea of the retina. If the
eye is rotated down (b), the image is displaced from the fovea.
However, if the central lens is moved downward by the appropriate amount (c), the image is once again brought onto the
fovea. (From Smith et al, 2004.54)
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image-shifting optics that are being used to develop a

portable, battery-driven device.54
Surgery
A range of operative procedures have been developed for
treatment of congenital nystagmus55 and have been proposed as treatment for acquired forms of nystagmus; formal evaluation is needed. Neurosurgery does have a clear
role in the therapy of the Arnold-Chiari syndrome; suboccipital decompression is reported to improve downbeat
nystagmus and to prevent progression of other neurological deficits.56 Injection of botulinum toxin either into
selected extraocular muscles or into the retrobulbar space
temporarily abolishes or suppresses nystagmus, but the
side effects ptosis and diplopia limit the therapeutic
value, except in selected patients.17,57,58
Summary
Disruption of the peripheral or central vestibular system
often results in vertigo, oscillopsia, and nystagmus.
Acute vertigo from peripheral vestibular lesions usually
recovers spontaneously and vestibular suppressant medications, although appropriate during the first 24 hours,
should be used sparingly after that initial period. The use
of medications in recurrent vertigo depends on the specific disorder affecting the vestibular system. Oscillopsia
due to loss of the vestibular sense often improves spontaneously, and medications do not aid the recovery; new
sensory substitution methods may provide a new therapeutic strategy. Oscillopsia due to nystagmus may be
helped if gabapentin, memantine, baclofen, clonazepam,
or acetazolamide can reduce the ocular oscillations.
Several different optical devices have been developed as
treatment for the visual consequences of nystagmus, and
electro-optical devices hold promise in the future. No
medications or optical devices can be applied uniformly
to all patients; careful diagnosis of the problem must be
made before any of these treatments is attempted.
Acknowledgments
The authors work described in this chapter is supported
by NIH grant EY06717, the Department of Veterans
Affairs, and the Evenor Armington Fund.
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23. Johnson RT: Vestibular neuritis, or driving dizzily through
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34. Das VE, Thomas CW, Zivotofsky AZ, Leigh RJ:
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47. Kalla R, Glasauer S, Schautzer F, et al: 4-Aminopyridine
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52. Yaniglos SS, Leigh RJ: Refinement of an optical device
that stabilizes vision in patients with nystagmus. Optom
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53. Stahl JS, Lehmkuhle M, Wu K, et al: Prospects for treating acquired pendular nystagmus with servo-controlled
optics. Invest Ophthalmol Vis Sci 2000;41:10841090.
54. Smith RM, Oommen BS, Stahl JS: Image-shifting optics
for a nystagmus treatment device. J Rehab Research
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55. Hertle RW, DellOsso LF, FitGibbon EJ, et al: Horizontal
rectus tenotomy in patients with congenital nystagmus.
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56. Pedersen RA, Troost BT, Abel LA, Zorub D: Intermittent
downbeat nystagmus and oscillopsia reversed by suboccipital craniectomy. Neurology 1980;30:12391242.
57. Leigh RJ, Tomsak RL, Grant MP, et al: Effectiveness of
botulinum toxin administered to abolish acquired nystagmus. Ann Neurol 1992;32:633642.
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12
Migraine, Mnires
Disease, and Motion
Sensitivity
Migraine is a common cause of episodic vertigo and dysequilibrium in children and adults. In practices treating
patients with headaches, 27 to 33 percent of patients out
of a population of 700 patients with migraine report
episodic vertigo.1,2 Thirty-six percent of these patients
experience vertigo during their headache-free period; the
others experience vertigo either just before or during a
headache. The occurrence of vertigo during the headache
period is much higher in patients with migraine headaches
with aura (classic migraine) as opposed to migraine without aura (common migraine) (Kuritzky et al, 1981).3 In
this chapter, the incidence of migraine, current classification and criteria used for diagnosing migraine, neurootological syndromes, and genetics related to migraine,
and the management of migraine will be described.
Incidence of Migraine
Migraine is an extremely prevalent disorder. An epidemiologic study involving over 20,000 individuals between
12 and 80 years of age found that 17.6 percent of all adult
females, 5.7 percent of all adult males, and 4 percent of all
children had one or more migraine headaches per year.4
This study used the diagnostic criteria recommended by
the International Headache Society5 (IHS), which will be
described later. Of those individuals with migraine,
approximately 18 percent experienced one or more
attacks per month. In both males and females, the preva188
lence of migraine was highest between the ages of 35

and 45 years. The type and severity of migraine often
varies within the same individual. Migraine with or without aura frequently begins between 12 and 30 years of
age. After the age of 50, migraine is much less common,
and it frequently presents as migraine aura without
headache.6
Symptoms of Migraine
Case Example
Patient is a 50 year old with dizziness. Several months
ago while standing looking out the window developed
severe vertigo, N/V and fell backwards. This was followed by a mild headache. Vertigo lasted 10 minutes,
H/A lasted for 1 day, felt washed out for days. Since then
he has had 5 more spells of vertigo, photophobia, phonophobia followed by headache. Feels better if takes a
short nap when spell occurs. He also notes increased
motion sensitivity while wife drives car, while he played
games on his computer or while he is driving a motorboat. In addition, he now has daily dizziness consisting of
light-headedness and sense that head is bobbing. There is
a sense of helplessness and increased stress now because
of overwhelming amount of work and he is unable to
return to work as a mechanic. He had a normal neurologic and otologic exam. He already had an audiogram,
ENG, and MRI of head, all off which were normal. He
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Chapter 12
MIGRAINE, MNIRES DISEASE, AND MOTION SENSITIVITY
Motion Sickness/
Vestibular
Hypersensitivity
Vestibular
Migraine
Anxiety/
Panic
Figure 12.1 Causes of symptoms in patients with migraine.
was told to come in next time he had a spell. When he

came in during a spell, he had a sustained horizontal jerk
nystagmus but the VOR gain was normal based on head
thrust.
Individuals with vestibular migraine often have several overlapping causes for their symptoms (Fig. 12.1).
This case example illustrates the overlapping symptoms
often found in patients with vestibular migraine. He started with vertigo with a migraine headacheconsistent
vestibular migraine. These attacks of vertigo are migraine
aura and can occur with or without headache. In addition,
he had increased motion sensitivity. This became a
chronic problem whenever there was a visual-vestibular
mismatch (watching computer games and as a passenger
in a moving vehicle). Finally, he developed anxiety and
depression. The three causes of dizziness in Figure 12.1
can occur separately, but frequently they occur together
in individuals with vestibular migraine.
189
Table 12-1 SYMPTOMS DURING

VESTIBULAR MIGRAINE
IN 38 PATIENTS
Symptom
No. of Cases (%)
Dizzy Symptoms
Vertigo:
21 (55)
Static
5 (13)
Dynamic
12 (32)
Non-vertigo:
35 (92)
Imbalance
30 (79)
Lightheadedness
26 (68)
Gait disorder
23 (61)
Non-Dizzy Symptoms
Tinnitus
10
Bilateral paresthesia
Blurred vision
Bilateral weakness
Scintillating scotoma
Bilateral paresthesia
Diplopia
Chronic Symptoms
Motion sickness/vestibular
hypersensitivity
78%
Generalized anxiety
disorder (GAD)
57%
GAD panic attacks
47%
Symptoms during
Vestibular Migraine Aura
Classification and Criteria

for Diagnosis
A questionnaire was given to 38 consecutive patients

with vestibular migraine to determine the type of symptoms and incidence (Table 12-1). The symptoms were
divided into different types of dizziness, non-dizzy symptoms, and chronic symptoms consisting of increased
motion sensitivity and anxiety disorders. The majority of
patients had dizziness during their aura that primarily
occurred when they moved through space (dynamic).
Some patients had spontaneous vertigo (static) that
occurred while seated or lying down (positional vertigo).
Migraine
Migraine disorders are usually subdivided into several
types. To help standardize terminology and diagnostic
criteria, a classification system for headaches was developed by the IHS.5 This classification was based on
2 years of discussion among 100 individuals with representatives from seven countries. The classification and
criteria for headaches pertinent to neuro-otological disorders is summarized in Box 121. The general features of
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Box 12-1
INTERNATIONAL HEADACHE SOCIETY CLASSIFICATION OF HEADACHE

1.1 Migraine without aura (replaces common
migraine):
A. At least 5 attacks fulfilling criteria BD.
B. Headache attacks lasting 472 hours untreated. In children 15 years, attack may last
248 hours.
C. Headache has at least two of the following
characteristics:
1. Unilateral location.
2. Pulsating quality.
3. Moderate or severe intensity that inhibits
or prohibits daily activities.
4. Aggravation by walking stairs or similar
routine physical activity.
D. During headache, at least one of the following:
1. Nausea and/or vomiting.
2. Photophobia and phonophobia.
E. At least one of the following:
1. History and physical examinations do not
suggest another disorder.
2. History and physical examinations do
suggest such disorder, but it is ruled out
by appropriate investigations (e.g., magnetic resonance imaging or computed
tomography of the head).
1.2 Migraine with aura (replaces classic migraine):
A. At least 2 attacks fulfilling B:
B. At least 3 of the following:
1. One or more reversible aura symptoms
indicating focal central nervous system
dysfunction.
2. At least 1 aura symptom develops gradually over more than 4 minutes, or 2 or
more symptoms occur in succession.
3. No aura symptom lasts more than 60 minutes unless more than 1 aura symptom is
present.
4. Headache occurs either before, during, or
up to 60 minutes after aura is completed.
C. Same as E above in criteria 1.1.
1.2.2 Migraine with prolonged aura (replaces

complicated migraine):
Fulfills criteria for 1.2, but at least one symptom lasts more than 60 minutes and less than
7 days.
1.2.4 Basilar migraine (replaces basilar artery
migraine):
Fulfills criteria for 1.2, but 2 or more aura
symptoms of the following types:
Vertigo, tinnitus, decreased hearing, ataxia,
visual symptoms in both hemifields of both
eyes, dysarthria, double vision, bilateral paresthesia, bilateral paresis, decreased level of consciousness.
1.2.5 Migraine aura without headache (replaces
migraine equivalent or acephalgic migraine):
Fulfills criteria for 1.2 but no headache.
1.5 Childhood periodic syndromes that
may be precursors to or associated with
migraine.
1.5.1 Benign paroxysmal vertigo of childhood:
A. Brief, sporadic episodes of disequilibrium, anxiety, and often nystagmus or
vomiting.
B. Normal neurological findings.
C. Normal electroencephalographic findings.
1.6.2 Migrainous infarction (replaces complicated
migraine):
A. Patient has previously fulfilled criteria for
1.2.
B. The present attack is typical of previous attacks, but neurological deficits
are not completely reversible within
7 days and/or neuroimaging demonstrates ischemic infarction in relevant
area.
C. Other causes of infarction are ruled out by
appropriate investigations.
Adapted from the Headache Classification Committee of the International Headache Society, 1988.5
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Chapter 12
Box 12-2
NEURO-OTOLOGICAL
DISORDERS
Neuro-otological disorders due to migraine:
Paroxysmal torticollis of infancy
Benign paroxysmal vertigo of childhood
Basilar migraine
Benign recurrent vertigo of adults
Migrainous infarct resulting in vertigo
Neuro-otological disorders associated with
migraine:
Motion sickness
Mnires disease
Benign paroxysmal positional vertigo
the relevant types of migraine are discussed briefly; the

features of specific neuro-otological disorders are discussed in greater detail (Box 12-2).
Migraine without Aura

Migraine without aura, which replaces common migraine, consists of periodic headaches that are usually
throbbing and unilateral, exacerbated by activity, and
associated with nausea, photophobia, and phonophobia.
These headaches are frequently referred to as sick
headaches (because of the nausea) or sinus headaches
(because of their location). Patients usually prefer to lie
down in a quiet, dark room during the headache and feel
better after sleep. A family history for migraine can usually be obtained in the immediate family.
Migraine with Aura

Migraine with aura, which replaces classic migraine, is
associated with transient neurological symptoms consisting of sensory, motor, or cognitive disorders. These neurological disorders usually precede the headache, but may
develop during or following the headache. The neurological disorder usually lasts 5 to 20 minutes, but can last as
long as 1 hour. There are three relevant subtypes. The first
is migraine with prolonged aura, in which neurological
symptoms can last up to 7 days. The second is called basilar migraine, which replaces basilar artery migraine,
and presents with symptoms in the distribution of the
basilar artery including vertigo, tinnitus, decreased hearing, and ataxia. The third is called migraine aura without
headache, which replaces migraine-equivalent spells or
191
acephalgic migraine. This presents with the neurological disorders found in migraine with aura except there is
no headache.
Basilar Migraine
Basilar migraine (IHS classification 1.2.4) was first
described by Bickerstaff,7 and has been subsequently
reported by a number of individuals.8,9 This disorder consists of two or more neurological problems (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual
symptoms in both hemifields of both eyes, diplopia, bilateral paresthesia or paresis, decreased level of consciousness) followed by a throbbing headache. The majority of
these occurs before 20 years of age, but can occur up until
age 60. Vertigo typically lasts between 5 minutes and 1
hour. In the majority of cases, audiograms are normal.
Many of these patients eventually develop more typical
migraine headaches with aura, and there is frequently a
positive family history for migraine. Transient ischemic
attacks (TIAs) need to be considered before basilar
migraine is diagnosed. TIAs within the vertebral-basilar
circulatory system (vertebrobasilar insufficiency) may
cause the same symptoms as basilar migraine, although
TIAs usually last less than a few minutes.10
Benign Recurrent Vertigo in Adults

This disorder was not formally classified by the IHS.
Based on the symptoms, it may either be referred to as
basilar migraine (1.2.4), or migraine aura without
headache (1.2.5). This was first described by Slater,11 and
is the most common neurotological syndrome caused by
migraine. This disorder consists of spells of vertigo,
occasionally with tinnitus but without hearing loss.12,13 In
some individuals, jerk nystagmus may occur during the
spell (see Case Study 1 at end of chapter). Vertigo typically lasts between minutes and hours; the majority last
less than 1 hour, and may occur with or without
headache. The spells usually occur between the ages of
20 and 60. Peripheral and central vestibular deficits diagnosed by caloric and spontaneous eye movements during
electronystagmography have been reported to occur in 5
to 80 percent of individuals with migraine in their
headache-free period.1416 This variation in abnormality
may be due to a difference in criteria used for diagnosing
vestibular deficits.15 In the majority of cases, audiograms
and caloric studies are normal. In this authors opinion,
concomitant Mnires disease was not always excluded
in all cases. Therefore, it is not clear that permanent
vestibular deficits can occur in migraine disease. Some
individuals develop exercise-induced spells from a variety of physical activities including sit-ups, heavy lifting,
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intercourse, and strenuous aerobic exercises17 (see Case

Study 2). One needs to rule out Mnires disease, benign
paroxysmal positional vertigo, TIAs, vestibular epilepsy,
and perilymphatic fistula before making a diagnosis of
migraine-induced vertigo.
acterize motion sickness. Motion sickness is partially due

to a visual-vestibular conflict or mismatch.28 Twenty-six
to sixty percent of patients with migraine have a history
of severe motion sickness compared to 8 to 24 percent of
the normal population.1,3,29 The cause for this relation is
not clear.
Childhood Periodic Syndromes

There are two neuro-otological disorders in children due
to migraine. (1) Benign paroxysmal vertigo of childhood
(IHS classification 1.5.1), which was first described by
Basser.18 This disorder consists of spells of vertigo and
dysequilibrium without hearing loss or tinnitus.1923 The
majority occurs between 1 and 4 years of age, but can
occur anytime during the first decade. Vertigo and dysequilibrium typically last for minutes, but can last up to
several hours. Patients may experience visual disturbance, flushing, nausea, and vomiting. In the majority of
cases, audiograms and caloric tests are normal. These
patients also have normal physical examinations and normal EEGs. Initially, headache is usually not a major feature of these spells. Many of these patients eventually
develop migraine with aura and there is frequently a
positive family history for migraine. The differential
diagnosis includes Mnires disease, vestibular epilepsy,
perilymphatic fistula, posterior fossa tumors, and psychogenic disorders. (2) Paroxysmal torticollis of infancy
was not specifically classified by the IHS, but may fit into
the same classification as benign paroxysmal vertigo of
childhood; these disorders frequently occur in the same
patient.22 This disorder was first described by Snyder,24
and has now been reported by a number of individuals.2527 Paroxysmal torticollis of infancy consists of
spells of head tilt and rotation without vertigo, hearing
loss, or tinnitus. These usually occur in the first 5 years
of life and typically last between 10 minutes and several
days. They may be associated with nausea, vomiting, pallor, agitation, and ataxia. In the majority of cases, audiograms and caloric tests are normal between the spells.
This syndrome is believed to be due to migraine auras
without headache. Some individuals complain of
headache when they become older. The differential diagnosis includes posterior fossa tumors and torticollis.
Disorders Associated with Migraine

Motion Sickness
Episodic dizziness, tiredness, pallor, diaphoresis, salivation, nausea, and occasional vomiting induced by passive
locomotion (e.g., riding in a car) or motion of the visual
surround while standing still (e.g., viewing a rotating
optokinetic stimulus or large screen motion picture) char-
Anxiety Disorders (DSM IV)

Anxiety disorders are diagnosed using the DSM IV
criteria.
Generalized Anxiety Disorder
Generalized and persistent unrealistic worry with motor
tension, autonomic hyperactivity, apprehensive expectation and vigilance for over 6 months.
Panic Attack
Discrete spells of intense fear or discomfort and 4
symptoms that develop abruptly and peak in 10 minutes.
Dizziness, unsteady feelings or faintness

Nausea or abdominal distress
Shortness of breath (or smothering sensations)
Palpitations or tachycardia
Trembling or shaking
Sweating
Choking
Depersonalization or derealization
Numbness or paresthesias
Flushes (hot flashes) or chills
Chest pain or discomfort
Fear of dying
Fear of going crazy or doing something uncontrolled
Pathophysiology of Migraine
There are four phases in migraine, which includes the
prodrome phase, aura, headache, and postdrome phase.
Each of these phases includes symptoms that are induced
by different neurotransmitters.
Dopamine D2 Receptor
There is a clinical overlap between dopamine stimulation
and migraine.30 As dopamine increases, yawning begins
to occur. With further dopamine increase, more symptoms occur that includes mood changes, nausea, gastrokinetic changes, hypotension, and vomiting. These are
similar symptoms as the prodrome phase in patients
with migraine. Patients with migraine have D2 receptor
hypersensitivity based on apomorphine response. During
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Chapter 12
migraine D2 is activated. The Ncol C allele in the DRD2

gene is higher than the Ncol T allele in patients with
migraine, generalized anxiety and panic disorders.31,32
Perhaps this common allele in individuals with migraine
and anxiety is the reason why these two entities frequently co-exist in the same individual. Dopamine stimulation may also be the cause of GI symptoms in the
headache phase and the postdrome phase, and the hung
over or washed out feeling in the postdrome phase.
Calcium Channel
Receptor (CACNA1A)
The discovery of the genetic cause of a migraine aura
phase (hemiplegic migraine) has been one of the most
promising breakthroughs in understanding and potentially treating this disorder. This aura causes transient hemiparalysis. Familial hemiplegic migraine is an autosomal
dominant disorder. In 50 percent of all families, this disorder is mapped to chromosome 19p13 in the gene called
the CACNA1A. This gene codes for a subunit of the P/Q
voltage-gated neuronal calcium channel.33 This same
chromosome locus may be involved also in other forms
of migraine aura.34 Defects involving this gene are
involved with other autosomal dominant disorders that
have neurotologic symptoms (Table 12-2). The symptoms of these disorders overlap extensively.35 Only 50
percent of families with familial hemiplegic migraine
map to chromosome 19p13. Other families with this disorder map to chromosome 1 (1q21-q21).51 Other chromosome defects are likely to be found in the future.
Noradrenergic System
Altered sensory processing mediated by serotoninergic
midbrain. Raphe nucleus and noradrenergic locus
ceruleus may be the cause of increased sensitivity to sensory stimuli in individuals with migraine to levels that
would not trouble a normal individual.36,37 This may be
the cause for increased motion sensitivity in individuals
with migraine. 26-60% of patients with migraine have a
history of severe motion sickness compared to 8-24% in
the normal population.1, 3 The noradrenergic system may
also be the cause of the hypersensitivity to sensory stimuli during the aura phase, headache phase, and postdrome phase of migraine.
Serotonin 5HT1 Receptor

and the Headache Phase
According to the neurogenic hypothesis, the headache
phase may be mediated by neurons containing serotonin (5-HT) within the trigeminal nucleus.38 5-HT is an
193
Table 12-2 CACNA1A GENE DEFECTS

THAT CAUSE AUTOSOMAL
DOMINANT DISORDERS
Gene Defect
Syndrome
Symptoms and Signs
Point mutation
Familial
hemiplegic
migraine
Episodic hemiparesis
for up to 60 minutes
followed by headache
GEN and DBN may
persist after spells
Point mutation
Episodic
ataxia-2
Episodic ataxia and

vertigo
GEN
DBN
Decreases in VOR
cancel and pursuit
Normal VOR
CAG repeats
SCA 6
Progressive ataxia
GEN
DBN
Decreases in VOR
cancel and pursuit
Normal VOR
DBN downbeat nystagmus; GEN gaze-evoked nystagmus; VOR

vestibulo-ocular reflex.
intracranial vasoconstrictor; it rises during the migraine

aura and falls during the headache. Platelet 5-HT levels
drop rapidly during the onset of migraine. Through
autoregulation, blood flow is reduced to this area of neuronal dysfunction. Agonists of these receptors block neuropeptide release and alter neurotransmission in
trigeminovascular neurons.39 These agonists are the most
effective drugs in aborting migraine headache.
Management
Management begins with identiftying to what extent the
patient is suffereing from spells due to vestiblar migraine,
or more chronic symptoms due to chronic anxiety and
increased motion sensitivity.
Treatment of Vestibular Migraine

Spells of vertigo and dysequilibrium secondary to
migraine usually respond to the same type of treatment as
that used for migraine headaches. Migraine is triggered
by a number of factors including stress, anxiety, hypo-
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glycemia, fluctuating estrogen, certain foods, and smoking.40-42 Treatment of migraine can be divided into (1) the
reduction of risk factors, (2) prophylactic medical therapy, and (3) abortive medical therapy.
Reduction of Risk Factors

Sometimes, in practice, patients with migraine are given
a management schedule to follow, which is explained at
the time of their first visit (Box 123). It may be pointed
out that there are several triggers for migraine, which can
be avoided by following the schedule.
Stress
All patients are started on an aerobic exercise program to
help reduce stress. This program is gradually increased
until the individual is exercising 3 to 5 times per week for
at least 30 minutes at the end of the day (jogging, swimming, fast walk, racquetball, tennis, etc.). Several good
aerobic exercise programs can be found in a paperback
Box 12-3
SCHEDULE TO TREAT
MIGRAINE DISORDERS
1. Reduction of stress:
a. Aerobic exercise at end of day (3 to 4
times/week). Get heart rate above 100 and
sustain it for at least 20 minutes.
b. Eat something at least every 8 hours to
avoid hypoglycemia. Eat breakfast at same
time each morning (breakfast on weekends
should be at the same time as on weekdays).
c. Maintain a regular sleep schedule.
2. Do not smoke or chew any products that contain nicotine.
3. Avoid exogenous estrogen (oral contraceptives, estrogen replacement).
4. Follow diet.
5. Keep a diary:
a. Note time and date of all headaches and/or
spells that interfere with daily routine.
b. Write down any foods that you had that are
listed on the other side of this sheet during
the 24 hours prior to the headache and/or
spell.
c. Bring diary in with you on your next visit!
6. Medications.
book by Cooper.43 If patients are reluctant or unable to

participate in an exercise program, other stress reduction
programs can be very helpful. These include biofeedback
and relaxation programs, which have been shown to significantly reduce the frequency of recurrent migraine disorders in clinical trials.43, 44 Patients are urged to avoid
hypoglycemia by eating something at least every 8 hours.
Many individuals skip breakfast; the need to eat breakfast
at the same time each morning, including weekends, is
emphasized. Finally, maintenance of a regular sleep
schedule (going to bed and getting up at the same time
each day) is strongly recommended.
Nicotine
Patients who smoke cigarettes are urged to stop smoking.
Estrogen
If patients are taking estrogen supplements (other than
vaginal creams), work with their gynecologist to either
eliminate the supplement or reduce the estrogen to the
lowest level possible for a 3-month trial.
Diet
All patients are placed on a diet schedule, which is given
to them in written form (see Table 12-2). This diet eliminates foods containing high levels of tyramine and other
substances known to exacerbate migraine.40, 41, 45 Some of
these foods cause migraine almost immediately (red
wine, MSG); most cause migraine the next day (chocolate, nuts, cheese). Aspartame, found in Nutrasweet, can
also provoke migraine.46
Diary
Finally, all patients are asked to keep a careful diary, noting the time and date of all spells or headaches that interrupt their daily activities. They are asked to write down
any foods from the list of foods to avoid (Table 12-3)
that they had during 24 hours prior to the headache or
spell. This forces the individual to become more aware of
the association of diet with migraine and potentially
identifies certain foods they should avoid.
Prophylactic Medical Therapy

When migraine occurs several times a month, prophylactic daily medical therapy designed to prevent migraine
should be used. There are a variety of drugs used in this
capacity including beta-blockers, amitriptyline, calciumchannel blockers, lithium carbonate, aspirin, and ibuprofen.47 All of these drugs have been found to be effective
in reducing the frequency and severity of headache with
or without aura. These drugs have also been found to be
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195
Table 12-3 DIET FOR PATIENTS WITH MIGRAINE

Food Category
Foods Allowed
Foods to Avoid
Beverages
Decaffeinated coffee, fruit juice,

club soda, noncola soda
Limit caffeine sources to 2
cups/day (coffee, tea, cola)
Chocolate, cocoa, certain alcoholic beverages (red wine, port,

sherry, scotch, bourbon, gin)
Excessive aspartame (Nutrasweet): no more than

24 oz/day of diet drink
Meats, fish,
and poultry
Fresh or frozen turkey, chicken,

fish, beef, lamb, veal, pork
Aged, canned, cured, or processed meats, including ham or

game, pickled herring, salad and dried fish
Chicken liver, bologna
Fermented sausage
Any food prepared with meat tenderizer, soy sauce, or brewers yeast
Any food containing nitrates or tyramine (smoked meats,
including bacon, sausage, ham, salami, pepperoni, hot dogs)
Limit eggs to 3/week

Tuna or tuna salad
Dairy products
Milk: Homogenized, 2%, or skim
Milk: Buttermilk, sour cream, chocolate milk
Cheeses: American, cottage,

farmer, ricotta, cream, Canadian,
processed cheese slice
Cheeses: Stilton, bleu, cheddar, mozzarella, cheese spread,

Roquefort, provolone, gruyere, muenster, feta, parmesan,
emmenthal, brie, brick, camembert types, cheddar, gouda,
romano
Yogurt (limit 1/2 cup/day)

Breads, cereals
Commercial bread, English

muffins, melba toast crackers,
bagels
All hot and dry cereals
Hot fresh homemade yeast bread, bread or crackers containing cheese

Fresh yeast coffee cake, doughnuts, sourdough bread
Any product containing chocolate or nuts
Potato or
substitute
White potato, sweet potato, rice,

macaroni, spaghetti, noodles
None
Vegetables
Any except those to avoid
Beans such as pole, broad, lima, Italian, fava, navy, pinto,

garbanzo
Snow peas, pea pods, sauerkraut, onions (except for flavoring), olives, pickles
Fruit
Any except those to avoid

Limit citrus fruits to1/2 cup/day
(1 orange)
Limit banana to1/2 per day
Avocados, figs, raisins, papaya, passion fruit, red plums
Soups
Cream soups made from foods

allowed in diet, homemade broth
Canned soup, soup or bouillon cubes, soup base with yeast or

monosodium glutamate (MSG; read labels)
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Table 12-3 DIET FOR PATIENTS WITH MIGRAINE (continued)

Food Category
Foods Allowed
Foods to Avoid
Desserts
Any cake, cookies without chocolate, nuts, or yeast

Any pudding or ice cream without
chocolate or nuts
Flavored gelatin
Any product containing chocolate, including ice cream,

pudding, cookies, cake or pies
Mincemeat pie
Sweets
Sugar, jelly, jam, honey, hard

candy
Chocolate candy or syrup, carob
Miscellaneous
Salt in moderation, lemon juice,

butter or margarine, cooking oil,
whipped cream, white vinegar,
commercial salad dressings
Pizza, cheese sauce, MSG in excessive amounts (including

Chinese food and Accent), meat tenderizer, seasoned salt,
yeast, yeast extract
Mixed dishes (including macaroni and cheese, beef
stroganoff, cheese blintzes, lasagna, frozen TV dinners)
Chocolate, nuts (including peanut butter)
All nonwhite vinegars
Anything fermented, pickled, or marinated
Modifed from Diamond, 1991,40 and Shulman et al, 1989.45
useful in preventing migraine-associated dizziness.48,49

Daily valproate recently has been found to be effective in
preventing migraine headaches50 and has been approved
for prophylactic treatment of migraine. To what extent
this drug stops vertigo due to migraine is not known.
With the exception of aspirin, ibuprofen, and valproate,
the mode of action of these prophylactic drugs may be
via their antagonist effect on 5-HT2 receptors.51
Based on personal observations, this author has
found that propranolol is quite effective in preventing
auras, including vertigo; therefore, it is the first drug used
to treat patients with frequent migraine auras.
Contraindications include congestive heart disease, cardiac block, asthma, diabetes, and orthostatic hypotension. Patients start on 40-mg tablets, 1/2 tablet bid and
increase this drug in 20-mg increments every 3 to 7 days,
depending on patient tolerance of the drug. The effective
dose is usually 80 to 200 mg/d. As this drug is increased,
heart rate and blood pressure are monitored. Once the
therapeutic dose is found, long-acting propranolol (80- to
120-mg capsules) may be prescribed. If they remain relatively symptom free for a few months, the medication is
tapered every 1 to 2 weeks to the lowest effective dose.
Finally, acetazolamide (Diamox) 250 mg bid has
been shown to decrease spells in patients with episodic
ataxia-2. It may also be helpful in patients with familial
hemiplegic migraine52 and those with familial migraine
with vertigo.53
Abortive Medical Therapy

The drugs used to abort migraine headache include
aspirin, ibuprofen, isometheptene mucate (Midrin), ergotamine, dihydroergotamine, and 5-HT agonists (serotonin).47 There are several types of serotonin receptors.
It has been postulated that the abortive drugs are 5-HT1
agonists, whereas the prophylactic drugs are 5-HT2 antagonists.51 Table 12-4 lists the serotonin receptor medications and their uses. Sumatriptan is a potent agonist of
the 5-HT1 receptor but does not cross the blood-brain
barrier well. Consequently, a host of other drugs are now
on the market with similar receptor agonists including
eletriptan, naratriptan, rizatriptan, and zolmitriptan.
Dihydroergotamine is also effective with 5-HT1 agonism.
These drugs are primarily designed to abort headache.
They have not been found to be effective in aborting
migraine auras to date. In fact, subcutaneous sumatriptan
is totally ineffective when given during the aura.54 There
are also now a host of selective serotonin 5-HT3 receptor
antagonists that prevent nausea and vomiting (see Table
12-4). These drugs, plus dexamethasone, are the most
effective regimen for prevention of acute vomiting caused
by cancer chemotherapy. They have been found to be
effective in other causes of severe nausea and vomiting
including central vertigo,55 but they have not yet been
approved for these conditions. They are expensive and
should not be used beyond a 24-hour period.
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Table 12-4 SEROTONIN (5-HT) RECEPTOR DRUGS

Receptor
Chemical (Trade Name)
Dose
Indications
Side Effects
5-HT1 agonists
Sumatriptan (Imitrex)
6 mg SC;
25100 mg PO;
20 mg nasal spray
Abortive therapy for migraine
Flushing, chest
discomfort
Zolmitriptan (Zomig)
2.5 mg PO
Flushing, chest
discomfort
Naratriptan
2.5 mg PO
Flushing, chest
discomfort
Eletriptan
Flushing, chest
discomfort
Rizatriptan
Flushing, chest
discomfort
5-HT3 antagonists
Ondansetron (Zofran)
8 mg PO 2;
32 mg IV
Prevention of severe nausea and

vomiting from chemotherapy
Mild headache
and dizziness
Dolasetron (Anzemet)
100 mg PO;
1.8 mg/kg IV

Mild headache
and dizziness
Granisetron (Kytril)
2 mg PO
10 mg/kg IV

Mild headache
and dizziness
IM intramuscular; IV intravenous; PO oral; SC subcutaneous.
Migraine versus
Mnires Disease
There is a great deal of confusion between migraine aura
without headache and vestibular hydrops (vestibular
Mnires disease).56, 57 Both can present with transient
vertigo, ear fullness, or occasional tinnitus, but without
any decrease in hearing (Table 12-5). A history of
headaches associated with the spells of vertigo may help
to distinguish these two syndromes, but occasionally the
diagnosis is made only following the patients response to
a therapeutic trial (see Case Study 3). Patients with welldocumented Mnires disease may later develop
migraine aura without headache. Therefore, they may initially do well with treatment for Mnires disease and
then appear to fail to respond to treatment when in fact
they have developed spells of vertigo due to migraine aura
without headache (see Case Study 4). Kayan and Hood1
and Hinchcliffe58 noted a higher than expected incidence
of both migraine and Mnires disease in the same individual. Whether there is a causal link between these two
disorders is unclear.
Table 12-5 MIGRAINE VERSUS

MNIRES DISEASE
Migraine
Mnires Disease
Tinnitus: high-pitched
Tinnitus: low-pitched, roar
May have ear fullness

(ache), phonophobia,
and photophobia
Usually ear fullness or

hearing loss
True spontaneous
vertigo is rare; can
occur for minutes
True spontaneous vertigo

is common; can occur for
hours
Short nap usually helps
Short naps usually do not

help
Visual auras are common
Visual auras are uncommon
Motion sickness
is common
Motion sickness is uncommon
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CASE STUDY 1
A 46-year-old owner of a blacktop paving company is
referred for spells of vertigo, nausea, vomiting, oscillopsia, and diaphoresis for past 2 years, each lasting
approximately 30 minutes. He had sustained tinnitus
and hearing loss on the right side, which did not fluctuate with his spells of vertigo. In addition, he had a
life-long history of sinus pressure discomfort in the
forehead, eyes, and behind the nose, for which he
took a decongestant. His last sinus discomfort was 3
years ago. In addition, he has recently had episodic
flashes of light lasting 10 to 15 minutes. He has a history of hypertension and angina, but a normal EKG
and coronary angiography. In the last 2 months, the
frequency of his spells of vertigo increased to 1 per
week and the last few spells were associated with left
arm paresthesia and dysarthria. One spell was witnessed and the patient was found to have a sustained
left-beating nystagmus for 20 minutes.
Comment
Migraine and Mnires disease can be frequently difficult to distinguish. An important feature in this
patients history that points to migraine is that his tin-
nitus and hearing loss did not fluctuate with his spells.
This feature applies only to patients that have sufficient hearing to notice fluctuation. Sinus headaches
and migraine are also frequently confused; both can
be located in the same area of the face and head.
Episodic flashes of light are a helpful tip pointing to
migraine aura. Basilar artery migraine is suggested by
the other signs and symptoms during the spell, including paresthesias, dysarthria, and left-beating nystagmus. A diagnosis of basilar artery stroke was
considered. A four-vessel cerebral arteriogram was
normal, as was an MRI of the head with contrast. In
summary, this patient was thought to be having
impending brainstem stroke with possible ischemia to
the right brainstem resulting in vertigo, left-beating
nystagmus, and left arm paresthesia. Of interest
was that he also had angina with normal coronary
arteries. He had a remote history of sinus headaches
and recently has been experiencing scintillating scotomas. A diagnosis of basilar artery migraine (IHS
classification 1.2.4) was made and his spells of
vertigo stopped after he was placed on a diet and propranolol.
CASE STUDY 2
A 28-year-old real estate developer is referred for
thirty 5 to 10 minute spells of dysequilibrium, vertigo, 15 tilt of world, and diplopia (vertical and horizontal) over the past 5 years. Many of these spells
occurred during a variety of physical activities
including running, weight lifting, intercourse, and
strenuous aerobic exercises (rowing machine, stairclimber, and stationary bicycle).
Comment
Because of the exercise-induced nature of these
spells, they were believed to be due to a perilympha-
tic fistula and surgery was initially recommended.

Features more characteristic of migraine included the
development of a dull soreness over his left occiput
following each spell, the association of certain foods
with spells (Chinese food, ice cream, cream cheese),
and the frequent omission of breakfast. Migraine can
be caused by exercise. Other features not consistent
with a perilymphatic fistula were a normal audiogram
and no history of barotrauma, ear surgery, or ear
infection. A diagnosis of basilar migraine (IHS classification 1.2.4) was made. These spells stopped after
he was placed on the antimigraine schedule listed in
Box 123.
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CASE STUDY 3
A 47-year-old medical transcriptionist is referred for
a 10-year history of spells of nausea, dysequilibrium,
and occasional vomiting and ear fullness without
hearing loss or tinnitus. Her audiogram was normal.
She was diagnosed with probable Mnires disease
and treated with chlorothiazide (Diuril), dimenhydrinate (Dramamine), and no caffeine or nicotine.
Because she continued to have bad attacks, she was
then treated with scopolamine patches. She then
began to develop headaches (usually left frontal),
and ear pressure with some of the spells, worse in
the summer. She had a history of severe headache
with her menses since the age of 30. She had a
normal caloric CT scan of the head, and rotary chair
test.
Comment
This is another case that illustrates the difficulty in
distinguishing migraine from Mnires disease. This
patient started off with spells without headache.
Because of a lack of headaches, she did not initially
satisfy the criteria for migraine. Although rare,

vestibular hydrops without hearing loss can occur.
This entity usually eventually also affects hearing.
Vestibular hydrops versus migraine aura without
headache can present with identical symptoms. Until
the diagnosis is secured, both entities are treated.
Headaches eventually occurred. She was diagnosed
with migraine with aura (IHS classification 1.1) and
migraine aura without headache (IHS classification
1.2.5). She was placed on an antimigraine schedule
and treated with isometheptene at the onset of the
spell, which did not help. She was then placed on an
increasing dose of amitriptyline and eventually
reached a dose of 50 mg each night. For the next year
she continued to get a headache a few days before her
menses, but no dizzy spells. Because of the complaint
of difficulty getting up in the morning and a dry
mouth, the amitriptyline was tapered and she was
placed on an increasing dose of propranolol. She
has had no headaches or spells of vertigo for the past
9 months.
CASE STUDY 4
A 35-year-old biochemist is referred for spells of vertigo, nausea, and vomiting lasting for less than 1 hour
during the past year. As a teenager, she recalled having occasional bad sinus headaches. Between the
ages of 22 and 32 she had spells of vertigo, nausea,
vomiting, fluctuating hearing loss, and tinnitus in the
left ear. At that time she was diagnosed with
Mnires disease and treated with diuretics, antihistamines, and a low-salt diet. Her current spells of vertigo were not associated with fluctuating hearing loss
or tinnitus, and were not altered by the use of a diuretic and a low-salt diet. Two years ago she had a visual
scintillation that lasted for a few minutes. She had a
normal neurological examination, normal caloric test,
and normal rotary chair test. She had moderate to
severe low-frequency sensorineural hearing defect,
and decreased speech discrimination on the left side.

Hearing was normal on the right. An MRI of the head
with gadolinium was normal.
Comment
This patient started off with Mnires disease
that responded well to treatment. Migraine and
Mnires disease are very common and patients frequently can have both. The peak incidence for
migraine is between the ages of 35 and 45. She was
diagnosed with migraine aura without headache (IHS
classification 1.2.5). She was placed on an antimigraine schedule. Over the next year her spells of
vertigo stopped, hearing in the low frequencies
became normal, and she developed normal speech
discrimination.
199
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CASE STUDY 5
A 33-year-old professor of history is referred for five
spells of vertigo beginning several years ago. These
spells usually lasted a few minutes and occurred in
the morning around the time of her menses. It was
unclear whether head movement triggered them. She
usually had dysequilibrium for up to 1 hour following
the vertigo. She also noted minor right-sided
headaches during her menses with queasiness, but
denied vomiting, hearing loss, and tinnitus. She
recalls having ear infections when she was young.
She wondered about anxiety attacks; she lost her husband 2-1/2 years previously to colon cancer. She had
normal neurological and neuro-otological examinations. She was reassured that no serious problem was
found and was told to come in if she developed
another attack. One month later she called and stated
the spells returned. She stated that she had just finished her menses and had a minor right-sided
headache. On examination she had sustained geotropic nystagmus during the Hallpike-Dix maneuver.
Comment
Migraine is most common during the week prior to
menstrual periods. During the migraine aura, head
movements usually provoke dizziness. In about 30
percent of patients with migraine-provoked dizziness,
true vertigo with the head still occurs. A variety of
types of nystagmus can be found, including spontaneous and position induced. Sustained geotropic nystagmus is central. Transient geotropic nystagmus can
be due to canalithiasis of the horizontal semicircular
canal and sustained ageotropic nystagmus can be due
to cupulolithiasis of the horizontal semicircular
canal. This patient was also placed on an antimigraine schedule. Her spell and positional nystagmus
resolved in a couple of days and she did not have any
recurrence of headache or vertigo during the 6
months she was followed.
Summary
References
It is becoming increasingly recognized that migraine is a

common cause of episodic vertigo and dysequilibrium in
children and adults. It may present as benign paroxysmal
vertigo of childhood, paroxysmal torticollis of infancy,
and benign recurrent vertigo in adults. In addition,
migraine is associated with motion sickness, Mnires
disease, and BPPV. Migraine is triggered by a number of
factors including stress, anxiety, hypoglycemia, fluctuating estrogen, certain foods, and smoking. Episodic vertigo and dysequilibrium from migraine should be treated
by reducing these risk factors and, if necessary, by medical therapy.
1. Kayan A, Hood JD: Neuro-otological manifestations

of migraine. Brain 1984;107:1123.
2. Selby G, Lance JW: Observations on 500 cases of
migraine and allied vascular headaches. J Neurol
3. Kuritzky A, et al: Vertigo, motion sickness and migraine.
Headache 1981;21:227.
4. Stewart WF, et al: Migraine headache: prevalence in the
United States by age, income, race and other sociodemographic factors. JAMA 1992;267:64.
5. Headache Classification Committee of the International
Headache Society: Classification and diagnostic criteria
for headache disorders, cranial neuralgias and facial pain.
Cephalalgia 1988;8(Suppl 7):1.
6. Fisher CM: Late-life migraine accompaniments as a cause
of unexplained transient ischemic attacks. Can J Neurol
Sci 1980;7:9.
7. Bickerstaff ER: Basilar artery migraine. Lancet 1961;1:15.
8. Eviatar L: Vestibular testing in basilar artery migraine.
Ann Neurol 1981;9:126.
9. Harker LA, Rassekh CH: Episodic vertigo in basilar
artery migraine. Otolaryngol Head Neck Surg 1987;
96:239.
10. Grad A, Baloh RW: Vertigo of vascular origin: clinical and oculographic features. Arch Neurol 1989;
46:281.
Patient Information
Glaxo Wellcome (1-800-377-0302). Obtain free pamphlets including Chart Your Route to Relief: A Personal
Migraine Management Program.
For free newsletters, contact the National Headache
Foundation at 1-800-843-2256 or http://www. headaches.
org/.
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Chapter 12
11. Slater R: Benign recurrent vertigo. J Neurol Neurosurg

Psychiatry 1979;42:363.
12. Harker LA, Rassekh CH: Migraine equivalent as a cause
of episodic vertigo. Laryngoscope 1988;98:160.
13. Moretti G, et al: Benign recurrent vertigo and its connection with migraine. Headache 1980;20:344.
14. Kuritzky A, et al: Vestibular function in migraine.
headache: The J of Head and Face Pain; 1981;21:110.
15. Schlake HP, et al: Electronystagmographic investigations
in migraine and cluster headache during the pain-free
interval. Cephalagia 1989;9:271.
16. Toglia JU, et al: Common migraine and vestibular function: electronystagmographic study and pathogenesis.
Ann Otol Rhinol Laryngol 1981;90:267.
17. Imes RK, Hoyt W: Exercise-induced transient visual
events in young healthy adults. J Clin Neuro-ophthalmol
1989;9:178.
18. Basser LS: Benign paroxysmal vertigo of childhood.
Brain 1964;87:141.
19. Fenichel GM: Migraine as a cause of benign paroxysmal
vertigo of childhood. J Pediatr 1967;71:114.
20. Koenigsberger MR, et al: Benign paroxysmal vertigo of
childhood. Neurology 1970;20:1108.
21. Lanzi G, et al: Benign paroxysmal vertigo of childhood: a
long-term follow-up. Cephalgia 1994;14:458.
22. Parker W: Migraine and the vestibular system in childhood and adolescence. Am J Otol 1989;10:364.
23. Watson P, Steele JC: Paroxysmal dysequilibrium in the
migraine syndrome of childhood. Arch Otolaryngol
1974;99:177.
24. Snyder CH: Paroxysmal torticollis in infancy. Am J Dis
Child 1969;117:458.
25. Gourley IM: Paroxysmal torticollis in infancy. Can Med
Assoc J 1971;105:504.
26. Hanukoglu A, et al: Benign paroxysmal torticollis in
infancy. Clin Pediatr 1984;23:272.
27. Lipson EH, Robertson WC: Paroxysmal torticollis of
infancy: familial occurrence. Am J Dis Child 1978;
132:422.
28. Brandt T, Daroff RB: The multisensory physiological
and pathological vertigo syndromes. Ann Neurol 1980;
7:195.
29. Childs AJ, Sweetnam MT: A study of 104 cases of
migraine. Br Industr Med 1961;18:234.
30. Peroutka SJ: Dopamine and migraine. Neurology
1997;49:650. 1998;43:711.
31. Peroutka SJ et al: Comorbid migraine with aura, anxiety,
and depression is associated with dopamine D2 receptor
(DRD2) NcoI alleles. Mol Med. 1998;4:14-21.
32. Breslau JN et al:, Headache types and panic disorder:
directionality and specificity. Neurology. 2001;56:
350-354.
33. Ophoff RA, et al: Familial hemiplegic migraine and
episodic ataxia type-2 are caused by mutations in the
Ca2 channel gene CACNL1A4. Cell 1996;87:543.
34. May A, et al: Familial hemiplegic migraine locus on
19p13 is involved in the common forms of migraine with
and without aura. Hum Genet 1995;96:604.
35. Elliot MA, et al: Familial hemiplegic migraine, nystagmus
and cerebellar atrophy. Ann Neurol 1996;39:100.
201
36. Main A. et al,: Photophobia and phonophobia in migraineurs between attacks. Headache. 1997;37:492.
37. Vingen JV et al, : Phonophobia in migraine. Cephalalgia.
1998;18:243.
38. Moskowitz MA, et al: Neocortical spreading depression
provokes the expression of c-fos protein-like immunoreactivity within trigeminal nucleus caudalis via trigeminovascular mechanisms. J Neurosci 1993;13:1167.
39. Goadsby PJ, Hoskin KL: Serotonin inhibits trigeminal
nucleus activity evoked by craniovascular stimulation
through a 5-HT receptor: a central action in migraine?
Ann Neurol; 1998;43:711.
40. Diamond S: Dietary factors in vascular headache. Neurol
Forum 1991;2:2.
41. Kin T: Discussion, ideas abound in migraine research:
consensus remains elusive. JAMA 1987;257:9.
42. Silberstein SD, Merriam GR: Estrogens, progestins,
and headache. Neurology 1991;41:786.
43. Cooper KH: The Aerobics Way. New York: Bantam
Books; 1997:312.
44. Holroyd KA, Penzien DB: Pharmacological versus nonpharmacological prophylaxis of recurrent migraine
headache: a meta-analytic review of clinical trials. Pain
1990;42:1.
45. Shulman KI, et al: Dietary restrictions, tyramine, and
the use of monoamine oxidase inhibitors. J Clin Psychopharmacol 1989;9:397.
46. van Den Eeden SK, et al: Aspartame ingestion and
headaches: a randomized crossover trial. Neurology
1994;44:1787.
47. Capobianco DJ, et al: An overview of the diagnosis and
pharmacologic treatment of migraine. Mayo Clin Proc
1996;71:1055.
48. Bikhazi P, et al: Efficacy of antimigrainous therapy in the
treatment of migraine-associated dizziness. Am J Otol
1997;18:350.
49. Johnson GD: Medical management of migraine-related
dizziness and vertigo. Laryngoscope 1998;108:1.
50. Jensen R, et al: Sodium valproate has a prophylactic
effect in migraine without aura. Neurology 1994;
44:647.
51. Peroutka SJ: The pharmacology of current anti-migraine
drugs. Headache 1990;30(Suppl):5.
52. Athwal BS, Lennox GG: Acetazolamide responsiveness in familial hemiplegic migraine. Ann Neurol
1996;40:820.
53. Baloh RW, et al: Familial migraine with vertigo and
essential tremor. Neurology 1996;46:458.
54. Bates D, et al: Subcutaneous sumatriptan during the
migraine aura. Neurology 1994;44:1587.
55. Rice GPA, Ebers GC: Ondansetron for intractable vertigo
complicating acute brainstem disorders. Lancet 1995;
345:1182.
56. Baloh RW: Neuro-otology of migraine. Headache
1997;37:615.
57. Dornhoffer JL, Arenberg IK: Diagnosis of vestibular
Mnires disease with electrocochleography. Am J
Otol 1993;14:161.
58. Hinchcliffe R: Headache and Mnires disease. Acta
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13
Therapy for Mal de
Dbarquement
Syndrome
Timothy C. Hain, MD
Mal de dbarquement syndrome (MDDS), literally,

sickness of disembarkment, refers to prolonged and
inappropriate sensations of movement after exposure to
motion. The syndrome typically follows a 7-day sea voyage, but similar conditions have been described after
extended airplane travel, train travel, and space flight.1
Symptoms include sensations of rocking and swaying
accompanied by imbalance. MDDS is distinguished from
ordinary motion sickness, seasickness (mal de mer), and
land-sickness by persistence of symptoms for a month
or longer.
A typical case history is as follows: A 50-year-old
woman went on her first ocean cruise. She had some
motion sickness on the cruise, which responded to transdermal scopolamine. After returning from the cruise, she
experienced land-sickness, consisting of imbalance and a
rocking sensation, accompanied by fatigue and difficulty
concentrating. Her description was Imagine feeling like
you are on rough seas 24 hours a day, 7 days a week.
The single largest study of MDDS was conducted
by Hain and associates,2 who reported 27 cases. Nearly
all patients were middle-aged women (26/27; mean age
49.3 years). Duration of symptoms ranged from 6 months
to 10 years (mean 3.5, SD 2.5). Subjects got little or no
relief from conventional antivertiginous medication such
as meclizine and scopolamine patches. The most effective medication was a benzodiazepine (Klonopin). Only a
small number of additional cases have been reported, all
showing a similar pattern.35
202
MDDS has similarities to land-sickness. The features differentiating land-sickness from MDDS are a
shorter duration of land-sickness, the association of landsickness with motion sickness, and gender differences.
Between 41% and 73% of persons disembarking from
seagoing voyages experience a brief unsteadiness syndrome, or land-sickness. 68 Males and females do not
seem to differ significantly in the incidence, intensity, or
duration of land-sickness symptoms.7 Persons with landsickness are also likely to have seasickness,6 but persons
with MDDS generally are untroubled by seasickness.
MDDS also has some similarities to motion sickness (mal de mer). However, motion sickness is easily
distinguished by the relatively short duration of motion
sickness and gender differences. Persons with MDDS
reliably have relief of symptoms when in motion, such as
driving a car, but experience recurrence of rocking once
motion has stopped (such as sitting in a chair). Many persons with motion sickness find driving very difficult, as
do persons with vestibular disorders.
Cause of the Syndrome:

Persistent Adaptation to
Swaying Environments?
MDDS does not have the features of a pathologic disease, in the sense that it does not appear to follow an
injury. Rather, it is provoked by exposure to motion that
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Chapter 13
does not trouble most individuals in a persistent manner.

Movements such as those experienced in a boat expose a
person to rhythmic upward and downward movements
along with tilts to the left and right. During this time the
brain must adjust motions of the legs and body so that
they counter the rhythmic pattern of shipboard motion.
Adapting to such movement is sometimes referred to as
gaining sea legs.
Persons with MDDS may be very good at adapting
to unusual motion situationsgaining sea legs during
ocean travelbut slow to give up their adaptation when
they return to the stable ground.5 In support of this idea
is that a brief period of rocking can be induced in normal
subjects by sway referencing, a procedure resembling
the situation on a boat.9
As discussed in Chapter 1, good balance requires
integration of sensory input from the inner ear, eyes,
ankles (somatosensory input), and internal models of orientation. One possibility, then, is that MDDS is a disorder of somatosensory integration. Some studies have
suggested that persons with MDDS become increasingly
reliant on somatosensory input after motion exposure and
reduce the weighting of vision and vestibular input.10 We
suspect that this observation is a red herring, as it is difficult to understand the rationale for such an adaptation in
the context of boat travel.
Another possibility is that individuals susceptible to
MDDS may become more reliant on visual and graviceptive information (and thus have decreased somatosensory
weighting). Unsurprisingly, this occurs in normal subjects
who are exposed to situations in which somatosensory
feedback is distorted.11 This particular theory is better
grounded in physiology but contradicts available data,
suggesting the exact opposite adaptation in MDDS.10
Either adaptation might result in inaccurate land sensorimotor integration. Neither of these adaptations explains
the rocking sensation of MDDS or the characteristic
improvement upon driving a car.
A third mechanistic possibility for MDDS arises
from internal model theory. On a boat, during quiet standing on deck, there are two main reasons why somatosensation at the ankles and foot might be altered. When the
boat rotates (pitch), the deck tilts in space. Sheer force
exerted on the soles of the feet alters somatosensation. In
this situation, it would be best for balance to allow bodily inertia to keep the body upright and not react with an
ankle torque. On the other hand, when the boat translates
forward (as in surging forward), sheer is created. Here it
would be best to rapidly respond with an ankle torque
to prevent a fall. An internal model of periodic boat
motionan internal oscillator that is entrained by boat
motionmight allow one to select out salient sensory
THERAPY FOR MAL DE DBARQUEMENT SYNDROME
203
input (boat surge) and ignore the nonsalient input (boat

pitch). In support of this idea, some animals exhibit persistent oscillations in central neurons after periodic
movement ends.12 Also post-movement illusions of
rocking can be induced by sinusoidal rotation in some
individuals.13 Such an internal oscillator might result in
persistent rocking when there is no ongoing periodic
motion.
Treatment
Conventional vestibular suppressants such as meclizine
and transdermal scopolamine are not helpful in MDDS.2
Benzodiazepines, such as clonazepam, are of the most
benefit. Zimbelman and Watson14 reported a case in
which physical therapy was used in an attempt to treat
MDDS; of course, it is not known how this patient would
have fared without intervention. In the largest study of
MDDS, many individuals underwent vestibular rehabilitation, again because of a lack of controls, but it was not
possible to determine whether they did any better than
subjects who were not treated.2 Thus, the efficacy of
vestibular rehabilitation for MDDS is currently unknown.
Our view is that in therapy of MDDS, the goal
should be to modify an inappropriate internal model. The
individual should be encouraged to seek out situations in
which there is abundant and accurate sensory information
regarding orientation in space and should practice balancing in a variety of sensory contexts. We advise
patients to avoid going back on boats or in other vehicles
incorporating periodic motion because symptoms frequently flare up after such experiences.
Although data that any intervention works are lacking, a number of physical therapy treatment strategies
might be tried in MDDS. As already mentioned, two
theories applicable to MDDS propose an inappropriate
weighting of somatosensory input (one too much, one
too little). Accordingly, if, during the assessment of the
patient, the clinician determines that somatosensory
weighting is inappropriate, he or she might attempt a
specific intervention.
For example, the patient who disregards proprioceptive information should practice detecting joint position
sense and kinesthetic awareness of the toes and ankles
while sitting with the eyes closed. Once there is heightened awareness of joint position sense, the patient should
use the sensory information during a dynamic task.
While standing on a firm surface with the eyes closed, the
patient may dynamically shift weight from anterior to
posterior for 1 to 2 minutes and then from side to side for
1 to 2 minutes. He or she may then be asked to walk with
eyes closed on mats with objects placed randomly
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beneath the mats to increase focus on the somatosensory

information. For persons who overweight somatosensory
information, efforts might be reasonably directed toward
up-weighting visual and vestibular inputs.
If MDDS is instead caused by an internal oscillator,
the treatment strategy should logically aim at manipulation of cognitive variables. Patients need to ignore their
aberrant internal signal, in the same way that persons
with tinnitus deal with abnormal internally generated
sounds. From this perspective, physical therapy that
focuses attention on the rocking sensation could even be
counterproductive. Controlled studies are needed regarding the effect of physical therapy on MDDS.
Summary
MDDS is an uncommon disorder in which an inappropriate sensation of rocking develops that is paradoxically
relieved by actual motion, such as driving. Research is
needed to establish the role of physical therapy in the
treatment of MDDS. As of this writing, strategies based
on provision of abundant and accurate sensory information about balance, possibly combined with attempts to
improve somatosensory integration, appear most reasonable.
References
1. Stott J: Adaptation to nauseogenic motion stimuli and its
application in the treatment of airsickness. Motion and
Space Sickness. Boca Raton, FL; CRC Press; 1990.
2. Hain TC, Hanna PA, Rheinberger MA Mal de debarquement. Arch Otolaryngol Head Neck Surg 1999;125:
615620.
3. Brown JJ, Baloh RW: Persistent mal de debarquement
syndrome: a motion-induced subjective disorder of balance. Am J Otolaryngol 1987;8:219222.
4. Murphy TP: Mal de debarquement syndrome: a forgotten entity? Otolaryngol Head Neck Surg 1993;109:
1013.
5. Mair I: The mal de debarquement syndrome. J Audiol
Med 1996;5:2125.
6. Gordon CR, Spitzer O, Doweck I, et al: Clinical features
of mal de debarquement: adaptation and habituation to sea
conditions. J Vestib Res 1995;5:363369.
7. Cohen H:. Mild mal de debarquement after sailing. Ann
N Y Acad Sci 1996;781:598600.
8. Gordon CR, Shupak A, Nachum Z: Mal de debarquement. Arch Otolaryngol Head Neck Surg 2000;126:
805806.
9. Peterka RJ, Loughlin PJ: Dynamic regulation of sensorimotor integration in human postural control. J
10. Nachum Z, Shupak A, Letichevsky V, et al: Mal de debarquement and posture: reduced reliance on vestibular and
visual cues. Laryngoscope 2004;114:581586.
11. Peterka, RJ. Sensorimotor integration in human postural
control. J Neurophysiol 2002;88:1097118.
12. Barmack NH, Shojaku H: Vestibularly induced slow oscillations in climbing fiber responses of Purkinje cells in the
cerebellar nodulus of the rabbit. Neuroscience 1992;
50:15.
13. Lewis RF: Frequency-specific mal de debarquement.
Neurology 2004;63:19831984.
14. Zimbelman JL, Watson TM: Vestibular rehabilitation of a
patient with persistent mal de debarquement. Physical
Therapy Case Reports 1992;2:129133.
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CHAPTER
14
Surgical Management
of Vestibular Disorders
The diagnosis of vestibular disorders is complicated by

overlapping symptoms among the various disorders and
the lack of pathognomonic diagnostic tests. At times,
determining which inner ear is causing the symptoms
may even be difficult. Most patients symptoms can be
managed with the medical and physical therapy measures
described elsewhere in this book. However, surgical
intervention may be appropriate when the symptoms
have failed to respond to aggressive nonsurgical medical
management.
With the exception of acoustic tumors, vestibular
disorders are a matter of lifestyle and comfort and are not
life-threatening. Therefore, the patient living with the
symptoms must make the decision whether to proceed
with surgery. The physician should discuss the likelihood
of a successful outcome, as well as the nature of potential
complications, and must leave the ultimate decision up to
the patient. In the authors experience, patients have a
broad spectrum of responses to their symptoms of vertigo. Some patients want immediate intervention; others
consider surgery only when life becomes unbearable.
Acoustic Neuromas
(Vestibular Schwannomas)
Acoustic neuromas are nerve sheath tumors occurring in
the internal auditory canal or cerebellopontine angle.1
They are the third most common intracranial tumor,
accounting for 8% to 10% of all intracranial tumors.
Most patients with acoustic neuromas present with progressive unilateral sensorineural hearing loss. However,
some patients first complain of vestibular symptoms or
sudden hearing loss.2
An acoustic neuroma should be suspected in any
patient with an unexplained unilateral sensorineural hearing loss, particularly if the patient has abnormal brainstem auditory responses or hypoactive (or absence of)
caloric responses. Magnetic resonance imaging (MRI)
with gadolinium contrast has become the gold standard
for the diagnosis of these tumors. Although there are rare
instances of false-positive results, usually from arachnoiditis, an enhancing mass in the cerebellopontine angle
extending into the internal auditory meatus on MRI is
almost always an acoustic neuroma.
Once the diagnosis is established, there are three
therapeutic options: watchful waiting, microsurgical
removal, and stereotactic radiosurgery (SRS). Watchful
waiting is indicated only in patients with very small intracanalicular tumors for which the diagnosis is inconclusive, and in patients who are elderly or in poor medical
condition. Several recent series have reported the results
of this approach. Wiet and colleagues3 found that in 40%
of 53 patients, continued growth of tumors required intervention over a mean follow-up of about 2 years. More
frightening is an experience reported by Charabi and
associates.4 In their series, 34% of 123 patients followed
for a mean of 3.4 years required intervention for enlarging tumor and 7 died of brainstem compression secondary to the tumor. Therefore, it may be concluded that
205
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there is a significant risk of tumor enlargement, and if a

wait-and-see approach is taken, the importance of serial scanning repeated at 6- to 12-month intervals must be
emphasized to the patient.
Surgical Approaches
Surgical removal of acoustic tumors has been the treatment of choice since described by Harvey Cushing5 in
1917. The three basic approaches are used for removal of
acoustic neuromas are (1) middle fossa craniotomy, (2)
translabyrinthine approach, and (3) suboccipital craniotomy.6,7 The choice of approach is based on the size and
location of the tumor and whether any attempt will be
made to preserve hearing.6,7
Middle Cranial Fossa

The middle cranial fossa approach is used for tumors
confined to the internal auditory canal in patients who
have usable hearing (Fig. 14.1). A vertical incision is
made in the scalp superior to the external auditory canal.
The soft tissues are elevated from the bone and a 3
4cm temporal craniotomy is performed. The dura and
temporal lobe are elevated from the floor of the middle
cranial fossa. The internal auditory canal is identified by
drilling the bone overlying it. The facial nerve, mastoid
air-cell system, and superior semicircular canal are
important landmarks. The bone is thinned over the entire
extent of the internal auditory canal, and then the dura of

the canal is incised. Care is taken not to damage the facial
nerve in the anterior superior quadrant of the internal
auditory canal. The cochlear nerve is anterior-inferior in
the canal and safely out of harms way.
The advantage of the middle cranial fossa approach
is that it does not destroy the inner ear and hearing. Care
must be taken to avoid damaging the facial nerve, because
it is superficial in the dissection. Managing tumors that
extend through the porus acusticus into the posterior
fossa with use of the middle cranial fossa approach is
very difficult. This approach, therefore, is indicated only
for tumors limited to the internal auditory canal.
Recovery after middle fossa craniotomy is prompt.
Unless the patient has significant vestibular symptoms, he
or she should be up and about the next day. Cerebrospinal
fluid (CSF) leakage is unlikely, but the patient should be
checked for both external leak and a leak down the eustachian tube into the nasopharynx after undergoing surgery
via this approach and all other approaches described in
this section.
Translabyrinthine Approach
The translabyrinthine approach is the procedure of
choice for tumors up to 3.0 cm in diameter when hearing
preservation is not a consideration (Fig. 14.2). The tumor
is approached as in a standard mastoidectomy. The cortical and pneumatized bone of the mastoid are drilled away
Figure 14.1 Middle fossa. This coronal section through the internal auditory canal and middle ear
shows the exposure of the internal auditory canal through the middle fossa. A drill is shown passing
through a small temporal craniotomy. The temporal lobe is elevated extradurally. The superior semicircular canal is identified, and the internal auditory canal is exposed by removal of the bone over the
auditory canal medial to the superior semicircular canal.
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Chapter 14 SURGICAL MANAGEMENT OF VESTIBULAR DISORDERS
207
Figure 14.2 Translabyrinthine approach for

removal of acoustic neuroma. A translabyrinthine
approach to the internal auditory canal is shown
in surgical position with anteriortop; superior
left. The tumor is exposed after completion of a
labyrinthectomy (see Fig. 14.5). The internal auditory canal has been dilated by the tumor. Removal
of the last shell of bone over the tumor as well as
the bone from the posterior fossa allows complete
removal of the tumor.
to expose the sigmoid sinus, posterior fossa dura, and

middle fossa dura. The facial nerve is protected by identification within its bony canal. A complete labyrinthectomy is performed to expose the internal auditory canal.
Once the intracanalicular portion of the tumor is mobilized, the dura of the posterior fossa is incised, and the
remainder of the tumor is removed.
Recovery after translabyrinthine removal of acoustic
tumors is generally prompt, and patients can be out of bed
in 2 to 3 days. This rapid recovery is attributable to the
lack of pressure or retraction of the cerebellum during
the procedure. The disadvantage of the translabyrinthine
approach is that hearing is automatically sacrificed. The
exposure is excellent for small and medium-sized tumors
but is inadequate for tumors more than 2.5 cm in diameter and for those that are adherent to the brainstem. In the
ideal case for translabyrinthine removal, computed
tomography (CT) or MRI shows a clear separation between the tumor and the brainstem.
from behind rather than in front of the sigmoid sinus. The

incision is placed 5 to 6 cm behind the ear, and a 5-cm
piece of the occipital skull is removed. This defect is
reconstructed with prosthetic mesh at the end of the
procedure.
Suboccipital Craniectomy
Suboccipital craniectomy gives the best exposure when
the tumor is large or adherent to the brainstem (Fig.
14.3). In rare cases in which there is good hearing preoperatively, the suboccipital approach offers the possibility
of preserving hearing. Maintenance of hearing requires
the preservation of both the cochlear nerve and the fragile capillary blood supply of the inner ear. Hearing can be
spared in one third to one half of the patients in whom
this approach is attempted.8
The suboccipital craniectomy differs from the translabyrinthine approach in that the angle of the approach is
Figure 14.3 Suboccipital craniectomy. This axial section

demonstrates a posterior fossa craniotomy behind the sigmoid sinus. The cerebellum drops away from the posterior
surface of the temporal bone. The tumor is exposed in the
cerebellopontine angle. The posterior lip of the internal auditory
canal must be drilled away to remove the tumor extending into
the canal.
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The cerebellum lies between the craniotomy and the

cerebellopontine angle; however, the operation is performed with the patient in the lateral position, allowing
the cerebellum to fall away by itself without additional
retraction.
After the tumor is identified, the capsule of the
tumor is incised, and the central core of the tumor is
removed with an ultrasonic aspirator or laser. After the
tumor has been decompressed, the portion of the tumor
within the internal auditory canal is removed by drilling
away the posterior surface of the canal. The facial nerve
is identified in the fundus of the internal auditory canal,
where its anatomy is constant. The tumor is mobilized
from the brainstem, and the VIIth nerve is identified
medial to the tumor.
Recovery time after a suboccipital craniotomy is
longer than from the other two approaches because of the
magnitude of the procedure, but patients are usually
ready for discharge from the hospital within a week.
Occasionally a patient experiences a postcraniotomy
headache that requires long-term pain management.
hearing preservation. Lin and associates13 found a drop in

serviceable hearing from 69% pretreatment to 6.7% at a
mean of 4 years after SRS.
Despite successful outcome in the majority of
patients treated with SRS, a small fraction have continued
growth of the tumor and require surgical salvage. Several
authorities have commented on the increased difficulty of
surgical dissection after SRS. A case-matched study by
Limb and colleagues14 showed severely increased fibrosis
of the tumor, more difficult dissection of the facial and
lower cranial nerves from the tumor capsule, longer operative times, and poorer facial nerve outcomes for surgery
after irradiation. The ideal indications for microsurgical
removal versus stereotactic radiosurgery for acoustic
tumors remain contentiously debated. I recommend surgical removal of tumors in younger patients, of medially
placed tumors, which tend to grow faster, of tumors larger than 3 cm or with significant brainstem compression,
and of small tumors in patients with a legitimate chance
of hearing preservation. SRS is ideal for middle-aged and
elderly patients and patients with medical problems that
make them poor surgical risks.
Complications
Complications after acoustic neuroma surgery are relatively uncommon. Hearing loss always occurs in translabyrinthine procedures and is common after suboccipital
removal of tumors larger than 1.5 cm. Transient facial
paralysis is common with larger tumors. Permanent facial
paralysis is seen in fewer than 5% of patients. CSF leaks
can occur postoperatively but are usually transient and
rarely require secondary surgical correction.
Stereotactic Radiosurgery
SRS was introduced by Leksell9 in 1971 and has gained
wide popularity in the last few years. In this procedure, a
single treatment of high-dose irradiation is administered
by stereotactically focused multiple radiation sources or
arced beams focused on the tumor. The tumor receives an
extremely high radiation dose while, with proper geometric planning, the surrounding neural and vascular
structures are spared.
The initial results of radiosurgery are encouraging.
Tumor control is achieved in 70% to 80% of patients, and
the procedure has a low incidence of complications,
especially facial paralysis.10,11 Pollock and coworkers12
compared the results of SRS and microsurgical removal
in 87 patients (40 surgery, 47 SRS). The results for surgery versus SRS, respectively, were as follows: tumor
control, 98% versus 94%; preservation of hearing, 14%
versus 75%; and normal facial function, 63% versus
83%. Longer-term follow-up is not as encouraging for
Mnires Disease
Although the underlying etiology of Mnires disease is
unknown, a consistent histopathological finding is
hydrops (dilation) of the endolymphatic spaces.15 The
hydrops presumably results from a malfunction of the
resorptive function of the endolymphatic sac. The classic
constellation of symptoms includes fluctuating hearing
loss, episodic vertigo, tinnitus, and a sensation of fullness
in the ear.16 These symptoms do not necessarily develop
simultaneously, however, and many patients do not experience them all. Subcategories of Mnires disease
describe these other conditionsfor instance, cochlear
hydrops (fluctuating hearing loss alone) and vestibular
hydrops (vestibular symptoms without hearing loss).16
In most patients, Mnires disease is ultimately
self-limited; over time, the patient suffers deterioration of
hearing and a gradual subsiding of the episodic dizzy
spells. This evolution, however, may require 10 or 20
years. In the interim, the patients lifestyle may be severely impaired.
Medical therapy of Mnires disease rests on
avoiding factors known to exacerbate the symptoms:
stress, caffeine, alcohol, nicotine, and foods high in salt.
Diuretics and vestibular suppressant drugs are usually
prescribed. This regimen, known as the Furstenberg regimen, can adequately control the symptoms in up to three
quarters of patients.17 A few patients, however, cannot be
adequately managed by medical means alone, and surgi-
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cal intervention must be considered. The surgical procedures for Mnires disease may be categorized as those
designed to improve the function of the endolymphatic
sac and those that ablate the vestibular system, with or
without preservation of hearing.
Surgical Management
of Mnires Disease
Endolymphatic Sac Surgery
Endolymphatic sac procedures attempt to reestablish
the function of the sac as the resorptive organ for the
endolymph of the inner ear by draining the excess
endolymphatic sac into the mastoid cavity.18 A standard
postauricular mastoidectomy is performed, and the sigmoid sinus, mastoid antrum and incus, facial nerve, and
lateral and posterior semicircular canals are identified.
The endolymphatic sac is found between the posterior
surface of the temporal bone and the dura of the posterior fossa. The bone is thinned until the dura and the sac
are identifiable through the last layer of bone. This bone
is picked away to expose the dura and the overlying
endolymphatic sac. The sac is opened, and polymeric silicone (Silastic) sheeting or another shunt device is inserted into the lumen of the endolymphatic sac and allowed
to drape into the mastoid cavity. Care must be taken to
open the endolymphatic sac without puncturing the
underlying dura and thereby possibly causing a CSF leak.
Any endolymph drained by the shunt is resorbed by the
mucous membranes of the mastoid cavity.
It is almost an understatement to say that endolymphatic sac surgery is controversial. The fluid spaces
involved are minuscule, and the ability of mechanical
means to improve function of the sac is doubtful. In a
clinical trial, similar results were obtained with real and
sham operations.19 Nonetheless, the procedure controls
the vertiginous attacks in one half to two thirds of patients
and has the advantage of relative ease and safety.
Vestibular Neurectomy and Labyrinthectomy

Although vestibular neurectomy and labyrinthectomy are
more complex than endolymphatic sac surgery, control of
vertigo is predictable and reliable in 90% to 95% of
patients with either procedure. These procedures should
completely relieve the vertiginous attacks, because
vestibular input from the operated ear is completely eliminated. The loss of all vestibular function on one side can
easily be compensated by an intact labyrinth on the opposite side.
When the hearing is worth preserving (the ability to
detect speechor speech reception thresholdis better
209
than 60dB, and the ability to understand speechor

discrimination scoreis better than 50%), a vestibular
neurectomy through either the middle cranial fossa or
retrolabyrinthine space is the procedure of choice.
The middle cranial fossa approach is the same as
described previously for acoustic tumors. Once the internal auditory canal has been identified and exposed, it can
be opened, and the superior and inferior vestibular nerves
divided.
The vestibular nerve can also be sectioned through
either a retrolabyrinthine or retrosigmoid (suboccipital)
approach (Fig. 14.4). In the retrolabyrinthine approach, a
complete mastoidectomy is performed as described for
the endolymphatic sac procedure.20 In addition, all of the
bone medial to the sigmoid sinus is removed to expose
the posterior fossa dura. The dura is opened to expose the
cerebellopontine angle. The vestibular and auditory
branches of the VIIIth nerve are directly in the field of
view, and the vestibular nerve is divided. A disadvantage
of this approach is that the auditory and vestibular portions of the VIIIth nerve are fused as they exit the brainstem and may not have separated before they enter the
internal auditory canal. Some surgeons have advocated a
retrosigmoid approach to drill away the posterior lip of
the internal auditory canal; this procedure permits identification of the vestibular nerve after it has separated from
the auditory nerve.21
If hearing preservation is not a goal, for example, in
patients with unilateral Mnires disease and severely
impaired hearing or discrimination, a labyrinthectomy is
the most effective treatment. Labyrinthectomy can be
performed either through the external auditory canal or
through the mastoid (Fig. 14.5). In the transcanal
approach, the tympanic membrane is elevated to expose
the middle ear. The stapes is removed, and the vestibule
is opened between the oval and round windows. The saccule, utricle, and ampullae of the superior, lateral, and
posterior semicircular canals are removed with an angled
pick. Reaching the ampulla of the posterior semicircular
canal is a blind maneuver and may leave neuroepithelium
behind. For this reason, I prefer the transmastoid
approach. A standard mastoidectomy is performed, and
all three semicircular canals are identified. Each one is
drilled away in turn, and the neuroepithelium is identified
under direct vision and removed. The three semicircular
canals lead to the vestibule, where once again the saccule
and utricle are removed.
Chemical Labyrinthectomy
Chemical labyrinthectomy with aminoglycosides has
gained popularity in the management of Mnires dis-
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Figure 14.4 Retrolabyrinthine vestibular nerve section. This surgeons view of a right ear in
surgical position (anteriortop; superiorleft) shows the exposure for a retrolabyrinthine nerve
section. The cerebellopontine angle is exposed by removal of the posterior surface of the temporal
bone between the sigmoid sinus and the posterior semicircular canal. The dura is opened, and the
VIIth and VIIIth nerves are identified. The demarcation between the vestibular and auditory portions
of the nerve is usually marked by a small branch of the anterior-inferior cerebellar artery (AICA).
The vestibular portion of the VIIIth nerve (superior half) is divided.
ease and has almost replaced surgical intervention in

some centers. Several protocols, doses, and dosing
schedules have been reported, but in essence, a low dose
of gentamicin is injected into the middle ear space, either
directly through the tympanic membrane with topical
Figure 14.5 Labyrinthectomy. A transmastoid labyrinthectomy of the right ear (anteriortop; superiorleft). The three
semicircular canals have been identified, and the lateral and
posterior canals have been partially opened. The canals will
be completely removed, and the vestibule will be opened to
remove all neuroepithelium. AICA = anterior-inferior cerebellar
artery; Roman numerals indicate cranial nerves.
anesthesia, through a myringotomy tube, or with a

continuous-perfusion device. 13,22 This procedure appears
to produce good control of vertigo attacks but poses significant risk to hearing.24 Cohen-Kerem and associates25
performed a meta-analysis of 15 studies totaling 627
patients treated with intratympanic gentamicin. Although
the doses and dosing schedules varied widely among the
studies, these researchers found that complete control of
vertigo had been achieved in 75% of patients, and complete or substantial control in 93%. The vertigo control
results did not appear to differ for the various treatment
regimens. Among multiple studies, progression in hearing loss occurs in about 30% of treated patients.
Intratympanic administration of aminoglycosides
has the great advantage of being nonoperative, thus
avoiding the risks of anesthesia and surgery and the cost
of hospitalization. Even though it is a simple procedure,
however, it must be taken with the same seriousness as
any other destructive procedure on the labyrinth. The
risks of chronic post-labyrinthectomy disequilibrium and
hearing loss must be carefully explained to the patient,
and the same rules of informed consent apply to this procedure as to a surgical intervention.
In all the procedures described, the implicit belief is
that the disease is unilateral or, if disease is bilateral, the
side producing the majority of symptoms can be determined. Surgical procedures, however, are seldom, if ever,
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indicated in patients who have active bilateral disease.

Special care should be taken in patients with bilateral or
contralateral labyrinthine hypofunction. A patient left
with bilateral vestibular loss may have chronic disequilibrium, significant difficulty walking in the dark, and
inability to keep the eyes fixed on a target during head
movements (oscillopsia).26
Post-Traumatic Vertigo
Post-traumatic vertigo is managed in a manner identical
to Mnires disease, with either a hearing-preserving or
hearing-sacrificing form of vestibular ablation. Most
authorities, however, report less reliable control of recurrent attacks of dizziness after such treatment for this disorder.27 The reasons for these results are unknown.
Benign Paroxysmal
Positional Vertigo
Unlike patients with Mnires disease, who experience
spontaneous episodes of dizziness, those suffering from
benign paroxysmal positional vertigo (BPPV) have
transient symptoms only when they assume certain positions.16 The most common position is in a lateral or headhanging position with the diseased ear down. The
symptoms generally have a few seconds latency before
onset, develop in a crescendo-decrescendo pattern, demonstrate torsional nystagmus, and habituate on repeated
trials. The site of the pathology is generally thought to be
in the posterior semicircular canal. Schuknecht15 has
described debris on the cupula of the posterior semicircular canal, which he has called cupulolithiasis. The
symptoms could arise from dislodged otoconia floating
in the posterior semicircular canal as well as from those
physically attached to the cupula.
BPPV is commonly a self-limiting condition that
resolves regardless of what treatment is given.16 A number of different physical therapy measures have been
designed to dislodge the otoconia from the posterior
semicircular canal. These measures are effective in the
vast majority of patients (see Chapter 17).
Rarely, a patient with BPPV has persistent symptoms despite physical therapy intervention and the passage of time. In these cases, two surgical procedures can
be considered. The first is singular neurectomydivision
of the branch of the vestibular nerve to the posterior
semicircular canal.28 This procedure is technically difficult and has been described as being performed at only a
few centers. The singular nerve passes just medial to the
round window niche before entering the ampulla of the
posterior canal. The lip of the round window is drilled
211
away, but the round window membrane must not be violated. Bone is removed posterior and inferior to the round
window membrane with tiny diamond spurs to expose
the singular canal. The canal is opened, and the nerve
avulsed.
Surgical blockade of the flow of endolymph in the
posterior semicircular canal has also been described.29
In this procedure, the bony posterior semicircular canal
is opened without violation of the membranous labyrinth.
Flow within the membranous labyrinth is blocked
by occlusion of the bony and membranous canals with
a bone plug. Reports from several centers confirm this
procedure as an effective and low-risk treatment for
those rare cases of BPPV that fail to respond to particlerepositioning maneuvers.30,31
Perilymphatic fistula is a direct communication between
the inner ear and the middle ear, usually through the
round or oval window (Fig. 14.6).29 Such leaks were initially described in association with barotrauma; however,
spontaneous leaks are being described with increasing
frequency. The symptoms of perilymph leak include
hearing loss, usually sudden or episodic; vertigo associated with the hearing loss; and, more recently, generalized spatial disorientation with normal hearing.
The diagnosis of perilymphatic fistula, and the indications and timing of surgery, are some of the most
controversial subjects in the otological literature. To date
no preoperative diagnostic test definitively confirms or
excludes the presence of a perilymphatic fistula. Even
upon surgical exploration, there may be disagreements
among observers as to the presence or absence of a fluid
leak. Biochemical and fluorescent tracer studies as well
as protein analyses are being developed as potential
markers for the presence or absence of the perilymph
fistula.33
Middle ear exploration for perilymph fistula is
straightforward. The middle ear is approached through
the external auditory canal, and the tympanic membrane
elevated. Both the oval and round windows are carefully
observed for the repeated accumulation of fluid. The leak
may become more obvious with a Valsalva maneuver
(increased intrathoracic pressure against a closed glottis).
The leak is repaired with autogenous tissue. Clinicians
generally believe that the patient should remain on
bedrest for some time after closure of perilymph fistula to
allow the graft to heal in place.32
In most cases, the patient feels better shortly after
repair of a perilymphatic fistula. Patients with persistent
symptoms present the physician with the difficulty of
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Figure 14.6 Perilymphatic fistula. A

right middle ear exploration for perilymph fistula is shown in the surgical
position (anteriortop; superiorright).
The tympanic membrane has been
reflected forward to expose the oval and
round windows. Close inspection of the
annular ligament of the oval window
demonstrates a leak of perilymph. This
will be closed with an autologous tissue
graft. VIIth = seventh cranial nerve.
deciding whether the repair has failed or the diagnosis

was wrong in the first place.
Vascular Loops
Vascular loops are elongated or tortuous vessels (arteries
or veins) within the intracranial cavity that are thought to
press on nerve roots as they exit from the brainstem (Fig.
14.7). The first well-described vascular syndrome was
hemifacial spasm, an uncontrollable twitching of one
side of the face. This was found by Janetta and collegues34 to be caused by an abnormal vessel pressing on
the root-entry zone of the facial nerve. This concept has
been expanded to include vestibular and auditory disorders.35 The significance of these vascular loops is difficult
to determine, because the symptoms overlap other diagnostic categories, including Mnires disease and perilymphatic fistula. Furthermore, tortuous vessels are
common in the cerebellopontine angle of normal individuals, especially after middle age. Nonetheless, there are
documented cases of vessels impinging on nerves and
causing abnormal stretching or displacement. It has been
suggested that radiologic confirmation can be obtained
Figure 14.7 Retrolabyrinthine exposure of vascular compression. The exposure is the same as shown in Figure 144.
The anterior-inferior cerebellar artery (AICA) is seen compressing the VIIIth nerve. This compression is treated by careful
elevation of the vessel and interposition of muscle or sponge
material between the vessel and the nerve. Roman numerals
indicate cranial nerves.
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with the combination of high-resolution CT with intravenous and air contrast.

Microvascular loop decompression is performed
through a standard posterior craniectomy. The offending
artery or vein is carefully dissected from the nerve, and a
small piece of muscle or polytetrafluoroethylene sponge
is interposed to keep the vessel from pressing on the
nerve.
Summary
The development of surgical interventions for vertigo is a
fascinating and challenging branch of neurotology.
Unfortunately at the moment, most of the procedures
used are ablative rather than restorative. Future developments in this field will be directed toward the rehabilitation and functional restoration of the diseased inner ear.
References
1. Nager, GT: Acoustic neurinomas. Acta Otolaryngol
(Stockh) 1985;99:245.
2. Thomsen J, et al: Acoustic neuromas: progression of hearing impairment and function of the eighth cranial nerve.
Am J Otol 1983;5:20.
3. Wiet RJ, et al: Conservative management of patients with
small acoustic tumors. Laryngoscope 1995;105:795.
4. Charabi S, et al: Acoustic neuroma (vestibular schwannoma): growth and surgical and nonsurgical consequences
of the wait-and-see policy. Otolaryngol Head Neck Surg
1995;113:5.
5. Cushing H: Tumors of the Nervus Acusticus and the
Syndrome of the Cerebellopontine Angle. Philadelphia:
WB Saunders; 1917.
6. Fisch U, Mattox DE: Microsurgery of the Skull Base.
New York: Thieme; 1988.
7. Brackmann DE: A review of acoustic tumors: 19791982.
Am J Otol 1984;5:233.
8. Harner SG, et al: Hearing preservation after removal of
acoustic neurinoma. Laryngoscope 1984;94:1431.
9. Leksell L: A note on the treatment of acoustic tumors. Act
Chir Scand 1971;137:763.
10. Yamamoto M, Noren G: Stereotactic radiosurgery in
acoustic neurinomas. No Shinkei Geka 1990;18:1101.
11. Flickinger JC, et al: Radiosurgery of acoustic neurinomas.
Cancer 1990;67:345.
12. Pollock BE, et al: Outcome analysis of acoustic neuroma
management: a comparison of microsurgery and stereotactic radiosurgery. Neurosurgery 1995;36:215.
13. Lin VYW, et al: Unilateral acoustic neuromas: long-term
hearing results in patients managed with fractionated
stereotactic radiotherapy, hearing preservation surgery,
and expectantly. Laryngoscope 2005;115:292.
14. Limb CJ, et al: Acoustic neuromas after failed radiation
therapy: challenges of surgical salvage. Laryngoscope
2005;115:93.
213
15. Schuknecht HF: Pathology of the Ear. Cambridge, MA:

Harvard University Press; 1974.
16. Paparella MM, et al: Mnires disease and other
labyrinthine diseases. In: Paparella MM, et al, eds.
Otolaryngology. Philadelphia: WB Saunders; 1991:1689.
17. Boles R, et al: Conservative management of Mnires
disease: Furstenberg regimen revisited. Ann Otol 1975;
84:513.
18. Arenberg IK: The fine points of valve implant surgery for
hydrops: an update. Am J Otol 1982;3:359.
19. Thomsen J, et al: Placebo effect in surgery for Mnires
disease. Arch Otolaryngol 1981;107:271.
20. Silverstein H, Norrell H: Retrolabyrinthine vestibular
neurectomy. Otolaryngol Head Neck Surg 1982;90:778.
21. Silverstein H, et al: Combined retrolab-retrosigmoid
vestibular nerve neurectomy: an evolution in approach.
Am J Otol 1989;10:166.
22. Nedzelski JM, et al: Intratympanic gentamicin instillation
as a treatment of unilateral Mnires disease: update of
an ongoing study. Am J Otol 1993;14:278.
23. Magnusson H, Padoanm S: Delayed onset of ototoxic
effects of gentamycin in treatment of Mnires disease:
rationale for extremely low dose therapy. Acta Otolaryngol (Stockh) 1991;111:671.
24. Toth AA, Parnes LS: Intratympanic gentamicin therapy
for Mnires disease: preliminary comparison of two
regimens. J Otolaryngol 1995;24:340.
25. Cohen-Kerem R, et al: Intratympanic gentamicin for
Menieres disease: a meta-analysis. Laryngoscope
2004;114:2086.
26. Schuknecht HF: Ablation therapy in the management of
Mnires disease. Acta Otolaryngol Suppl (Stockh)
1957;132:142.
27. Kemink, JL, et al: Retrolabyrinthine vestibular nerve section: Efficacy in disorders other than Mnires disease.
Laryngoscope 101:523, 1991.
28. Gacek RR: Singular neurectomy update. Ann Otol Rhinol
Laryngol 1982;91:469.
29. Parnes LS, McClure JA: Posterior semicircular canal
occlusion for intractable benign paroxysmal positional
vertigo. Ann Otol Rhinol Laryngol 1990;99:330.
30. Parnes LS: Update on posterior canal occlusion for benign
paroxysmal positional vertigo. Otolaryngol Clin North
Am 1996;29:333.
31. Zappia JJ: Posterior semicircular canal occlusion for
benign paroxysmal positional vertigo. Am J Otol
1996;17:749.
32. Mattox DE: Perilymph fistulas. In: Cummings CWC, et
al, eds. Otolaryngology Head and Neck Surgery St. Louis:
Mosby, 1986:3113.
33. Paugh DR, et al: Identification of perilymph proteins by
two-dimensional gel electrophoresis. Otolaryngol Head
Neck Surg 1991;104:517.
34. Janetta PJ, et al: Etiology and definitive microsurgical treatment of hemifacial spasm. J Neurosurg 1977;
47:321.
35. Janetta PJ: Neurovascular cross-compensation of the
eighth cranial nerve in patients with vertigo and tinnitus.
In: Sammi M, Janetta PJ, eds. The Cranial Nerves. New
York: Springer-Verlag, 1981:552.
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15
Psychological
Problems and the
Dizzy Patient
It is more important to know what kind of patient

has the disease than to know what kind of disease
the patient has.
The good physician will treat the disease, but
the great physician will treat the whole patient.
Sir William Osler
Dizziness can cause extreme stress, which may in
turn lead to anxiety (including panic attacks and agoraphobia), depression, and somatoform disorders. These
psychological problems can also cause severe dizziness.
At times, these psychological causes may become the
primary cause of dizziness and may replace the initial
organic cause of dizziness.
Two good longitudinal studies have assessed the
role of psychological problems in dizziness. Kroenke and
associates1 examined 94 patients at onset of dizziness and
then had them complete questionnaires at 4 months and 1
year later. Symptoms improved for 51 patients, stayed the
same for 32, and worsened for 11. Etiology of the dizziness affected outcome. The majority of patients with
benign paroxysmal positional vertigo (BPPV), neuritis,
migraine, or presyncope experienced improvement. Less
than half of those with Mnires disease or psychiatric
or non-vestibular disequilibrium showed improvement.
The four multivariate predictors of poor outcome were 1)
primary psychiatric etiology, 2) dysequilibrium, 3) daily
dizziness, and 4) dizziness aggravated by walking.
214
Yardley and colleagues2 examined 101 patients at

onset of dizziness and 7 months later. The best longitudinal predictors of poor outcome were autonomic symptoms (heart pounding, excessive sweating, hot or cold
spells, feeling faint or short of breath) and somatization
(general tendency to complain of a diversity of unrelated
health problems, ranging from pains in the back to difficulty concentrating). These symptoms had a better prediction of poor outcome than did the etiology of true
vertigo, severity, duration, test results, or medication.
High and persistent handicap arose from psychiatric or
psychosocial problems unrelated to the vertigo.
This chapter summarizes the interaction between
dizziness and psychological problems. It also discusses
conversion disorders and malingering. Finally, it presents
a practical clinical approach to these problems.
and Their Prevalence
Dizziness in Patients with
Prevalence of Psychological Disorders
The prevalence of psychological problems in the general
population is very high. Table 15-1 lists the prevalence in
the United States.
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Chapter 15
Table 15-1 PSYCHOLOGICAL

DISORDERS IN THE U.S.
POPULATION (NIMH)
Disorder
No. Affected
in U.S.
Anxiety disorders:
23.2 million
% Affected
in U.S.
12.6:
10.9
Phobia
Obsessivecompulsive
disorder
2.1
Panic with and

without agoraphobia
1.3
PSYCHOLOGICAL PROBLEMS AND THE DIZZY PATIENT
215
(DSM-III), criteria for panic disorder, agoraphobia, or

both and that these patients rate themselves as much more
disabled by their dizziness than patients with no psychiatric disorder. The prevalence of psychiatric disorders as
the primary cause of dizziness declines with increasing
patient age.1,11 In patients older than 60 years, 38% have
psychological diagnosis contributing to dizziness, but of
these, only 6% were believed to have a primary psychological cause for the dizziness. Psychological problems
often coexist with a significant balance disorder.
Patients with and without

Peripheral Vestibular Deficits
Depressive disorders
17.5 million
9.5
Somatization disorders
400,000
0.2
Abnormal Results of Vestibular Tests in

Patients with Psychological Problems
To what extent patients with panic disorder have a
vestibular defect is controversial. Several authorities have
reported abnormal results on a variety of tests used to
assess dizziness, including caloric testing, rotary chair
testing, vestibular autorotation, and posturography.37
Few articles have sufficient detail to allow determination
whether these deficits are truly due to vestibular dysfunction (high vestibulo-ocular reflex [VOR] gain on rotary
chair testing or decreased response on caloric testing). Of
these more detailed articles, one article suggest that as
many as 14% of patients with panic but without agoraphobia and 39% of patients with panic and agoraphobia
have compensated peripheral vestibular defects.5 Another
article found discrepancies in the VOR but no caloric
deficits in patients with panic disorder.4
Psychological Problems
in Patients with Dizziness
There is a high prevalence of unrecognized mood and
psychological problems in dizzy patients, especially anxiety disorders.8,9 Forty percent of all dizzy patients have
psychological disorders.1 Stein and coworkers10 report
that 15% of all dizzy patients meet the Diagnostic and
Statistical Manual of Mental Disorders, 3rd edition
Forty percent of patients with vestibular hypofunction

presenting to an otolaryngology clinic have an additional
panic disorder with and without agoraphobia.12 Fifty percent of patients with vestibular hypofunction evaluated 3
to 5 years after the original referral still had a significant
psychiatric disturbance (panic disorder or major depression).13 In my experience, panic attacks do occur in a
number of patients with vestibular deficits, but not to the
same extent as reported in these studies conducted by
psychiatrists. Chronic anxiety is much more prevalent.
The level of anxiety in these patients is usually not high
enough to warrant psychotherapy or medication. Space
phobia,14 motorists disorientation syndrome,15 and
phobic postural vertigo16 have also been described as
syndromes seen after vestibular defects. Patients without
evidence of peripheral vestibular deficit have a greater
mean number of lifetime psychiatric diagnoses, especially major depression and panic disorder, than those with
a vestibular deficit.9 Patients without vestibular deficits
more frequently have somatization disorders as well
as more current and lifetime unexplained medical
symptoms.
Disability
Clark and associates17 have evaluated disability in dizzy
patients with and without vestibular defects. They found
that severe impairment of the ability to function was
more strongly associated with the presence of a psychiatric disorder than was the presence of a vestibular disorder. Nausea, vomiting, palpitations, weakness, and
difficulty with speech in patients with complaints of
dizziness were indicators of a psychiatric disorder and
not of a peripheral vestibular disorder. This finding suggests that the clinician should look for comorbid psychiatric disorder in patients with persistent complaints of
these symptoms.
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Assessment
Scales
A number of questionnaires can be helpful in the diagnosis and assessment of psychological problems. They are
discussed here.
Millon Behavioral Medicine Diagnostic

The Millon Behavioral Medicine Diagnostic (MBMD) is
an inventory developed in the early 1970s and extensively revised during the 1990s.18 It is a 165-item, self-report
inventory with 29 clinical scales. It was designed to
assess psychological factors that can influence the course
of treatment of medically ill patients. The MBMD has
been validated in physically ill patients and behavioral
medicine patients 18 to 85 years old. It takes 20 to 25
minutes to complete and requires a 6th grade reading
level (see Case Study 1 at the end of the chapter).
Positive and Negative Affective Scale

The Positive and Negative Affective Scale (PANAS) is a
good screening scale for anxiety and depression.19 The
patient is given a paper form similar to the representation
in Box 15-1. The patients form does not contain the (P)
and (N) labels at the ends of the items, which indicate
positive and negative terms.
The numbers assigned to each (P) term are added

up. The mean score for (P) is 35.0 6.4. Depression
should be considered if the subject scores less than 22 (2
standard deviations below the mean). The numbers
assigned to each (N) term are then added up. The mean
score for this term is 18.1 5.9. Anxiety should be considered if the subject scores more than 29.9 (2 standard
deviations above the mean).
Dizziness Handicap Inventory

The Dizziness Handicap Inventory (DHI) is a measure of
self-perceived disability attributable to vestibular disease.
Twenty-five questions classified into physical, functional, and emotional domains are given (listed in Table
15-2).20 A yes response is scored 4 points, sometimes
is scored 2 points, and no response is scored 0 points.
Thus, the total score ranges from 0 (no perceived disability) to 100 (maximum perceived disability). The
developers of the test, Jacobson and Newman,20 gave
the test to 106 consecutive patients seen for vestibular
testing. The mean score and standard deviation were
32.7 21.9.
The DHI can be used to identify specific functional,
emotional, or physical problems associated with dizziness. No significant correlation has been found between
DHI and the results of caloric or rotary chair testing.20,21
Whether there is a correlation between the sensory aspect
Box 15-1
POSITIVE AND NEGATIVE AFFECTIVE SCALE (PANAS)

This scale consists of a number of words that describe different feelings and emotions. Read each item and then
mark the appropriate answer in the space next to it. Indicate to what extent you generally feel this way, that is,
how you feel on the average. Use the following scale to record your answers.
1
2
3
4
5
very slightly
a little
moderately
quite a bit
extremely
interested (P)
distressed (N)
excited (P)
upset (N)
strong (P)
guilty (N)
scared (N)
irritable (N)
alert (P)
ashamed (N)
inspired (P)
nervous (N)
determined (P)
attentive (P)
jittery (N)
active (P)
afraid (N)
hostile (N)
enthusiastic (P)
proud (P)
(N) negative term; (P) positive term. The patients form does not contain these labels. See text for explanation of scoring.
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217
Table 15-2 ITEMS CONSTITUTING THE DIZZINESS HANDICAP INVENTORY*

P1.
Does looking up increase your problem?
E2.
Because of your problem, do you feel frustrated?
F3.
Because of your problem, do you restrict your travel for business or recreation?
P4.
Does walking down the aisle of a supermarket increase your problem?
F5.
Because of your problems, do you have difficulty getting into or out of bed?
F6.
Does your problem significantly restrict your participation in social activities, such as going out to dinner, movies, dancing, or parties?
F7.
Because of your problem do you have difficulty reading?
P8.
Does performing more ambitious activities, like sports, dancing, and household chores such as sweeping
or putting dishes away, increase your problem?
E9.
Because of your problems, are you afraid to leave your home without having someone accompany
you?
E10.
Because of your problem, have you been embarrassed in front of others?
P11.
Do quick movements of your head increase your problem?
F12.
Because of your problem, do you avoid heights?
P13.
Does turning over in bed increase your problem?
F14.
Because of your problem, is it difficult for you to do strenuous housework or yard work?
E15.
Because of your problem are you afraid people may think you are intoxicated?
F16.
Because of your problem, is it difficult for you to go for a walk by yourself?
P17.
Does walking down a sidewalk increase your problem?
E18.
Because of your problem, is it difficult for you to concentrate?
F19.
Because of your problem, is it difficult for you to walk around your house in the dark?
E20.
Because of your problem, are you afraid to stay home alone?
E21.
Because of your problem, do you feel handicapped?
E22.
Has your problem placed stress on your relationships with members of your family or friends?
E23.
Because of your problem are you depressed?
F24.
Does you problem interfere with your job or household responsibilities?
P25.
Does bending over increase your problem?
*E emotional subscale items; F functional subscale items; P physical subscale items.
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of posturography and DHI is controversial.21,22 Nevertheless, this self-assessment inventory is reliable,

requires little time to administer, has a high internal consistency, and may be useful to evaluate the efficacy of
treatment.
Disability Scale
Shepard and colleagues23 developed a disability scale
that can be used as a screen to predict whether patients
with vestibular defects will improve with vestibular rehabilitation. This scale has been validated for extent of perceived disability in patients with unilateral and bilateral
vestibular loss (UVL and BVL, respectively). The patient
is asked to pick one statement out of six that best fits
how he or she feels (Table 15-3). A score of 4 or higher
is correlated with poor outcome from vestibular rehabilitation.
Other Scales
Other standardized questionnaires are listed here. My
colleagues and I have not used them in our clinic, but
Table 15-3 DISABILITY SCALE*

For the following, please pick the one statement that
best describes how you feel
Statement
Score
they may be useful for assessing the effect of certain

forms of therapy on clinical outcome.
Structured Clinical Interview for DSM-IV: A structured interview in which a series of standard questions are asked in standard order, with options to
focus on the most relevant points for that patient.24
Beck Anxiety Inventory25 and the Beck Depression Inventory26: Specific screens for anxiety and
depression.
Symptom Checklist-90 (SCL-90-R): A standardized questionnaire for medical, functional, and
demographic data; it also contains anxiety,
depression, somatization, and phobic anxiety
subscales.
Examination for Psychogenic
Stance and Gait Disorders
On the basis of a review of videotapes from 37 patients
with psychogenic balance and gait, Lempert and associates27 have identified six characteristic clinical features
that are useful in the diagnosis of psychogenic stance and
gait disorders. Table 15-4 lists these features and their
prevalence in the 37 patients in the Lempert study. This
Table 15-4 CLINICAL FEATURES

OF PATIENTS WITH
PSYCHOGENIC BALANCE
AND GAIT DISORDERS
Negligible symptoms
Bothersome symptoms
Performs usual work duties but symptoms

interfere with outside activities
Moment-to-moment fluctuations
in the level of impairment
51
Symptoms disrupt performance of

both usual work duties and outside
activities
Excessive slowness or hesitation
51
Exaggerated sway on Romberg test,

often improved by distraction
32
Currently on medical leave or had to change

jobs because of symptoms
4
Uneconomical postures with waste
of muscular energy
30
Unable to work for over one year or established permanent disability with
compensation payments
5
Extreme caution with restricted
steps (walking on ice)
30
Sudden buckling of the knees,

typically without falling
27
Patient is given a paper with the statements on it and asked, Please

pick the one statement that best describes how you feel. See text
for scoring.
Feature
Frequency (%)
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review found psychogenic gait disorders in 9% of their

neurologic inpatients. In 5 years, 47% had favorable
outcomes.16
Aphysiological Spasm of Convergence

Patients sometimes demonstrate convergence of the eyes
(cross-eyed) while being examined. This is usually
associated with pupillary constriction. It is aphysiological (functional) when it is episodic and there are no
other ocular motor defects.28 When other dorsal midbrain abnormalities are present (chronic pupillary
changes, upgaze defect), an organic basis should be considered.
Voluntary Nystagmus
Voluntary nystagmus is a type of nystagmus that some
individuals can learn to exhibit volitionally.29 Historically,
it was used by young American men to avoid military
draft. It should not be confused with flutter. Voluntary
nystagmus is commonly associated with vergence eye
movements and pupillary constriction.
A number of studies have found characteristic features on
dynamic posturography in patients with psychogenic balance disorders.3032 Box 15-2 lists the key patterns in
such patients. Figure 15.1 compares the sensory test
results of a patient with a psychogenic balance disorder
with those of a patient with an acute UVL.
Anxiety
Panic Attacks with and
without Agoraphobia
Dizziness is the most common symptom in patients with
panic disorder, occurring in 50% to 85% of all such
patients.33,34 Panic attacks consists of discrete spells of
intense fear or discomfort, in which at least four of the
symptoms listed in Box 15-3 develop abruptly and reach
crescendo within 10 minutes. Panic attacks can be unexpected (uncued) or situationally bound (cued). An example of the latter is spells induced when entering a car.
Agoraphobia is the aversion of open spaces, including
leaving the house. Agoraphobia is commonly found in
patients with severe panic attacks.
219
Box 15-2
KEY PATTERNS ON DYNAMIC

POSTUROGRAPHY IN PATIENTS
WITH PSYCHOGENIC BALANCE
DISORDERS
Substandard performance on sensory tests
1 and 231,32
Better performance on harder tests (sensory
5 & 6) compared with easier tests (sensory
1 & 2)31
Large intertrial variability30
Repetitive anterior-posterior sway without
falling (voluntary sway)
Large amplitude ( 5 degrees) anteriorposterior sway without falling on sensory
tests 4630
Large amplitude lateral sway ( 1.25
degrees) on sensory tests 4 630
Obsessive-Compulsive Disorder
An obsession is a repetitive intrusive thought, impulse,
or image that causes marked anxiety. A compulsion is
a repetitive ritualistic behavior or mental act that aims
to reduce anxiety. Examples of the latter include handwashing and checking to see that doors are locked.
Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by generalized and persistent anxiety with motor tension, autonomic hyperactivity, apprehensive expectation, and vigilance.
An essential feature is unrealistic worry. For the diagnosis, the duration of these symptoms should be at least
6 months (see Case Studies 2 and 3 at the end of this
chapter).
Mood Disorders
Minor depressive disorders have the following criteria:
At least five of the symptoms listed in Box 15-4 must be
present during the same day and must represent a change
from previous functioning; in addition, the patient must
have either Depressed mood or Loss of interest or
pleasure in usual activities, including social contact. The
disturbance causes significant impairment in social or
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100
100
75
75
50
50
FF
AA
LL
LL
25
FALL
F
A
L
L
F
A
L
L
FALL
6
Trial 2
Composite
38
C
Trial 1
FFF
A AA
LLL
LLL
25
FFF
A AA
LLL
LLL
Composite
38
D
Trial 3
shear
Trial 1
Trial 2
Trial 3
AP sway
5 degrees; 35lb Force

24 seconds
Figure 15.1 Sensory tests during dynamic posturography in a patient with psychogenic
balance disorder (A and C) and a patient with an acute unilateral vestibular loss (B and D).
A and B show the mean sway on the 6 sensory test conditions repeated three times (100
indicates no sway; 0 indicates sway beyond level of stability or a fall). The patient with psychogenic balance disorder shows better performance for age on the more difficult tests
(5 and 6) compared with easier tests (2 and 4). In addition, there is considerable variability
from trial to trial within a given test. The patient with the psychogenic balance disorder also
shows a regular frequency of sway on all trials suggesting voluntary control (B). In contrast,
the patient with the unilateral vestibular loss has increased difficulty performing the harder
tests (5 and 6), has less variability from trial to trial, and does not have a regular periodicity
of sway. The shaded areas in A and B indicate the regions where scores are abnormal for
age. Note that the two subjects were in the same age bracket and that their overall composite
scores were equal.
occupational functioning, or marked distress. There is no

substance abuse and no manic episodes.
Somatoform Disorders
Somatization
Somatization is the propensity to experience and report
somatic symptoms that have no pathophysiological
explanation, to misattribute them to disease, and to seek
medical attention for them. Much of general medical
practice is devoted to the care of somatizing patients who
are symptomatic but not seriously ill.35
Conversion
The development of a symptom or deficit suggestive of a
neurological disorder that affects sensation (including
vestibular) or voluntary motor function (including imbalance) is conversion. There is a temporal relationship
between the symptoms or deficits and psychological
stressors, conflicts, or needs. The patient has no conscious intention of producing the symptoms (i.e., factitious disorder or malingering). The symptoms or signs
cause significant impairment in social or occupational
functioning or marked distress, or require medical attention or investigation (see Case Study 4).
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Box 15-3
SYMPTOMS OF PANIC ATTACK

Dizziness, unsteady feelings or faintness
Nausea or abdominal distress
Shortness of breath (or smothering sensations)
Palpitations or tachycardia
Trembling or shaking
Sweating
Choking
Depersonalization or derealization
Numbness or paresthesias
Flushes (hot flashes) or chills
Chest pain or discomfort
Fear of dying
Fear of going crazy or doing something
uncontrolled
Box 15-4
SYMPTOMS CONSISTENT
WITH DEPRESSION
Change in appetite or weight (down or
up)
Difficulty sleeping or sleeping too much
Loss of energy, fatigability, or tiredness
Psychomotor agitation or retardation
Loss of interest or pleasure in usual activities, including social contact
Feelings of self-reproach or excessive or
inappropriate guilt
Diminished ability to think or concentrate
Recurrent thoughts of death or suicide
Tearful or sad face
Pessimistic attitude
Brooding about past or current unpleasant
events
Preoccupation with feeling of inadequacy
Resentful, irritable, angry, or complaining
Demanding or clinging dependency
Self-pity
Excessive somatic concern
221
Factitious and Malingering Disorders

Factitious Disorder
Factitious disorder is intentional complaint of psychological signs and symptoms or intentional production of
physical signs and symptoms motivated by the psychological need to assume a sick role. For this diagnosis,
there must not be external incentives, such as economic
gain and obtaining better care.
Malingering
Malingering is similar to factitious disorders, but the
malingering patient has an external incentive (usually
economic gain) (see Case Study 5).
Management
Success in treatment of the psychological problems related to dizziness depends on a positive discussion with the
patient. Physicians can have this discussion during the
first clinic visit. For therapists, the discussion may be
delayed until the patient is well into the course of rehabilitation, when a good rapport has been established. An
excellent approach has been outlined by Bursztajn and
Barsky.36
If the opportunity arises, the clinician should:
Discuss how emotions and stress can cause the
same types of symptoms as a vestibular disorder
Try to eliminate any stigma or low self-esteem
by stating the prevalence of the psychological
disorder
Assure the patient of the clinicians continuing
interest and involvement.
A statement about a possible psychological problem
should be included in the clinicians notes to the referring
physician. The clinician should never merely tell a
patient that he or she needs to see a psychiatrist. Patients
object to the suggestion of a psychiatric referral for several reasons, including the social stigma of being a psychiatric patient, the creation of low self-esteem, a poor
understanding of the role of emotions in causing symptoms, and a feeling of rejection. Using the term psychogenic to describe the problem, which is diagnostically
neutral, may be preferred to functional or hysterical
(Box 15-5).
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Box 15-5
SUMMARY OF MANAGEMENT
Recognize the type of psychological disorder to
determine whether you can begin or recommend
treatment.
If you believe the patient does have a psychological disorder that will respond to treatment, do the
following:
Discuss the problem in clinic, discuss model,
other patients, and reassure the patient.
Have the patient start a home exercise program.
When appropriate, refer the patient for medication and/or counseling.
Medications
Physicians may want to start the patient on medication,
as listed in Table 15-5. The agents listed as daily medication are nonaddictive, take up to 3 weeks to become
effective, and can be taken for years. These medications
are all antidepressants and are approved by the U.S. Food
and Drug Administration (FDA) for treatment of anxiety.
Paroxetine (Paxil) and sertraline (Zoloft) should be given
in the morning because they can impair sleep. Agents
listed as intermittent medications are addictive, can cause
sedation, act immediately, and are strictly for anxiety. For
patients with severe chronic anxiety or panic attacks, I
usually start two drugs, one from the intermittent medication group and one from the daily medication group. I
Table 15-5 MEDICATION FOR

PSYCHOLOGICAL
PROBLEMS
Dose
HalfLife (hr)
Xanax (alprazolam)
0.21 mg tid
1115
Ativan (lorazepam)
0.55 mg bid
1020
Klonopin (clonazepam)
0.510 mg bid
1850
Valium (diazepam)
210 mg bid
2050
Medication
Intermittent medication:
Daily medication:
Paxil (paroxetine
hydrochloride)
1020 mg qam
Zoloft (sertraline
hydrochloride)
50100 mg qam
Tofranil
(imipramine)
1075 mg/day
Norpramin
(desipramine)
50100 mg/day
usually use the lowest dose listed in Table 15-5. After 3

weeks, I either taper the intermittent medication completely or limit its use to 1 or 2 days per week at most.
CASE STUDY 1
A 51-year-old woman is referred for evaluation
prior to removal of a small left vestibular schwannoma totally within the internal auditory canal. Her
major complaints are listed here in decreasing
order of severity as judged by the patient: The most
severe problem is poor balance. She still depends on
a cane. She even sometimes uses a walker, when
she is tired. She has fallen twice in the house
without injury. Coupled with that is head fullness,
which increases whenever she does vestibular
enhancement exercises. She feels as though she has
severe fullness in the head. A third complaint is of
poor stamina.
Clinical examination shows decreased VOR for

head thrust to left- and right-beating nystagmus after
horizontal head shake. Her neurologic findings are
otherwise normal except for gait, which is shown in
video clip Aphysiological gait 1. Caloric testing
shows 80% decrease on the left; dynamic visual acuity (DVA) is normal for age. Rotary chair testing
shows normal gain during constant velocity steps at
60 degrees per second (deg/sec) and decreased gain to
the left at 240 deg/sec chair rotations; low gain and
high phase for low-frequency sinusoidal chair rotation
but normal values at high-frequency rotations. The
patients Millon Inventory is shown in Figure 15.2.
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Comment
This patient shows evidence of good central compensation of a left vestibular defect based on DVA and
rotary chair testing (see Chapter 8 for more detail).
This is what is expected in the majority of individuals
with vestibular schwannomas, because these tumors
are slow-growing, allowing good central compensation. Her history reveals more subjective complaints
than would be expected. The Millon Inventory result
suggests that she may have a functional defect (aphysiological) and may not be comfortable discussing her
medical problems or how she is coping. Her gait is
consistent with an aphysiological component.
This patient underwent tumor removal, and her
vestibular rehabilitation took three times longer than
average. She was referred to counseling, but she did
not believe she had a problem coping so did not gain
much benefit from it.
Figure 15.2 Sample of the Millon Inventory in a dizzy patient.
223
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CASE STUDY 2
A 37-year-old man experienced severe nausea and
vertigo 7 months ago when he put his head down in
bed after a trip to a theme park. Vertigo persisted for
a few days, resolved, then reoccurred 2 weeks later
accompanied by shortness of breath, palpitations,
trembling, and chest pain. These symptoms were so
incapacitating that he was hospitalized for a few days
for tests. MRI of the head and neurological examination results were normal. Since then the patient has
had chronic dizziness. He also now has head pressure, decreased energy, decreased weight, trouble
sleeping, and apprehension. He stopped all exercise
after the onset of dizziness. Findings of the current
examination are entirely normal, as are all vestibular

test results.
Comment
This patient exemplifies chronic anxiety with features
of panic attacks. There was no evidence on clinical
examination nor on vestibular function testing of
vestibular hypofunction. His original problem was
probably BPPV and anxiety. His management now
focused on reassurance. He also was prescribed
Xanax, 0.25mg qhs 3 weeks and Paxil, 10 mg qam,
and told to restart his exercise program.
CASE STUDY 3
A 27-year-old repairman complains of dizziness for
the past 2 years. He uses trouble walking, poor balance, linear movement, tilt, floating, rocking, and
blurred vision all as equal terms for his dizziness. The
problem started while he was working on a high lift
for 2 hours. He was at a height that caused a sense of
rocking on the platform. In addition, he attributes his
dizziness to inhalation of fumes of a floor sealant on
the job. Since then he has constant dizziness, which is
severe when he first awakens in the morning. It is also
severe when he is fatigued or is walking in a dark
room. His head feels heavy. He denies vertigo, hearing loss, and tinnitus. Because of his symptoms, he
has reduced his exercise program. In the last 6 months
he has experienced loss of strength and energy, memory loss, paresthesias, muscle and joint aches, trouble
sleeping and speaking, tremor, incoordination, and
headaches.
The patients past medical history includes surgery
to the knee years ago that required intravenous antibiotic therapy, gonorrhea treated with antibiotics, and
anxiety and panic attacks 2 years ago. His mother has
been on long-term benzodiazepine therapy for stress.
In the last 6 months, the patients dizziness has interfered with his activities 95% of the time, and currently, it is moderately intense. It has markedly changed
his ability to work or do household chores. Dizziness
has severely decreased the amount of satisfaction
or enjoyment the patient finds from taking part in

family-related or social activities. On the PANAS, he
scores 34 on positive affect and 19 on negative affect,
which are normal.
The physical findings are normal, including a visual acuity of 20/26-2 static, 20/30-1 dynamic, normal
VOR gain to head thrust, no head-shaking or positional nystagmus, normal pursuit and saccades, normal hearing, and normal gait and balance. He has
already undergone MRI with and without gadolinium
that included VIIIth nerve cuts and a caloric test.
Results of both were normal.
Comment
This patient has several features consistent with
chronic anxiety. His complaints are vague, numerous,
and out of proportion to the findings. Complaints of
floating and rocking are typical in patients with
anxiety or depression. He has a history of panic
attacks 2 years ago. There is likely a family history of
anxiety, as his mother has been on benzodiazepines
for stress. Patients with anxiety commonly have a
family history of stress, anxiety, or nervousness.
Exercise is an excellent stress reducer; the patient
stopped all exercise 2 years ago. Even though the
PANAS score is useful, it is not positive for anxiety in
this patient.
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A tentative diagnosis of chronic anxiety is made.

The symptoms from stress and anxiety are discussed
with the patient. He is told that these symptoms are
very real and can be extreme. The role of his past
medical and family history for anxiety are also discussed. He is encouraged to restart a regular exercise
program to help reduce stress. He is started on Paxil,
10 mg qam, and Klonopin, 0.5 mg qpm; the side

effects of each agent are explained. He is asked to
return in 3 weeks.
When he returns to the clinic, most of his symptoms have resolved. He is exercising on a regular
basis. The Klonopin dosage is tapered over a 3-week
period, but the Paxil is continued for 1 year.
CASE STUDY 4
A 12-year-old girl is brought to the physician by her
mother because of inability to walk for 2 weeks. She
can take only a few steps before she has to sit down or
her knees buckle. She started attending a new school
3 weeks before her illness. She was doing very well
until the dizziness started. There is an older daughter
who is excelling in the same school. The patient has
undergone head CT and audiography, results of both
of which were normal. She had a positive tilt table
response to isoproterenol, suggesting possible orthostatic hypotension, and was started on medication and
salt tablets; this may have initially helped but for only
a week. Her physical findings are normal except for
her stance and gait; there is significant sway at the
hips with eyes open and closed, but she does not fall.
While walking, she has sudden buckling of the knees
but is still able to walk. There is much side-to-side
swaying and waste of muscular energy.
Comment
This patient has a conversion disorder. She has a
deficit that suggested a neurologic disorder but no
disorder was found. She has a psychogenic stance and

gait disorder with several of the features described in
Table 15-4. Her symptoms began temporally with the
stress of starting a new schoolthe same school
attended by her overachiever sister. There is no evidence of external economic gain, as one would expect
for malingering. She does not have a history of
assuming a sick role motivated by psychological
need, as one would expect for a factitious disorder. As
in several cases of conversion disorder, this case
prompted extensive evaluations and an organic diagnosis (orthostatic hypotension) that proved later to be
wrong. The tilt table test, especially with isoproterenol, has a number of false-positive results.
The diagnosis of conversion disorder is not discussed with the girl. It is discussed with the mother.
The social problems with starting a new school
attended by an overachieving sister are discussed.
School counseling is recommended.
The patients gait disorder slowly resolves after she
is switched to a different school (i.e., one not attended by her sister). Medications are not used.
CASE STUDY 5
A 45-year-old man fell off a scaffold and hit the right
side of his head 10 months ago. He is referred as part
of a Workmans Compensation case. During the accident, he had brief loss of consciousness. Initially, he
had positional vertigo while getting out of bed
(BPPV), which was treated. Now he has poor balance. Clinical findings, including those of vestibular
and neurologic examinations, are normal except for
gait. Dizziness interferes with his activities 100%,
resulting in an extremely changed ability to work or
do household chores. The PANAS score is normal, as
is the caloric test result.
Comment
This patient has a functional (aphysiological) gait
(see Table 15-4). He shows no evidence for anxiety or
depression based on the PANAS scale. There is secondary gain, in that he does not have to work while
his case is reviewed. The physician may want to give
him limited gait and balance physical therapy (4 sessions) to see whether he responds, but there is a high
probability that he will not improve with PT at this
time.
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Summary
Psychological problems, especially anxiety, are a major
contributing factor in all patients with dizziness. The
therapist needs to recognize and deal with this fact for a
good outcome. Treatment usually requires simply patient
education and reassurance by the referring physician or
therapist. Some patients need medication or stress-reducing programs. If a patient is not progressing during therapy as expected, the therapist should consider a
significant psychological problem. Re-evaluation by the
physician may be indicated.
References
1. Kroenke K, Lucas CA, Rosenberg ML, et al: Causes of
persistent dizziness. Ann Intern Med 1992;117:898904.
2. Yardley L, Luxon LM, Haacke NP: A longitudinal study
of symptoms, anxiety and subjective well-being in
patients with vertigo. Clin Otolaryngol 1994;19:109116.
2a. NIH Publication No. 06-4584, 2006 revised. www.nimh.
nihgov/publicat/numbers.cfm
3. Asmundson GJG, Larsen DK, Stein MB: Panic disorder
and vestibular disturbance: an overview of empirical findings and clinical implications. J Psychosom Res 1998;44:
107120.
4. Swinson RP, Cox BJ, Rutka J, et al: Otoneurological
functioning in panic disorder patients with prominent
dizziness. Compr Psychiatry 1993;34:127129.
5. Jacob RG, Furman JM, Durrant JD, Turner SM: Panic,
agoraphobia, and vestibular dysfunction. Am J Psychiatry
1996;153:503512.
6. Hoffman DL, OLeary DP, Munjack DJ: Autorotation
test abnormalities of the horizontal and vertical vestibuloocular reflexes in panic disorder. Otolaryngol Head Neck
Surg 1994;110:259269.
7. Sklare DA, Stein MB, Pikus AM, Uhde TW: Dysequilibrium and audiovestibular function in panic disorder:
symptom profiles and test findings. Am J Otol
1990;11:338341.
8. Simpson RB, Nedzelski JM, Barber HO, Thomas MR:
Psychiatric diagnoses in patients with psychogenic dizziness or severe tinnitus. J Otolaryngol 1988;17:325330.
9. Sullivan M, Clark MR, et al: Psychiatric and otologic
diagnoses in patients complaining of dizziness. Arch
Intern Med 1993;153:14791484.
10. Stein MB, et al: Panic disorder in patients attending a
clinic for vestibular disorders. Am J Psychiatry 1994;
151:16971700.
11. Sloane PD, Hartman M, Mitchell CM: Psychological factors associated with chronic dizziness in patients aged 60
and older. J Am Geriatric Soc 1994;42:847852.
12. Clark DB, et al: Panic in otolaryngology patients presenting with dizziness or hearing loss. Am J Psychiatry
1994;151:12231225.
13. Eagger S, Luxon LM, Davies RA, et al: Psychiatric morbidity in patients with peripheral vestibular disorders: a
clinical and neuro-otological study. J Neurol Neurosurg
Psychiatry 1992;55:383387.
14. Marks IM. Space phobia: a pseudo-agoraphobic syndrome. J Neurol Neurosurg Psychiatry 1981;44:387391.
15. Page NGR, Gresty MA: Motorists vestibular disorientation syndrome. J Neurol Neurosurg Psychiatry 1985;48:
729735.
16. Brandt T, Huppert D, Dieterich M: Phobic postural vertigo: a first follow-up. J Neurol 1994;241:191195.
17. Clark MR, et al: Psychiatric and medical factors associated with disability in patients with dizziness.
Psychosomatics 1993;34:409415.
18. Millon T, Davis R, Millon C: Millon Clinical Multiaxial
Inventory-III, 2nd ed. Minneapolis: National Computer
Systems; 1997.
19. Watson D, Clark LA, Carey G: Positive and negative
affectivity and their relation to anxiety and depressive
disorders. J Abnormal Psychol 1988;97:346353.
20. Jacobson GP, Newman CW: The development of the
dizziness handicap inventory. Arch Otolaryngol Head
Neck Surg 1990;116:424427.
21. Jacobson GP, Newman CW, Hunter L, et al: Balance
function test correlates of the Dizziness Handicap
Inventory. J Am Acad Audiol 1991;2:253261.
22. Robertson DD, Ireland DJ: Dizziness handicap inventory
correlates of computerized dynamic posturography. J
Neurol Clin 1990;8:459475.
24. Spitzer RL, Williams JBW, Gibbon M, First MB:
Structured Clinical Interview for DSM-III-R-Non-Patient
Version (SCID-NP, Version 1). Washington DC: American
Psychiatric Press; 1990.
25. Beck AT, et al: An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol
1988;56:893897.
26. Beck AT, et al: An inventory for measuring depression.
Arch Gen Psychiatry 1961;4:561571.
27. Lempert T, Brandt T, Dieterich M, Huppert D: How to
identify psychogenic disorders of stance and gait. J
Neurol 1991;238:140146.
28. Knapp C, Sachdev A, Gottlob I: Spasm of the near reflex
associated with head injury. Strabismus 2002;10:14.
29. Hotson JR: Convergence-initiated voluntary flutter: a
normal intrinsic capability in man. Brain Res 1984;294:
299304.
30. Gianoli G, McWilliams S, Soileau J, Belafsky P: Posturographic performance in patients with the potential for secondary gain. Otolaryngol Head Neck Surg 2000;122:
11-18.
31. Cevette MJ, Puetz B, Marion MS, et al: Aphysiologic performance on dynamic posturography. Otolaryngol Head
Neck Surg 1995;112:676688.
32. Goebel JA, Sataloff RT, Hanson JM et al: Posturographic
evidence of nonorganic sway patterns in normal subjects,
patients and suspected malingers. Otolaryngol Head Neck
Surg 1997;117:293302.
33. Aronson TA, Logue CM: Phenomenology of panic
attacks: a descriptive study of panic disorder patients
self-reports. J Clin Psychiatry 1988;49:813.
34. Jacob RG: Panic disorder and the vestibular system.
Psychiatr Clin North Am 1988;11:361373.
35. Barsky AJ, Borus JF: Somatization and medicalization in
the era of managed care. JAMA 1995;274:19311934.
36. Bursztajn H, Barsky AJ: Facilitating patient acceptance of
a psychiatric referral. Arch Intern Med 1985;145:7375.
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FOUR
Rehabilitation
Assessment and
Management
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16
Physical Therapy
Diagnosis for
As our profession assumes more independence in patient

management, it becomes increasingly important that we
prepare ourselves to screen patients for a multitude of
problems and to make decisions about treatment and
referral. Dizziness is one of the most prevalent complaints for which people seek medical help,1 with an estimated 90 million Americans older than 16 years (roughly
42% of the population) having experienced it.2 Dizziness
can have significant consequences for an individual; 33%
of patients with dizziness report that it affects their professional activities, and 14% that they have changed or
abandoned their profession.2 Although dizziness can be
caused by many different medical conditions, it is estimated that as many as 45% of cases are due to vestibular
disorders.2
This chapter provides a decision-making strategy
that can be used when the clinician suspects that a patient
may have a vestibular deficit. Diagnosis can be defined as
the art of distinguishing one disease from another.3 In
medicine, the identification of a particular disease leads
to specific medical and/or surgical treatment. A physical
therapy (PT) diagnosis differs from a medical diagnosis
in that, rather than an attempt to identify a particular disease, a constellation of symptoms and signs is identified
toward which physical and occupational therapy will be
directed. Once the PT diagnosis is achieved, the vestibular exercise approach can be identified (Table 16-1).
Certainly there are times when the medical diagnosis and
the PT diagnosis are the same, for example, in benign
228
paroxysmal positional vertigo (BPPV). However, there

are also times when the diagnoses differ. For example,
vestibular neuronitis is a medical diagnosis. As therapists, however, we do not treat the inflammatory process
of vestibular neuronitis. A more appropriate diagnosis for
PT purposes would be vestibular hypofunction.
Physical Therapy Diagnosis and

the International Classification
of Functioning, Disability, and
Health Model of Diasablement
The International Classification of Functioning,
Disability, and Health Model of Disablement (ICF) was
developed by the World Health Organization specifically
to provide a framework for the description of healthrelated states that includes both positive experiences and
negative consequences of disease.4 This scheme consists
of three domains that can be used to describe the effect of
different disorders or diseases on a persons health, with
a number of environmental and personal factors that
affect each of those domains (Box 16-1).
In the diagnostic schematic presented here, PT
Diagnosis is determined from information gained at the
level of the body (normal structure and function versus
impairment). Modifiers for treatment are identified at the
level of the individual (activities and limitations) and
from contextual factors. Outcome of treatment would
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Chapter 16 PHYSICAL THERAPY DIAGNOSIS FOR VESTIBULAR DISORDERS
History
Table 16-1 DIAGNOSIS-DRIVEN

TREATMENT
Diagnosis
Treatment Options
Benign paroxysmal
positional vertigo
Canalith repositioning,
Liberatory, Brandt-Daroff,
Appiani maneuvers
Unilateral vestibular
hypofunction
Adaptation, substitution
(habituation)
Motion sensitivity
Habituation
Bilateral vestibular loss
Substitution, adaptation
Central vestibular
Habituation
Of special importance in the patients history are the

nature of the patients symptoms and the temporal quality of those symptoms. The nature of the symptoms refers
to whether the patient is complaining of vertigo (an illusion of movement, typically vertigo or spinning) or of
disequilibrium (the sense of being off-balance). The temporal quality of the symptoms refers to whether the symptoms are episodic or continuous in nature. If the
symptoms are episodic, it is important to establish the
duration of the episodes; for example, episodes of vertigo lasting seconds or less than 1 minute suggest BPPV.
then be measured at the level of the individual and at the

societal level.
The diagnostic schematic presented here is a work
in progress. It is offered as a framework for arriving at a
physical diagnosis for patients with vestibular problems.
Each of the PT diagnoses presented should demonstrate
commonalities among all persons with that diagnosis.
There are two phases to making the PT diagnosis. The
first is in the history of the patients complaints; the
second consists of some simple clinical tests of the
vestibulo-ocular system.
The first of the simple clinical tests of the vestibuloocular system is positional testing. A positive response to
positional testing would consist of vertigo and nystagmus
being provoked when the patients head is in specific
positions. The duration and direction of the nystagmus
are used to diagnose positional vertigo that is peripheral
(e.g., BPPV; see Chapter 17) or central in origin.
The second clinical test is the assessment of the gain
of the vestibulo-ocular reflex (VOR) using rapid (highacceleration) head movements (head-thrust test; see
Chapters 7 and 19). The presence of the corrective saccade (positive head-thrust test) indicates the low gain of
the vestibular system. If the person makes a corrective
saccade after a head thrust to the right, the vestibular loss
Box 16-1
HEALTH CONDITION
vs.
Impairment
(body level)
Activities
vs.
Limitations
(individual level)
Participation
vs.
Restriction
(societal level)
Contextual Factors
Environmental Factors:
Natural environment
Attitude of family
Attitude of society
229
Personal Factors:
Gender, age
Comorbidities
Social background
Past experience
Coping and character style
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Section FOUR REHABILITATION ASSESSMENT AND MANAGEMENT
is on the right. A person who makes corrective saccades

with head thrusts to the right and to the left has bilateral
vestibular loss. The sensitivity of the head-thrust test for
identifying patients with unilateral vestibular loss is actually fairly low (35%), but its specificity is very high
(95%).5 That is, many patients with unilateral vestibular
loss do not have a positive head-thrust test, but the patient
who does have a positive test almost certainly has a
vestibular deficit. The findings in the Dizziness and
Balance Center at Emory University with patients with
bilateral vestibular loss suggest that the sensitivity of the
head-thrust test may be a higher for this patient group.
Another simple clinical test that can be used to

assess vestibular function is the measure of visual acuity
during horizontal head movement (dynamic visual acuity
[DVA]; see Chapter 19). The sensitivity of the clinical
DVA test for vestibular deficits is approximately 85%,
and its specificity is 55%.6
Diagnostic Flowchart
The first question one must ask is whether or not the
patient has complaints of vertigo (Fig. 16.1). If the
patient has a history of vertigo (spinning), the next step is
Figure 16.1 This flow diagram begins with the history (center). Patients should be asked whether
they have experienced vertigo (a sense of spinning). If the answer is yes, the next series of questions deals with the temporal nature of that vertigo. (Middle column: 1 minute, 12 hours, 12
hours, continuous). The temporal quality of the vertigo then leads to diagnoses of benign paroxysmal
positional vertigo (BPPV), episodic vertigo, unilateral vestibular loss (UVL), continuous vertigo, and
motion sensitivity. Note that some of these diagnoses are appropriate for physical therapy treatment
and others are not. If, during history-taking, the patient states that he or she has not experienced
vertigo but rather has complaints of disequilibrium, the path leads to diagnoses that must be distinguished on basis of clinical findings (left column). Note how the presence or absence of corrective
saccades to rapid head thrusts (HT) is used to identify unilateral and bilateral vestibular loss. OTR
ocular tilt reaction; SVV subjective visual vertical; tx treatment.
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Chapter 16 PHYSICAL THERAPY DIAGNOSIS FOR VESTIBULAR DISORDERS
to determine the duration of the vertigo. Spells of vertigo

lasting for brief periods ( 1 minute) suggest BPPV, the
most common cause of vertigo due to a peripheral
vestibular problem (see Chapter 17 for the diagnostic
flowchart for BPPV). It is important to distinguish
whether the nystagmus is typical for BPPV (combined
torsional and vertical, or horizontal) or for a central
lesion (pure vertical), or whether the history suggests
another problem, such as a perilymphatic fistula.
One should note that positional testing may not provoke vertigo and nystagmus; however, this result does not
mean that the patient does not have BPPV. The appearance of vertigo and nystagmus during testing is notoriously inconsistent. A diagnosis of BPPV may be reached,
at least tentatively, through history alone. Also, the possibility of a diagnosis of BPPV is raised regardless of the
patients description of the duration of the spell of vertigo. Patients are often poor historians and may believe the
vertigo lasts for extended periods because they continue
to feel poorly even after the actual spinning has stopped.
In fact, all patients should be tested for BPPV, including
those without complaints of true vertigo. BPPV is very
common and has been identified in patients who also
have unilateral or bilateral vestibular hypofunction (see
Chapters 20 and 21).
Vertigo that lasts for a few hours is most likely to be
from Mnires disease (see Chapters 6 and 12) or may
be a migraine-related event (see Chapter 12). These types
of episodic vertigo are not appropriate for treatment with
vestibular rehabilitation and must be managed medically.
The exception would be the patient who has persistent
complaints of imbalance between these episodes of vertigo, in whom unilateral vestibular hypofunction might
have developed with repeated episodes of Mnires
disease. The head-thrust test may help identify this problem, although formal vestibular function tests may be
necessary.
Vertigo lasting 12 hours to days typically signifies
the sudden onset of unilateral vestibular hypofunction
(see Chapter 6). During the acute period following onset,
spontaneous nystagmus in the light and, possibly, a skew
deviation would be observed. Both should resolve within
1 to 2 weeks. Failure of spontaneous nystagmus, or of a
skew deviation, to resolve strongly suggests central
involvement of the structures responsible for compensation. Thus, the presence of spontaneous nystagmus in the
light should be correlated with time from onset to determine whether there is central involvement.
Continuous vertigo has several possible explanations. First, the patient may be in the acute phase after
onset of unilateral dysfunction. This can be easily verified
by determining when the vertigo started. Additionally, if
the problem is acute, the patient should still have sponta-
231
neous nystagmus that follows Alexanders Law. Second,

if the patient describes vertigo but there is no nystagmus
when fixation is blocked (with Frenzel lenses or infrared
goggles), it is not likely that the patient has a vestibular
deficit that is treatable with exercises, and the patient
should be referred to a neurologist. Unfortunately, looking for nystagmus with the patient looking at a Ganzfeld
may not be sufficient for this examination unless the clinician can truly attest that the patient could not be suppressing nystagmus by fixating on a target. Third, the
patient may not be actually experiencing vertigo continuously or may be misusing the word vertigo. For example,
the patient may be experiencing movement-provoked
symptoms or motion sensitivity. This implies that movement of the individual, or movement of the environment,
produces symptoms that may include lightheadedness,
nausea, and even an illusion of movement. Although this
can occur after unilateral or bilateral vestibular loss, it can
also occur in patients with other, non-vestibular problems
such as migraine. Finally, complaints of continuous vertigo of long duration suggest problems for which the
patient should be referred to a neurologist.
The patient may deny a history of vertigo but may
complain of disequilibrium. There are many underlying
etiologies for the complaint of disequilibrium, both
vestibular and non-vestibular. The head-thrust test can be
used to identify whether the patient has chronic unilateral vestibular hypofunction (positive response to one side
only) or bilateral vestibular loss (positive response to
head thrusts in both directions). Patients with apparently
normal VOR to rapid head thrusts may still have a
vestibular deficit, so further testing (vestibular function
tests) may be needed to reach this diagnosis.
The complaint of disequilibrium (a sense of imbalance) may also be an aspect of motion sensitivity. If
patients with disequilibrium specifically have complaints
of lateropulsion (and abnormal subjective visual vertical
and an ocular tilt reaction), they probably have a central
vestibular problem above the level of the vestibular
nuclei (see Chapter 25). The complaint of disequilibrium
may be used by a patient to describe motion sensitivity,
leading to questions as to whether or not the patient is
experiencing migraine or migraine-equivalent events.
Finally, disequilibrium may be related to other neuromuscular problems.
Identification of Modifiers
Once a PT diagnosis has been achieved on the basis of
history and results of positional testing and the head
thrust test, it is necessary to perform other assessments to
identify other problems that will modify the exercise
program for the individual patient. These modifiers
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Table 16-2 MODIFIERS OF TREATMENT

Activity
level
Personal
factors
Environmental
factors
Basic activities of daily living

(ADLs)bath, dress, meals,
cleaning
Balancegait speed, fall risk,
endurance
Fall historycircumstance, frequency, injury
Drivingday, night
Workharder to perform, changed
jobs, not working
Visualcataracts, macular degeneration, field
Somatosensoryperipheral neuropathy
Musculoskeletalcervical, back,
arthritis, strength, range of motion
Central nervous systemstroke
(e.g., brainstem), cerebellar disease
Gender
Psychological:
Coping strategy
Anxiety, depression
Perception of disability
Somatoform, conversion
Severity of subjective complaints
Secondary gain issues
Family support
Availability of transportaion
Location of stairs, bedroom, bathrooms
Table 16-3 FUNCTIONAL ASSESSMENT

Problem
Tests
Subjective
complaints
Visual analog scales

Symptom scale
(DHI)
Visual acuity during

head movement
Clinical Dynamic V Acuity

(DVA) test
Computerized DVA test
Balance in stance
Romberg test
Sharpened Romberg test
Single-leg stance
Balance while
ambulating
Qualitative gait description

Dynamic Gait Index
Gait deviations
Gait with head turn
Quality of life
Vestibular disordersActivities
of Daily Living (ADL) Scale
DHI
Disability Scale
Medical Outcome Study 36-Item
Short-Form Health Survey
assessment of factors that will result in modifications in

how those exercises are applied, should enable the therapist to develop a problem list, goals, and treatment plan
for the patient.
References
include disorders affecting other systems, subjective
complaints, psychological factors, and the patients premorbid activity level (Table 16-2). Finally, specific
assessments must be performed to establish the patients
baseline performance so that changes in status can be
assessed following treatment and the patients return to
improved or normal participation at the societal level can
be evaluated (Table 16-3).
Summary
The use of the paradigm presented in this chapter should
enable the therapist to arrive at a diagnosis in which all
patients have a common group of symptoms and signs
and that will indicate the appropriate treatments for an
individual patient. The complete examination, including
1. Horak FB, Jones-Rycewicz C, Black FO, Shumway-Cook

A: Effects of vestibular rehabilitation on dizziness and
imbalance. Otolaryngol Head Neck Surg 1992;106:
175180.
2. National Institute on Deafness and Other Communication
Disorders, National Institutes of Health: A Report of the
Task Force on the National Strategic Research Plan.
Bethesda, MD: NIH; 1989;12.
3. Dorlands Illustrated Medical Dictionary, 29th ed.
Philadelphia: WB Saunders; 1994:490.
4. World Health Organization 2001: http://www3.who.int/icf/
beginners/bg.pdf
5. Harvey SA, et al: Relationship of the head impulse test and
head-shake nystagmus in reference to caloric testing. Am J
Otol 1997;18:207.
6. Venuto PJ, et al: Interrater reliability of the clinical dynamic visual acuity test. Presented to: Scientific Meeting and
Exposition of the American Physical Therapy Association,
1998;78:S21,19.
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CHAPTER
17
Physical Therapy
Management of Benign
Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is perhaps

the most common cause of vertigo in adults and, fortunately, is a very simple disorder to manage.1,2 Symptoms
remit with one treatment in more than 85% of cases. This
chapter describes the etiology of BPPV, treatment for the
various forms of the disorder, and the research that addresses treatment, and then provides suggestions for how
to approach more complicated cases of positional vertigo.
Characteristics and History

BPPV is characterized by brief episodes of vertigo when
the head is moved into certain positions. It has been
reported in adults of all ages (Table 17-1), although it is
uncommon in children.1,3 BPPV occurs spontaneously in
many patients but may follow head trauma, labyrinthitis,
or ischemia in the distribution of the anterior vestibular
artery.3 Spontaneous remission is common. For patients
in whom the episodic vertigo persists, this disorder can
be annoying, disruptive, and often leads to significant
changes in normal activities.
Patients with BPPV commonly report vertigo triggered by lying down, rolling over in bed, bending over,
and looking up. Common situations in which vertigo is
provoked include getting out of bed, gardening, washing
hair in the shower, and going to the dentist or beauty
parlor. Other complaints associated with BPPV are bal-
ance problems that may last for hours or days after the
episodic vertigo has stopped as well as more vague sensations, such as lightheadedness and a feeling of floating
(Table 17-2).
Mechanism
Schuknecht,2 in 1969, proposed that degenerative debris
from the utricle (possibly fragments of otoconia) adhere
to the cupula of the posterior canal, making the ampulla
gravity sensitive. This theory, cupulolithiasis, was supported by the presence of basophilic deposits on the
cupula of the posterior canal in patients with a history of
BPPV. Presumably, the presence of the debris adhering to
the cupula significantly increases the density of the cupula and, therefore, produces an inappropriate deflection of
the cupula of the posterior canal when the head is positioned with the affected ear below the horizon (Fig. 17.1).
The result is vertigo, nystagmus, and nausea. Because the
cupula remains deflected as long as the patient is in the
provoking position, the nystagmus and vertigo persist,
although the intensity may decrease slightly because of
central adaptation or because the patient may also have
canalithiasis.5 Thus, cupulolithiasis is characterized by (1)
immediate onset of vertigo when the patient moves into
the provoking position, (2) the presence of a nystagmus,
which appears with the same latency as the complaints of
233
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Table 17-1 AGE DISTRIBUTION OF

BENIGN PAROXYSMAL
POSITIONAL VERTIGO
(BPPV)*
Age (yr)
Patients with
Complaints of
Dizziness (No.)
Table 17-2 FREQUENCY OF

COMPLAINTS IN 100
CONSECUTIVE PATIENTS
WITH BENIGN
PAROXYSMAL POSITIONAL
VERTIGO (BPPV)
Patients with BPPV

Percentage
No.
09
0.0
1019
32
3.1
2029
64
3.1
3039
191
17.8
34
4049
261
16.5
43
5059
207
22.2
46
6069
298
26.2
78
7079
376
23.7
89
8089
176
33.1
58
9099
14
50.0
*Cases seen at the Dizziness and Balance Center, University of Miami

Dept of Physical Therapy and Bascom Palmer Eye Institute, 199498.
Complaint
Frequency (%)
Poor balance
57
Sense of rotation (vertigo)
53
Trouble walking
48
Lightheaded
42
Nausea
35
Queasy
29
Spinning inside head
29
Sense of tilt
24
Sweating
22
Sense of floating
22
Blurred vision
15
Jumping vision
13
Adapted from Tusa and Herdman, 1998.4
vertigo, and (3) persistence of the vertigo and nystagmus

as long as the patients head is kept in the provoking position. This form of BPPV is relatively uncommon.
A second theory, canalithiasis, was proposed by
Hall and colleagues,7 who suggested that the degenerative debris is not adherent to the cupula of the posterior
canal but, instead, is floating freely in the endolymph of
the canal. Freely moving debris has been visualized
through a microscope in patients in whom the membranous labyrinth has been exposed during surgery.8 When
the head is moved into the provoking position, the otoconia move to the most dependent position in the canal
(see Fig. 17.1). The movement of the otoconia results in
movement of the endolymph, which in turn pulls on the
cupula and changes the firing rate of the neurons of that
canal. The latency of the response is related to the time
needed for the cupula to be deflected by the pull of the
endolymph. The intensity of vertigo and nystagmus are
related to the extent of deflection of the cupula. Vertigo
and nystagmus stop as the position is maintained because
the endolymph ceases to move. Thus, BPPV from canalithiasis is characterized by (1) delay in the onset of the
vertigo of 1 to 40 seconds after the patient has moved into
the provoking position, (2) the presence of a nystagmus,
which appears with the same latency as the complaints
of vertigo, and (3) a fluctuation in the intensity of the vertigo and nystagmus, which increase and then decrease,
disappearing within 60 seconds. BPPV from canalithiasis
is the most common form of this disorder.
Semicircular Canal Involvement

Initially, BPPV was believed to involve only the posterior
semicircular canal (SCC), because the most commonly
observed nystagmus, upbeat and torsional, would be produced by excitation of the posterior canal. It has now
been recognized that involvement of anterior and horizontal canals also occurs.914 The frequency of BPPV in
each of the canals is shown in Table 17-3. Which canal or
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Chapter 17 PHYSICAL THERAPY MANAGEMENT OF BENIGN POSITIONAL VERTIGO
235
Figure 17.1 (A) In canalithiasis, the calcium carbonate crystals are floating freely in the long arm of the
canal (shown here for posterior canal). When the head
is moved into the head-hanging position (Hallpike-Dix
test), the debris moves to the most dependent portion
of the canal. The movement of the debris causes the
endolymph to move, in turn overcoming the inertia of
the cupula, and an abnormal signal is sent to the central nervous system. (B) In cupulolithiasis, the debris is
adhering to the cupula of the semicircular canal (shown
here for posterior canal). With movement into the headhanging position, gravity displaces the weighted cupula,
again resulting in an abnormal signal from that canal.
(Modified from Herdman SJ et al, 1993.5)
canals are involved can be determined by the direction of

the nystagmus when the patient moves into the provoking
position (Table 17-4). Observation of the direction of the
reversal phase of the nystagmus and the direction of the
nystagmus when the patient returns to a sitting position
can also be used to identify which canal is involved (see
Table 17-4). Proper identification of the involved canal
and determination whether cupulolithiasis or canalithiasis is the underlying problem dictate which treatment is
appropriate.
Table 17-3 CANAL INVOLVEMENT IN

BENIGN PAROXYSMAL
POSITIONAL VERTIGO
(BPPV) IN 200
SEEN IN OUR CLINIC
Semicircular Canal
% of Patients
Posterior
76
Diagnosis
Anterior
13
Three different maneuvers can be used to test for the

presence of BPPV. Because observation of the direction
and duration of the nystagmus is critical to development
of a treatment plan, the patient must understand what to
expect. The patient should keep the eyes open and should
try to stay in the provoking position. The examiner
should explain to the patient that the vertigo will stop or
decrease if he or she stays in the position. If the patients
history suggests which side is affected, it is best to test
the presumed unaffected side first to minimize nausea.
For patients with severe nausea and a history of emesis
Horizontal
Posterior or anterior SCC?
Dizziness and Balance Center, Johns Hopkins University and

University of Miami.
associated with vertigo, the testing maneuvers should be

performed more slowly, although slower performance
decreases the likelihood of provoking the nystagmus.
All tests for BPPV can be performed in room light,
but the use of Frenzel lenses or an infrared camera system
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Table 17-4 IDENTIFICATION OF CANAL INVOLVEMENT BASED ON DIRECTION

OF NYSTAGMUS DURING RIGHT HALLPIKE-DIX TEST
Canal
Right Hallpike-Dix Test
Reversal Phase
Return to Sitting
Right posterior
Upbeating and rightward torsionala
Downbeating and leftward

torsional
Downbeating and leftward

torsional
Right anterior
Downbeating and rightward torsional
Upbeating and leftward

torsional
Upbeating and leftward

torsional
Left anterior
Downbeating and leftward torsional
Upbeating and rightward

torsional
Upbeating and rightward

torsional
Torsional is defined as the direction movement of the superior pole of the eyes (e.g. in rightward torsional, the superior poles of both eyes move to
the patients right [quick phase]).
to prevent fixation suppression of horizontal and vertical

nystagmus will raise the likelihood of observing nystagmus. Torsional nystagmus is not suppressed by fixation.
Dix-Hallpike Test
The Dix-Hallpike test, sometimes called the Barany
maneuver or the Nylen-Barany maneuver, is the test most
commonly used to confirm the diagnosis of BPPV.15 In
this test, the patients head is turned 45 degree horizontally while the patient is in the sitting position (Fig. 17.2
position 1). The patient then quickly lies down with
the head hanging over the edge of the treatment table
approximately 30 degrees below horizontal (Fig. 17.2
position 2). This maneuver places the posterior canal on
the downside ear in the plane of the pull of gravity.
Debris adhering to the cupula or free-floating in the long
arm of the canal will shift down, resulting in vertigo and
nystagmus. In most cases of BPPV, nystagmus and vertigo occur within a few seconds of position change, but
occasionally, they appear only after 30 seconds because
of debris plugging within the canal. Therefore, the patient
should be kept in this position for at least 30 seconds.
If the patient has BPPV, vertigo and nystagmus will
be provoked when the affected ear is inferior. Then the
patient can be slowly returned to a sitting position. If vertigo was provoked when the patient was moved into the
head-hanging position, he or she may experience vertigo
again when returned to a sitting position. The test can
then be repeated with the patients head turned to the
other side. Note that the anterior canal of the downside
ear is also in a more dependent position during this test,
so the maneuver may also trigger vertigo due to anterior
canal involvement of the downside ear (see Fig. 17.2
Figure 17.2 Dix-Hallpike test for anterior or posterior

canal benign paroxysmal positional vertigo. The patient sits
on the bed or examination table, and the head is turned
45 degrees horizontally toward the labyrinth to be tested
(position 1). The examiner quickly brings the head and trunk
straight back en bloc, so that the head is hanging over
the edge of the examination table by 20 to 30 degrees
(position 2). The examiner asks whether the patient has
vertigo and observes for nystagmus. The patients upper
body is then brought up slowly to a sitting position with the
head still turned 45 degrees, and nystagmus is sought again
(not shown). This test then is repeated with the head turned
45 degrees in the other direction. This figure also shows the
right labyrinth with free-floating otoconia in the right posterior
semicircular canals (large black arrows). During the HallpikeDix test, this debris would move, resulting in nystagmus and
vertigo when the test is performed to the right side but not
when the test is performed to the left side. (Modified from
Tusa and Herdman, 1998.4)
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position 2). The nystagmus in anterior canal BPPV is

downbeat and torsional.
Side-Lying Test
In the side-lying test, the patient sits on the side of the
treatment table (Fig. 17.3 position 1). The head is turned
45 degrees to one side, and the patient then quickly lies
down on the opposite side (Fig. 17.3 position 2). This
again puts the posterior canal on the downside ear in the
plane of the pull of gravity and may provoke a response
in either canalithiasis or cupulolithiasis. Similarly, debris
in the anterior canal of the downside or inferior ear also
moves, provoking vertigo and downbeat and torsional
nystagmus. The patient then returns to a sitting position.
After waiting to be sure that the patient does not experi-
237
ence any vertigo in sitting, the test is repeated to the

opposite side. The side-lying test can be substituted for
the Dix-Hallpike test if the patient cannot extend the head
sufficiently (head-hanging position in the Dix-Hallpike
test) or cannot lie on the back.
Roll Test
In patients with horizontal canal BPPV, the Hallpike-Dix
test may not provoke vertigo and nystagmus.11 The best
maneuver would be one that moves the patients head in
the plane of the horizontal canal, which the roll test does.
The patient lies supine with the head flexed 20 degrees
(Fig. 17.4A). Then the head is quickly rolled to one side
and kept in that position for up to 1 minute to test whether
the patient experiences any vertigo (Fig. 17.4B). The
head is then slowly rolled back to midline (still in slight
flexion) (Fig. 17.4C) and then quickly rolled to the other
side (Fig. 17.4D). In horizontal canal BPPV, vertigo and
nystagmus occur when the head is turned to both the right
and the left, because the debris moves back and forth
within the canal. The slow-phase eye velocity, duration of
the nystagmus, and the patients subjective complaints are
believed to be worse when the head is turned toward
the affected ear.11 The direction of nystagmus in horizontal canal BPPV depends on whether the debris is freefloating (canalithiasis) or adhering to the cupula (cupulolithiasis) (Fig. 17.5).13 In a patient with canalithiasis of
the horizontal canal, the nystagmus is geotropic (quick
phases of nystagmus beat to earth) and will fatigue,
whereas in a patient with cupulolithiasis, the nystagmus is
apogeotropic (beats away from earth) and is persistent.
Test Series
Figure 17.3 Side-lying test for anterior or posterior canal
benign paroxysmal positional vertigo. The patient sits on the bed
or examination table with the legs over the side, and the head is
rotated 45 degrees horizontally away from the labyrinth to be
tested (position 1). The examiner then quickly brings the
patients head and trunk down on the side opposite to the direction the head is turned (position 2). The patient is asked to
report any vertigo and is observed for nystagmus. The patient is
then brought to a sitting position with the head still turned 45
degrees, and the examiner rechecks for nystagmus and vertigo
(not shown). The test is repeated with head turned 45 degrees
horizontally to the other side. This figure also shows the right
labyrinth with free-floating otoconia in the right posterior SCC
(large black arrows). During the Side-lying test, the debris would
move, resulting in nystagmus and vertigo when the test is performed to the affected side but not when it is is performed to the
unaffected side. This test is also useful for anterior canal BPPV,
because debris in this canal would move when the test is done
on the affected side. (Modified from Tusa and Herdman, 1998.4)
One can easily assess all three canals for BPPV quickly
with the following test procedure. For sake of discussion,
assume that the patient complains of vertigo when lying
on the right side. The series is as follows:
1. Perform the Dix-Hallpike test on the left side.
2. Perform the Dix-Hallpike test on the right side.
3. If the patient has no vertigo: Before sitting the
patient up from the right side, perform a roll
test by having the patient turn the head quickly
to the left.
4. After 30 seconds, have the patient quickly turn
the head back to the right.
5. After 30 seconds, have the patient sit up.
If, at any time during this series of tests, nystagmus
and vertigo appropriate for BPPV occur, the testing
should be stopped, and the patient treated.
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Figure 17.4 Roll test for horizontal canal benign paroxysmal positional vertigo. (A) The patient is
laid supine with the head flexed 20 degrees. (B) The head is quickly rolled to one side, nystagmus
is looked for and the patient is asked to report any vertigo. (C) The head is then slowly rolled back
to a supine position. (D) The head is then quickly rolled to the other side, nystagmus is looked for,
and the patient is asked to report any vertigo. (Modified from Tusa and Herdman, 1998.4)
Treatment
Successful treatment depends on identifying which canal
is involved and whether the debris is free-floating or
adhering to the cupula. There are three basic bedside
treatments for BPPV, each with its own indications for
use: Canalith Repositioning, the Liberatory maneuver,
and the Brandt-Daroff habituation exercises. Variations
of these treatments have been developed depending upon
which canal is involved. Studies on the efficacy of these
treatments indicate that all three treatments facilitate

recovery.5,1624 The results of these studies must be interpreted cautiously, however, because of the high incidence
of spontaneous remission that occurs in patients with
BPPV. Several authorities have reported spontaneous
recovery within 3 to 4 weeks,22,25 although Brandt and
Daroff26 suggest that the vertigo may disappear spontaneously after several months even if left untreated.
The choice of which exercise is most appropriate for
a particular patient depends on which canal is involved as
Figure 17.5 Direction of nystagmus in horizontal canal (HC) benign paroxysmal positional vertigo.
For both HC cupulolithiasis (A) and HC canalithiasis (B), the patient would have nystagmus and vertigo when the head is rolled to either side, but the duration and direction of the nystagmus would differ in these two types of BPPV. For cupulolithiasis, the nystagmus is persistent, and the direction of
the quick phases is away from earth (apogeotropic). For canalithiasis, the nystagmus is transient, and
the direction of the quick phases is toward the earth (geotropic). (Modified from Baloh et al, 1993.11)
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239
Table 17-5 TREATMENT FOR BENIGN PAROXYSMAL POSITIONAL

VERTIGO: OPTIONS AND INDICATIONS*
Semicircular
Canal Involved
Severe Canalithiasis
Mild Canalithiasis
Cupulolithiasis
Posterior
CRT*
Liberatory maneuver
Brandt-Daroff exercises
Brandt-Daroff exercises*
CRT
Liberatory maneuver
Liberatory maneuver *
Anterior
CRT*
Liberatory maneuverAC
Brandt-Daroff exercises*
CRT
Liberatory maneuverAC
Liberatory maneuverAC *
Horizontal
Bar-B-Que roll treatment*

Forced prolonged position
Bar-B-Que roll treatment*

Forced prolonged position
Bar-B-Que (quick movements)
*Preferred method is listed first.

AC anterior canal; CRT, canalith repositioning treatment.
well as whether the patient has the canalithiasis or cupulolithiasis form of BPPV (Table 17-5). We typically use
the canalith repositioning treatment (for canalithiasis) or
the Liberatory maneuver (for cupulolithiasis) first. The
Brandt-Daroff habituation exercises are used for milder
residual complaints.
detail the modifications that have been proposed over the

years. We then give instructions on how to perform CRT
correctly.
Treatment of the Most Common Form

of BPPV: Posterior Canal Canalithiasis
The canalith repositioning procedure (CRP) was developed for treatment of posterior SCC BPPV and consisted
of the following five key elements17,26:
The Original Canalith

Repositioning Procedure
Consider the following case:

The patient is a 66-year-old woman who experienced severe vertigo when she rolled over in bed
in the morning about 12 days ago. The vertigo
lasted only seconds, although she continued to
feel off-balance for the next 24 hours. She avoided lying down after that incidence and has been
sleeping on three pillows at night. Three days
ago, she was seen by a neurologist, who diagnosed BPPV on the basis of the upbeat and rightward torsional nystagmus with concurrent vertigo
that was elicited when she was moved into the
right Dix-Hallpike position. He treated her with
CRT and referred her to you for follow-up care.
On examination today, she still has an upbeat and
rightward torsional nystagmus with vertigo that
lasts for 8 seconds when she is moved into the
right Dix-Hallpike position. She states, however,
that it is 50% better than it was when the neurologist treated her 3 days ago. You are concerned
that the treatment was not done correctly.
In this section, we first describe the original components of the canalith repositioning procedure and then
Premedication of the Patient. Approximately 1 hour
before treatment, the patient is given transdermal scopolamine or diazepam in order to reduce nausea and prevent
vomiting during testing and treatment. The patient is then
seated in a treatment chair for the actual maneuver.
Specific Positions Used in the Maneuver Itself. The specif-
ic sequence of head positions recommended involves

moving the head in 90-degree increments so the debris
will move through the long arm of the posterior canal and
into the utricle (Fig. 17.6). Note that with each change in
head position, the debris should move away from the
cupula of the posterior SCC.
The Timing of Shifts from One Position to Another.
The timing used for each change in position is based on

the duration of the nystagmus observed during the
maneuver. Once the patients head has been moved into
a new position, that position is maintained until the
nystagmus slows down. At that point, the head is moved
into the next position in the sequence. If no nystagmus
is observed, the amount of time the head is maintained in that position is based on the duration of the
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Figure 17.6 Canalith repositioning treatment for treatment of posterior or anterior semicircular canal (SCC) benign
paroxysmal positional vertigo. The patient is first moved into the Hallpike-Dix position toward the side of the affected ear
(shown here for left) and kept in that position for up to 1 minute (A to B). Then, the head is slowly rotated through moderate extension toward the unaffected side and kept in the new position briefly (C) before the patient is rolled to a sidelying position with the head turned 45 degrees down (toward the floor) (D). In each of these positions, the patient may
experience a short spell of vertigo and nystagmus with the same characteristics as the original nystagmus, indicating that
the debris is moving through the posterior canal. With the head kept deviated toward the unaffected side and pitched down,
the patient then slowly sits up (E). Some clinicans recommend having the patient wear a soft collar for the remainder of the day
to ensure that the patient does not bend over, lie back, move the head up or down, or tilt the head to either side. If a soft collar
is used, the examiner should tell the patient to turn the head from side to side every hour to avoid muscle spasm. Black arrows
indicate location of free-floating debris in the posterior SCC. Note that the movement of the patients head will gradually shift
the debris away from the cupula and into the common crus. (Modified from Tusa and Herdman, 1998.4)
last occurrence of nystagmus. In general, each position is

maintained for between 6 and 13 seconds.17 The maneuver is repeated until either nystagmus is no longer
observed or there have been no changes in nystagmus for
two repetitions.
Use of Vibration during the Maneuver. Vibration is
applied to the mastoid region on the affected side during

the repositioning maneuvers. In the original procedure,
Epley17 suggested that two different applications be
used: during one cycle, a standard electromagnetic bone
conductor vibrator is used, and then in another cycle
of the maneuver, a handheld vibrator (80 Hz) is
used.17 The theoretical purpose of the vibration was to
prevent the debris from adhering to the walls of the canal
and to aid in the movement of the debris through the
canal.
Post-procedure Instructions. The last component of the
CRP was the post-treatment instruction. The patient

was advised to keep the head upright for 48 hours
after the treatment. The follow-up visit for reassessment
and another treatment, if needed, would be scheduled for
1 week later.
Modification of the Canalith

Repositioning Procedure
As more and more clinicians have used the CRP,
numerous modifications of the procedure have been
proposed (Table 17-6). These modifications encompass elimination of premedication regimens, as well
as changes in positions used, timing, use of vibration,
and post-treatment instruction. Some of the modifications resulted in less optimal outcome, and others simplified the CRP as proposed by Epley17 without affecting outcome. We use the term canalith repositioning treatment (CRT) to distinguish the modified
treatment approaches from the originally proposed
procedure.
Premedication. The purpose of premedicating a patient
with a history suggesting BPPV is to reduce nausea

and prevent vomiting during testing and treatment. In
contrast to the original procedure proposed by Epley,17
most reports do not mention medicating patients prior to
treatment.5,21,24,2729 We recommend that an exception
would be the patient with a history of emesis associated
with BPPV. In that situation, the use of an antiemetic medication such as promethazine (Phenergan) or
prochlorperazine (Compazine) would be appropriate
and humane. As an alternative or supplement to medication, we suggest that the patient with a history of significant nausea and vomiting be moved slowly into the
provoking position. If no vertigo or nystagmus is evoked,
the positioning maneuver can be repeated more rapidly.
Furthermore, if nystagmus and vertigo occur during
positional testing (Dix-Hallpike or Sidelying test), the
patient should immediately be taken through the CRT
rather than being subjected to repeated provoking
tests.
Transdermal
scopolamine
or diazepam
Transdermal
scopolamine
or diazepam
Epley, 199464
Epley, 199626
n 400
241
*Later dropped from protocol.

H-D Hallpike-Dix position
Pausing in each
position
No vibration
Vibration
(60 Hz)
5 position cycle
to nose down
Sargent et al 200134:
n104
n 64
None mentioned
Vibration
n 44
None
No vibration
4-position cycle 4 minutes in each

to opposite H-D position
Hain et al, 200033:

n 50
None
Wolf et al, 199929

n 107
None
None
None
80 Hz applied
indirectly
80 Hz applied
indirectly;
optional
No vibration
Vibration
None
n 30

5-position cycle 34 minutes in
to nose down
each position
5 position
Typically 613
cycleincludes seconds but may
nose down
be 30 seconds
5 position
Typically 613
cycleincludes seconds
nose down
Li, 199518:
(n 10)
(n 27)
None
Repetitions
Until no nystagmus
or no change over
two repetitions
One maneuver only
100%
Remission
Rate
Upright for 48 hours
73%
84%
(p 0.151)
No significant
difference
No significant
difference
0%
70%
80%
83%
92%
57%
Upright for 48 hours; 80% in one

treatment;
treatment repeated
weekly or in 1-2 days 95% overall
Upright for 48 hours; 90%

treatment repeated
weekly or in 12 days
Repeated maneuvers Upright for 48 hours

in same session
One maneuver only Upright for 48 hours
One maneuver only
Until no nystagmus
or no change over
two repetitions
Until no nystagmus
or no change over
two repetitions
Upright for 48 hours;

treatment repeated at
weekly intervals
Post-Treatment
Instructions
1:49 PM
n 30
Mastoid
Oscillation
5-position
Sum of latency and 700 Hz for one Until no nystagmus
cycle*; 80 Hz or no change over
cycleincludes duration of nysfor at least
nose down
tagmus (typically
two repetitions
one cycle
613 seconds)
Timing of
Position Changes
2/16/07
Herdman et al, 19935:

None
n 30
Transdermal
scopolamine
or diazepam
Premedication Positions
Epley, 199217
n 30
Study and No.

of Subjects
Table 17-6 MODIFICATIONS OF THE CANALITH REPOSITIONING TREATMENT AND THEIR OUTCOME
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Positions. The original series of position changes suggest-
ed by Epley have remained unchanged. Herdman and colleagues5 compared the use of the five positions suggested
by Epley with use of only four positions, omitting the
position in which the patients head is turned so that the
nose is down toward the floor, and found a significant difference in the rate of remission.16 When only four positions were used (sitting to Dix-Hallpike position to
opposite Dix-Hallpike position to sitting), a 57% rate of
remission was achieved. In contrast, when all five positions were used or when the four-position maneuver was
repeated several times, the outcome was significantly
better. Herdman and colleagues5 also showed that when
the patient was moved once through all the positions suggested by Epley, remission of BPPV was 83%. When
patients were moved through four positions multiple
times, a 93% remission rate was achieved. This latter
finding has been confirmed by Wolf and associates,29 who
found a 93.4% remission rate in patients treated with only
the first four positions. Therefore, it seems that either
approachusing five positions or using four positions but
repeating the maneuver multiple timesis effective.
An interesting, and quite different, series of position
changes has been suggested by Furman and coworkers.30
Called the heels-over-head rotation, the patient sits in a
treatment chair that can be rotated in pitch 360 degrees.
The head is positioned at each stage of the maneuver so
the movement is always in the plane of the posterior
canal. All of the 11 patients in this study had complete
remission of symptoms with the first treatment. Although
effective, this approach requires relatively sophisticated
equipment and seems to be unnecessarily complicated
and awkward for the patient.
Timing. The timing of the position changes in the CRP
was based on the combination of the latency until nystagmus begins plus the time until the nystagmus stops. If
nystagmus is not observed in any given position, which
happens frequently, then the timing is based on the duration established during the initial Dix-Hallpike maneuver. Several studies have used a longer period between
each change in position,5,29,31,32 with essentially the same
results as by Epley17. It is useful to know that it is not
necessary to move the patient through the different positions quickly. Waiting longer between changes in positions allows the nausea to decrease and helps prevent
actual emesis.
Mastoid Oscillation. Later studies have failed to identify
any difference in outcome when a vibrator is used or
not.33, 34 In our practice, we do not routinely use mastoid
oscillation. The exception is the patient who has shown
no response to CRP. We think that in some patients

(5%), the debris does not move easily through the SCC.
When that happens, the treatment is unsuccessful. We
have found that keeping the orientation of the labyrinth
well below the horizon during the position change from
the initial Dix-Hallpike position (see Fig. 17.6B) to the
second Dix-Hallpike position (see Fig. 17.6C) facilitates
movement of the debris through the canal. We do this by
either hyperextending the patients neck 30 degrees during position B and C in Figure 17.6, or, in patients with
limited neck range of motion or with cervical pain, by
lowering the head end of the treatment table. If that fails,
we use mastoid oscillation during the treatment. Contrary
to other investigators,33,34 we believe it is important to
recognize that in a case of canal jam, there would be no
nystagmus or vertigo with change in head position, because the debris would block movement of the
endolymph, and therefore, the cupula would not be displaced.
Post-treatment Instructions. Keeping the head upright for
48 hours, presumably to prevent the loose otoconia in the
utricle from moving back into the posterior SCC, is difficult for many patients. Patients would report not sleeping
well or a sore neck. Fortunately, these post-treatment
instructions do not appear to be necessary to the success
of the treatment.31,37,38 Massoud and Ireland31 examined
the need for the post-treatment instruction to stay upright
for 48 hours. Two groups of patients were given CRT or
another treatment (Liberatory maneuver) and were asked
to sleep upright for 2 nights and then on the normal side
for an additional 5 nights. Two other groups were given
the same treatments but were not given any post-treatment
instructions other than to avoid brisk head movements for
1 week. All patients had follow-up visits 1 week after
treatment. These researchers found no statistical difference among the four groups (analysis of variance, P
.2). The success rate of the maneuvers was 88% to 96%.
Similar results were reported by Nuti and colleagues,38
who examined 52 patients at 20 minutes, 24 hours, and 7
days after the Liberatory maneuver for posterior canal
BPPV. After the maneuver, the patients were asked to
remain in a seated position for 20 minutes; 47 of the
patients had no vertigo when retested at 20 minutes after
the maneuver. After this first test, they were given no postmaneuver instructions. At 24 hours, 2 of the 47 patients
had a recurrence and were re-treated. At 7 days, all 47
patients were still in remission. Nuti and colleagues38
concluded that post-maneuver instructions are not necessary, including the use of a soft collar. We found similar
results when we asked patients to sleep upright for 24, 48,
or 72 hours (Fig. 17.7).37
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Remission Rate
243
100%
80%
60%
40%
20%
0%
1
%remission
2
Days
%mild
3
%no remission
Figure 17.7 Bar graph showing the outcome of canalith repositioning treatment for posterior
semicircular canal benign paroxysmal positional vertigo based on the number of days the patients
stayed upright after treatment. All patients were seen 7 days later. Outcome was determined from
the presence of posterior canal nystagmus during the Dix-Hallpike test using video-infrared goggles
and the occurrence of vertigo during the test. Cure was defined as no nystagmus and no vertigo,
mild as nystagmus but no vertigo, and no cure as nystagmus and vertigo.
In summary, there appears to be no need to keep

patients upright overnight after either CRT or Liberatory
maneuver. Having patients stay upright for as little as 20
minutes after the maneuver is sufficient for remission of
BPPV. Keeping patients upright for 3 days does not
improve the efficacy of the treatment. These results raise
the question what happens to the otoconia once they are
moved out of the posterior SCC into the utricle. Is the
free otoconium reabsorbed into the macule once it is
placed back into the utricle, or does it simply dissolve
within the endolymph of the utricle? Further studies are
needed to settle this issue.
Specific Instructions for the

Canalith Repositioning Treatment
for Posterior SCC BPPV
The CRT Procedure. During the CRT, the patient first is
moved from sitting into the Dix-Hallpike position toward

the side of the affected ear and then remains in that position until the nystagmus ceases (see Fig. 17.6). In some
cases, the patient may remain in that position until any
residual nausea decreases before the head (labyrinth) is
shifted to the next position. The second phase of the treatment is either to rotate the patients head slowly through
moderate extension of the neck toward the unaffected
side or to roll the patients entire body onto the side if the
treatment table has been prepositioned so the head is
below horizontal. Again, the patient stays in the new position until the nystagmus stops. If there is no nystagmus,
the position is maintained for approximately 20 seconds.
The patient is then rolled to a side-lying position with the
head turned 45 degrees down (toward the floor) and kept
in that position for 20 seconds. Finally, keeping the head

deviated toward the unaffected side and pitched down, the
patient slowly sits up. Some patients experience vertigo
shortly after returning to the seated position.
Use of a Soft Collar. To make certain the otoconia stay in
the utricle after the treatment, the therapist can fit the
patient with a soft collar and tell the patient not to bend
over, lie back, move the head up and down, or tilt the head
to either side for the rest of the day. The soft collar serves
as a reminder to the patient to avoid those head positions
and does not have to be fitted with the same rigor as one
would fit a cervical collar on someone with a neck injury.
The soft collar should be removed before bedtime. We no
longer use a soft collar unless the patient requests one.
Home Treatment. The patient is told to perform the treat-
ment at home. We review the treatment with the patient

and any friends or family members who came to the
clinic by demonstrating the treatment again and by giving
the patient a handout with illustrations (Fig. 17.8). We ask
the patient to repeat the treatment on his or her own the
next morning. The patient is instructed that if he or she
still experiences vertigo during the treatment, the treatment should be repeated once each morning until the vertigo is not elicited during the treatment. We have patients
perform this home therapy for two reasons. First, patients
learn how to do the treatment, which is useful if they have
a recurrence of BPPV. Second, it raises the success rate of
the treatment. We schedule a follow-up clinic visit a few
days later to make certain the patient is in true remission.
Some patients cannot perform the CRT on their
own. In that situation, we teach them how to perform the
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Figure 17.8 Handouts given to patients for home treatment (canalith repositioning) for
posterior SCC BPPV. A, Diagram shows treatment for left-sided problem, and B shows
treatment for right-sided problems. (Adapted from Tusa and Herdman, Emory University,
Atlanta, 1999.)
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Brandt-Daroff habituation exercises. Radtke and associates28 compared the success of using two different home
self-treatments, Brandt-Daroff habituation exercises, and
CRT. They found CRT to be much more successful.
Common Sense Recommendations

for Treatment
Preventing Visual Fixation. The diagnosis of BPPV is
made by eliciting nystagmus and vertigo after the head is
moved in the plane of one of the SCCs. Using a device
to prevent visual fixation (such as Frenzel glasses, 20diopter lenses, or infrared goggles) is important. Torsional
nystagmus may not be suppressed by visual fixation,
although both horizontal and vertical nystagmus can be
suppressed. Without accurate identification of the presence, direction, and duration of the nystagmus, an incorrect diagnosis may be made. Additionally, observation of
nystagmus during the treatment will identify whether the
debris is moving in an appropriate direction at all stages
of the treatment. With each position change, the debris
should move away from the cupula. Therefore, the direction of the nystagmus should be the same with each
change in head (labyrinth) position. A reversal or change
in the type of nystagmus would suggest that the debris has
moved back toward the cupula or into another canal.39
Educating the Patient. It is important to educate the
patient before performing the testing maneuver or treatment. The therapist needs to know whether or not the
patient has experienced extreme vertigo or nausea with
changes in head position. If the patient describes having
severe vertigo, it may be best to reduce the speed used for
the Dix-Hallpike or side-lying maneuvers. If there is no
vertigo when the test is performed slowly, the test can be
repeated at a faster speed. The patient can also be premedicated.
Patients should be instructed as follows:
1. They should keep their eyes open and should
not look around during the test.
2. They may experience vertigo during the test or
treatment.
3. They must remain in the test position until the
vertigo has stopped.
4. If they absolutely cannot remain in the position,
the therapist will help them slowly return to a
sitting position.
5. The therapist will not let them fall.
If not educated about the procedure, the patient may
become frightened, close the eyes, or attempt to sit up
when the vertigo is provoked.
245
Efficient Testing Reduces Patient Discomfort. We typically
use the Dix-Hallpike maneuver as the first test for BPPV.

If the patient has no vertigo or nystagmus after testing on
one side, he or she is slowly returned to the sitting position. It is important to bring the patient slowly to sitting
to avoid or minimize orthostatic symptoms. The DixHallpike maneuver is then performed to the other side. If
the patient has no vertigo or nystagmus on the second
side, we lift the patients head slightly and perform the
roll test for horizontal canal BPPV. If that also is negative,
we slowly bring the patient up to a sitting position. We
then test the patient using the side-lying test. Patients are
often willing to lie down faster on their sides than on their
backs, an observation that may explain why the side-lying
test result may be positive in some patients with a negative Dix-Hallpike test result. If the patient knows which
side down produces vertigo, it is best to check the opposite side first during the test to keep nausea to a minimum.
Focus on Moving the Labyrinth. In patients with neck
pain, limited neck range of motion, or cervical dysfunction that prohibits neck extension and rotation, it is helpful to remember that you are trying to move the labyrinth
into a particular position, not the head and neck. The
required position of the labyrinth can be obtained by tilting the entire support surface first. Then, when the patient
lies down, the labyrinth is in the appropriate alignment to
provoke the signs and symptoms of BPPV.
Dealing with Balance Problems. Complaints of imbalance
are common in people with BPPV, although testing for

balance problems and the possibility of treatment for
imbalance can be deferred until after resolution of vertigo has been achieved.40,41 In our experience, vague complaints of imbalance often resolve without intervention in
about 2 weeks. Persistent balance problems or high risk
for falling are indications that intervention is needed.
Treatment of Posterior
Canal BPPV: Cupulolithiasis
The Liberatory Maneuver
The single treatment approach known as the Liberatory
maneuver was developed by Semont and associates.22
For the sake of discussion, let us assume that BPPV in the
patient being treated has been identified to be in the right
posterior canal. The Liberatory maneuver is performed as
follows:
1. The patient is told to sit sideways on the examination table, and the therapist turns the head
45 degrees to the left.
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2. The patient is quickly moved onto the right

side while keeping the head turned left; the
patient is kept in that position for 2 to 3 minutes
(Fig. 17.9).
3. The patient is then rapidly moved up through
the sitting position and down into the opposite
side-lying position, while the therapist maintains the alignment of the neck and head on the
body (in this case with the head always turned
to the left). Thus, the final position will have the
patieng lying with the face at a 45 degree angle
toward the table.
4. Typically, nystagmus and vertigo reappear in
this second position. If the patient does not
experience vertigo in this second position,
the head is abruptly shaken once or twice,
through a small amplitude, presumably to
free the debris. The patient stays in this
position for 5 minutes.
5. The patient then slowly moves into a seated
position.
Patients must remain in a vertical position for

48 hours (including while sleeping) and must avoid the
provoking position for 1 week following the treatment.
Like CRT, the liberatory maneuver usually requires only
a single treatment. Reportedly, this approach works by
floating the debris through the canal system to the common crus, but it may also dislodge debris adhering to the
cupula. It is not clear why the procedure calls for the
patient to be kept in each position for such an extended
period. We typically use only 1 minute in each position,
but even that duration may be excessive. The issue has
not been examined in a controlled study.

Proposed by Brandt and Daroff,16 this treatment requires
the patient to move into the provoking position repeatedly several times a day. It is performed as follows:
1. The patient first sits over the edge of the table
and turns his or head 45 degrees toward the side
Figure 17.9 Liberatory maneuver for treatment of posterior semicircular canal (SCC)
benign paroxysmal positional vertigo (BPPV),
shown for here for right posterior SCC BPPV.
(A) The patient sits on the examination table
sideways, and the head is rotated 45 degrees
toward the unaffected side. (B) The patient is
then moved quickly onto the affected side
(parallel to the plane of the affected posterior
canal) until the head is hanging 20 degrees
down. (C) After 1 minute, the patient is rapidly
moved through the initial sitting position to the
opposite side with the head still positioned
45 degrees toward the unaffected side (the
nose will now be angled 45 degrees down
toward the floor). (D) The patient holds this
position for 1 minute and then moves slowly
to a sitting position. A soft collar is then
placed, and the patient is given the same
instructions as that described for canalith
repositioning treatment (see Fig. 17.6). AC
anterior canal; PC posterior canal. Arrows
indicate position and movement of debris.
(Modified from Tusa and Herdman, 1998.4)
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that is symptom free and then is moved rapidly

into the side-lying position that causes the
vertigo (Fig. 17.10). A torsional and upbeating
nystagmus occurs with the onset of the vertigo.
The severity of the vertigo will be directly related to how rapidly the patient moves into the
provoking position.
2. The patient stays in that position until the
vertigo stops and then sits up again. Usually,
moving to the sitting position also results in
vertigo, although less severe and of a shorter
duration. Nystagmus, if reoccurring, will be
in the opposite direction.
3. The patient remains in the upright position for
30 seconds, turns his or her head 45 degrees in
the opposite direction and then moves rapidly
247
into the mirror-image position on the other side,

stays there for 30 seconds, and then sits up.
4. The patient then repeats the entire maneuver
until the vertigo diminishes.
5. The entire sequence is repeated every 3 hours
until the patient has 2 consecutive days without
vertigo.
It is not clear why these exercises result in a
decrease in the vertigo and nystagmus. One explanation
is that the debris becomes dislodged from the cupula of
the posterior SCC and moves to a location that no longer
affects the cupula during head movement. A second possibility is that the debris dissolves in the endolymph,
much like a lump of sugar dissolves with stirring. A third
possibility is that central adaptation occurs, reducing the
Figure 17.10 Brandt-Daroff treatment for treatment of posterior semicircular canal benign paroxysmal positional vertigo. (A to B) The patient is moved quickly into the side-lying position on the
affected side (shown here as right side) and stays in that position until 30 seconds after the vertigo
has stopped. (C) The patient then sits up and again waits for the vertigo to stop. The patient then
repeats the movement to the opposite side (D), stays there for 30 seconds after vertigo stops (E),
and sits up (F). The entire treatment is repeated 10 to 20 times, three times a day, until the patient
has no vertigo for 2 days in a row. AC anterior canal; PC posterior canal. Black arrows indicate
position and movement of debris. (Modified from Tusa and Herdman, 1998.4)
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nervous system response to the signal from the posterior

canal. Brandt and Daroff16 argue against central adaptation as a mechanism for recovery because many patients
recover abruptly with these exercises.
The Brandt-Daroff exercises for posterior canal
BPPV can be modified for horizontal canal cupulolithiasis. The patient performs rapid, repetitive movements in
the plane of the horizontal canal (the head stays facing
forward all the time). Although this approach appears to
be an effective treatment, only anecdotal evidence for it
exists at this time because of the relatively low occurrence of horizontal SCC BPPV. Presumably this treatment works by dislodging the debris from the cupula.
Variations in SCC Involvement

Up to now, we have discussed BPPV involving the posterior SCC, but BPPV also can occur in the anterior and
horizontal SCCs (see Table 17-3). In 6% of our patients,
we could not determine whether BPPV involved the anterior or posterior SCC because only the torsional component of nystagmus was present. The high prevalence of
posterior SCC BPPV is likely determined by the ease in
which otoconia can enter into this SCC when the patient
lies down. Which SCC the debris is in can be determined
from the direction of the nystagmus elicited by the DixHallpike or Side-lying tests for BPPV (see Table 17-4).
Horizontal SCC BPPV

In some cases of horizontal SCC BPPV, the Dix-Hallpike
test does not elicit nystagmus or vertigo.9 The optimal test
for eliciting horizontal SCC BPPV is a roll in the plane of
the horizontal SCC. For screening purposes, the patient is
laid supine, and the head is then quickly rolled to one
side. If no vertigo occurs, the head is quickly rolled to the
other side. If vertigo does occur, the roll test needs to be
more precise to determine the side of the defect.
One can improve the precision by always starting
the roll from a nose-up position (see Fig. 17.4A and B).
The head is rolled quickly to one direction, and nystagmus and vertigo are checked for. The head is then slowly
rolled back to center (see Fig.17.4C). Nystagmus and
vertigo are sought again after the patient is rolled to
the other side (see Fig. 17.4D). In a patient with horizontal SCC BPPV, nystagmus and vertigo occur for rolls in
both directions, but slow-phase eye velocity and duration
of nystagmus are greater when the patient is rolled
toward the affected ear.11 The direction of the nystagmus
depends on whether the otoconia is free-floating
(canalithiasis) or fixed to the cupula (cupulolithiasis) (see
Fig. 17.5).43 In canalithiasis of the horizontal SCC, nystagmus is geotropic and fatigues; in cupulolithiasis, nystagmus is apogeotropic and persists.
Bar-B-Que Roll Treatment for Horizontal Canalithiasis

The CRT has been modified for horizontal SCC BPPV
into a treatment referred to as the bar-b-que treatment (see Table 17-5).37,43,44 We have found this
treatment optimal for severe forms of horizontal SCC
BPPV due to canalithiasis.37 It can also be used
as an alternative treatment for horizontal SCC BPPV
due to mild canalithiasis. To begin the bar-b-que treatment, the patient lies on their back on the examination table or bed with the affected ear down (Fig.
17.11)one should recall that the affected ear is identified as the side that causes more nystagmus and vertigo
during the roll test. The patient moves from one position to the next with the clinicians assistance, as
follows:
1. The patients head slowly rolls away from the
affected ear until the face is pointed up; this
position is held for about 15 seconds, or until
the dizziness stops.
2. The patient continues to roll the head in the
same direction until the affected ear is up; this
position is held for about 15 seconds, or until
the dizziness stops.
3. The patient rolls the head and body in the same
direction until the face is down.
4. After 15 seconds, the patient slowly sits up,
keeping the head level or pitched down
30 degrees.
As with regular CRT, the patient may be fitted
with a soft collar. The follow-up treatment is the same
as for regular CRT, in that the patient may lie down at
night and then perform the bar-b-que roll treatment
each morning.
Liberatory Maneuver for Horizontal Canal Canalithiasis
Although called Liberatory maneuver by Appiani and
colleagues,45 it does not parallel Semonts Liberatory
maneuver for posterior canal BPPV cupulolithiasis.
Instead, this treatment was developed for patients with
horizontal SCC canalithiasis. Like the CRT treatment,
the theory underlying the treatment is that the head is
moved in such a way as to cause debris floating freely in
the horizontal SCC to move into the utricle. It is performed as follows:
1. The patient starts in a sitting position, looking
straight ahead, and then quickly lies on the
unaffected side (Fig. 17.12).
2. After holding that side-lying position for
2 minutes, the patient quickly turns the head
45 degrees down and remains in that position
for 2 minutes before sitting up.
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Figure 17.11 Bar-B-Que roll or Canalith repositioning treatment (CRT) for horizontal SCC BPPV. (A) The patient lies
supine on the examination table or bed with the affected ear
down (shown here for right horizontal SCC BPPV). (B) The
patients head is then slowly rolled away from the affected
ear until the face is pointed up; this position is maintained for
about 15 seconds or until any vertigo stops. (C) The patient
then continues to roll the head in the same direction until
the affected ear is up. This position is also maintained for 15
seconds or until the dizziness stops. (D) The patient then
rolls the head and body in the same direction until the face is
down and stays in that position for 15 seconds. At this point in
the treatment, the patient should be asymptomatic if the treatment has been effective. The patient can either sit up by moving first to a hands and knees position and then sitting sideways or can get off the treatment table by sliding one leg to
the floor, keeping the head straight ahead. (E) Alternatively,
the head and body are rolled in the same direction to the original position with the affected ear down, and then the patient
slowly sits up, keeping the head level or pitched down 30
degrees. These two variations of the CRT for horizontal SCC
BPPV are referred to as the 270-degree roll and the 360degree roll, respectively. Patients can be taught to perform this
treatment at home. The follow-up visit is usually scheduled for
within a few days of treatment. (Modified from Tusa and
Herdman, 1998.4)
Forced Prolonged Position (FFP)

for Horizontal Canal BPPV
Another treatment for horizontal SCC canalithiasis
BPPV is forced prolonged position.14 In this treatment,
the patient lies on the ear that contains the debris (side of
BPPV) for 20 seconds, and then slowly rolls towards the
healthy ear until the healthy ear is down. The patient
remains in this position all night. The forced prolonged
249
Figure 17.12 Liberatory maneuver for horizontal

canal canalithiasis. The patient starts in a sitting position
looking straight ahead and then quickly lies on the unaffected
side. After holding that side-lying position for 2 minutes, the
patient quickly turns the head 45 degrees down, and remains
in that position for 2 minutes before sitting up. Arrows
point toward the affected side. (Modified from Appiani
et al, 2001.45)
position can be combined with the bar-b-que treatment

by having the patient perform the bar-b-que treatment at
night prior to performing the FFP.
Quick Bar-B-Que Roll Treatment
for Cupulolithiasis BPPV
In order to dislodge otoconia attached to the cupula of the
horizontal SCC (cupulolithiasis), we follow the same
procedure as for horizontal SCC canalithiasis (described
previously), but we ask the patient to perform each head
turn as quickly as possible. After this quick bar-b-que roll
treatment, we ask patients to keep the head upright for
the rest of the day, but we do not ask them to sleep
upright. We have patients repeat this treatment once each
morning until they experience no symptoms during the
treatment.
Modified Semont Maneuver for
Horizontal Canal Cupulolithiasis
Another method for dislodging otoconia from the cupula
of the horizontal SCC has been proposed by Casani and
associates.46 The patient moves quickly from sitting to
side-lying position on the affected side. The patient then
quickly turns the head so the nose is down 45 degrees and
remains in that position for 2 to 3 minutes before sitting
up again (Fig. 17.13). The actual movement is similar to
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to treat. The best way to decide is based on the direction of the nystagmus rather than on the side of the
dependent labyrinth (ear) during the Dix-Hallpike test.
During the Dix-Hallpike test, any debris in the anterior
canal of the dependent labyrinth moves away from the
cupula, resulting in downbeating and torsional nystagmus (see Fig 17.14). One can imagine, however, that if
the head were positioned into more extension than usual,
debris in the opposite labyrinth might move, also away
from the cupula.
As shown in Figure 17.14, for example, debris
in the anterior canal of the right labyrinth would move
away from the cupula when the patient is positioned
in the right Dix-Hallpike position. This would result
in a downbeat and rightward torsional nystagmus. If
there were debris in the left anterior canal, either it
would not move or, with more neck extension, the debris
might move away from the left cupula of the anterior
canal, resulting in a downbeat and leftward torsional
nystagmus. That pattern would suggest left anterior
canal BPPV and could be confirmed by the response
when the patient is moved into the left Dix-Hallpike
position.
Figure 17.13 Modified Semont maneuver for horizontal

canal cupulolithiasis. The patient moves quickly from sitting to
lying on the affected side. The patient then quickly turns the
head so the nose is down 45 degrees, and stays in that position
for 2 to 3 minutes before sitting up again. (Adapted from Casani
et al, 2002.46)
the Appiani Liberatory

canalithiasis, except that
lies on the affected side.
remission of symptoms
maneuver.
maneuver for horizontal SCC

for cupulolithiasis, the patient
Casani and associates46 report
in 75% of patients with one
Anterior SCC BPPV

For anterior SCC BPPV, the nystagmus is primarily
downbeat and torsional (during quick phases of nystagmus, the superior pole of each eye torts toward the
dependent or inferior ear while lying).
Canalith Repositioning Treatment
for Anterior SCC BPPV
Anterior SCC BPPV is treated the same way as posterior
SCC BPPV. The difficulty lies in deciding which side
Liberatory Maneuver (Semont or

Brisk Treatment) for Anterior SCC BPPV
For anterior SCC BPPV, the procedure must be modified in order to move the head in the plane of the anterior SCC. For sake of discussion, assume that the patient
has debris in the right anterior SCC. The procedure
is as follows:
1. The patient sits on the examination table sideways, but the head is rotated 45 degrees toward
the right side.
2. The patient is then moved rapidly onto the right
side (parallel to the plane of the affected anterior SCC).
3. After 1 minute, the patient is rapidly moved
through the initial sitting position to the left
side with the head still positioned 45 degrees
toward the right side (nose is now angled 45
degrees up toward the ceiling).
4. The patient holds this position for 1 minute and
then moves slowly to a sitting position.
for Anterior SCC BPPV
Brandt-Daroff exercises can be used to treat anterior SCC
BPPV, because the head is moved in the plane of the posterior SCC on one side and of the anterior SCC on the
other side.
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251
Figure 17.14 Position testing for anterior semicircular canal (SCC) benign paroxysmal positional vertigo. (A) In the
Dix-Hallpike test, the patient sits on the
examination table, and the head is turned
45 degrees horizontally. (B) The head and
trunk are quickly brought straight back en
bloc, so that the head is hanging over the
edge of the examination table by 20
degrees. Nystagmus is observed, and the
patient is asked whether he or she has vertigo. Although not shown in the figure, the
patient is then brought up slowly to a sitting position with the head still turned 45
degrees, and nystagmus is observed again.
This test then is repeated with the head
turned 45 degrees in the other direction.
This figure also shows movement of freefloating otoconia (canalithiasis) in the right
anterior SCC during the Dix-Hallpike test.
In this example, the patient would have a
downbeat and rightward torsional nystagmus and vertigo when the test is done on
the right side, but not when the test is
done on the left side. AC anterior canal;
PC, posterior canal.
Algorithm for Treatment of BPPV
Evidence-Based Practice
Figure 17.15 is an algorithm for arriving at the appropriate treatment for BPPV. Identification of the affected
side, which canal is involved (based on direction of
nystagmus), and whether the problem is due to canalithiasis or cupulolithiasis leads to specific treatments or to
consideration that the nystagmus may be of central
origin.

Repositioning Maneuvers to Treat BPPV
The quality of evidence that CRT successfully treats posterior SCC BPPV includes randomized controlled studies, randomized noncontrolled studies, prospective
studies, and retrospective studies.47 A brief summary of
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History of episodic vertigo

of short duration;
or screening for BPPV
Clear for neck problems
Elicits up-beating and

rightward torsional nystagmus
Lasts > 60 s
PC cupulolithiasis
or central
Treat
but notify MD;
Lasts < 60 s
PC canalithiasis
Treat with CRT
Lasts < 60 s
PC canalithiasis
Treat with CRT
To right
Dix-Hallpike test;
if no response to
Dix-Hallpike, do
side-lying test
Liberatory maneuver;
reconsider central if
ineffective
Should achieve
remission in one or
two treatments;
rethink treatment if
ineffective
To left
Elicits up-beating and

leftward torsional nystagmus;
Lasts > 60 s
Elicits down-beating
appropriate torsional nystagmus
(rightward to right side;
leftward to left side)
Elicits horizontal nystagmus
on right and left sides
Lasts > 60 s
Lasts < 60 s
Lasts < 60 s
Geotropic
No response;
do roll test
Nystagmus is
Treat for PC cupulolithiasis with

PC cupulolithiasis
Liberatory maneuver; reconsider
or central; notify MD
central if treatment ineffective
Treat for AC cupulolithiasis with Liberatory
AC cupulolithiasis
maneuver; but notify MD; reconsider
or central
central if ineffective
Should achieve
Treat with CRT
AC canalithiasis
remission in one or
two treatments;
rethink treatment if
Treat for HC canalithiasis
ineffective
Lasts > 60 s
Not BPPV
Lasts < 60 s
Not BPPV
Lasts > 60 s
Treat for HC cupulolithiasis
Ageotropic
Elicits no nystagmus
BPPV not present
Figure 17.15 Algorithm for assessment leading to treatment of benign paroxysmal positional vertigo (BPPV). Identification of the direction and duration of the nystagmus leads to the determination of
the canal involved and whether the BPPV is from canalithiasis or cupulolithiasis. This information
directs the appropriate choice of treatment. AC anterior canal; BPP benign paroxysmal positional vertigo; CRT canalith repositioning treatment; MD medical doctor; PC posterior canal.
the randomized, controlled studies is given in Table 17-7.

Overall, these studies indicate that successful remission
of the signs and symptoms of posterior canal BPPV is
obtained in 67% to 94% of all patients treated with CRT,
compared with none to 48% for the control treatment.
Blakely51 published the only study that showed no difference in outcome between patients treated with CRT and
those not treated at all; this study was criticized because
the maneuver used was not clearly stated, follow-up was
delayed (1 month after treatment), and the follow-up step
did not examine the patients (telephone follow-up only).
Li18 stated that vibration was necessary during CRT for a
good outcome, but the majority of studies used no vibration. Despite the number of excellent studies that show
the effectiveness of CRT in treating BPPV, patients are
still told that there is no treatment or are given medication for their dizziness. Hopefully this misconception
will diminish with more publications of randomized controlled trials. For a review of the randomized controlled
trials on CRT of BPPV, see Tusa and coworkers.47
Quality of Available Evidence to Use the

Liberatory Maneuver to Treat BPPV
Semont and colleagues22 reported on a series of 711
patients with BPPV treated over an 8-year period. They
found a cure rate of 84% after a single treatment and of
93% after two treatments. Recurrence of the symptoms
was infrequent (4%). Other studies have reported somewhat lower remission rates. Hausler and Pampurik,52 for
example, examined the efficacy of the Liberatory
manuever in a randomized controlled trial of 77 subjects.
At 18 days after treatment, 51% of the patients treated
with the Liberatory maneuver were in remission, com-
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253
Table 17-7 RANDOMIZED CONTROLLED STUDIES USING

REPOSITIONING MANEUVERS FOR BPPV
Type of Study
Procedure and Remission Rate (%)
No. Subjects
Study
Single-blind, randomized,
controlled
CRT (89%) vs. no treatment (27%) at 1 month

(follow-up evaluator was blinded to the treatment type)
36
Lynn et al, 199521
controlled
CRT (71%) vs. sham treatment (0%) at 1 week

(patient did not know which treatment was to
be given, crossover study was done)
29
Lempert et al, 199744
controlled
CRT (67%) vs. untreated (38%) at 10 days

(follow-up evaluator was blinded as to treatment type)
50
Froehling et al, 20001
controlled
CRT (76%) vs. no treatment (48%) at 1 week

(follow-up evaluator was blinded as to treatment type)
58
Yimtae et al, 200348
Randomized, controlled
CRT (50%) vs. no treatment (43%) at 1 month
38
Blakley, 199451
CRT with mastoid vibration (92%) vs. CRT

without mastoid vibration (60%) vs. no treatment (0%) at 1 week
60
Li, 199518
CRT (93.4%) vs. no treatment (50%) by

21 days (1 treatment per week)
41
Wolf et al, 199949
CRT (94%) vs. no treatment (?) at 1 month
Asawavichianginda
et al, 200050
BPPV benign paroxysmal positional vertigo; CRT canalith repositioning treatment.
pared with 18% of the untreated control group.52 Levrat

and coworkers53 reported remission of symptoms in
62.6% of their subjects treated with only one maneuver. In
a prospective, randomized study that included 30 subjects
treated with the Semont maneuver, we reported remission
of symptoms and signs or significant improvement in
90% of the cases after a single treatment.5
In a later study, Ireland23 examined the effectiveness
of the Liberatory maneuver in a series of patients using
the patients as their own controls. The patients were first
treated with the Liberatory maneuver but on the unaffected side. None of the patients had any relief from vertigo.
The patients were then treated with only the routine postmaneuver instructions to keep the head upright for 48
hours, including sleeping in a sitting position. Again, at
the end of 1 week, all patients were symptomatic. Then
the patients were treated with the Liberatory maneuver
on the affected side. At the end of 1 week, all patients
were symptom-free. Although the number of subjects in
this study is small (n 10), the results do support the

effectiveness of the Liberatory maneuver as treatment for
BPPV.
Quality of Available Evidence to

Use Brandt-Daroff Habituation
Exercises to Treat BPPV
Brandt and Daroff16 studied a series of 67 patients with
BPPV of 2 days to 8 months in duration. None of these
patients had evidence of other neurological or neurotological disease. These investigators reported that 98% of
the subjects had no symptoms after 3 to 14 days of exercises. The only subject who did not show response to
treatment had a perilymphatic fistula requiring surgical
repair. Recurrence was low, affecting only 3% of the
patients.
In our experience with a series of 20 patients with
BPPV who were treated with exercises similar to those
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advocated by Brandt and Daroff,16 the time until the

patients were symptom-free (n 12) or had at least a
moderate reduction in symptoms (n 7) was more protracted, extending from 1 week to 6 months (this last case
involving a patient who was afraid to lie down; the treatment course was therefore several extra months while he
worked at home just to achieve a supine position).
Patients in whom there was only partial recovery complained most frequently of an intermittent swimming
sensation rather than of true vertigo. One patient experienced no change of vertigo. All of these patients had histories of BPPV extending from a few days to 35 years.
The more protracted the course, the more resistant the
BPPV may be to treatment.
Managing Persistent Imbalance

in Patients with BPPV
More than 50% of patients with posterior SCC BPPV
subjectively report imbalance.37,54 The presence of imbalance in such subjects, relative to age-matched controls,
has been quantified with computerized static and dynamic sway platform testing.40,41,5559 The CRT and liberatory
maneuver may completely resolve positional nystagmus
and vertigo based on repeat Dix-Hallpike test, and
improve balance, based on repeat computerized platform
testing,40,41,56,59 but 8% to 14% of patients may still complain of imbalance.5,60,61
Benyon61 has postulated that this imbalance may be

due either to persistent BPPV that is not sufficient to
deflect the cupula during testing or to vestibular hypofunction that was not detected during the initial evaluation. We do not believe that the persistent imbalance is
caused by either one of these problems. We quantified the
severity of imbalance in patients with posterior canal
BPPV using computerized dynamic posturography
before and after CRT in 33 patients.41 Patients who had
vestibular hypofunction confirmed by bithermal water
caloric testing, bilateral BPPV, or head trauma were
excluded. Figure 17.16 shows the mean posturography
scores for patients with BPPV before CRT, for the same
patients 1 week after CRT, and for age-matched controls.
Analysis of the balance tests before CRT shows that
scores for the patients with BPPV, as a group, did not
differ significantly from normative scores on tests 1, 2,
and 3. However, the scores for these patients on tests 4,
5, and 6 were significantly worse than the normative values. Balance improved in the patients with BPPV as a
group after CRT. Scores in about 33% of patients with
imbalance improved to normal values after CRT; scores
in the remaining patients either did not improve or
improved to subnormal values. The patients with persistent imbalance had no evidence of BPPV based on symptoms or on signs using video infrared cameras during the
Dix-Hallpike test. Di Girolamo and colleagues40 reported
similar results on posturography in patients with BPPV
Figure 17.16 Mean posturography scores for 33 patients with benign paroxysmal positional
vertigo (BPPV) before canalith repositioning treatment (CRT) (pre-tx pre-treatment) and 1 week
after CRT (post-tx post-treatment) compared with age-matched controls. * significant difference in anterior-posterior sway amplitude. Blatt PJ, Georgakakis GA, Herdman SJ, et al: With permission from Am J Otol 2000;21:356.
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and no evidence of vestibular hypofunction with use of

the bithermal water caloric test.
So what is the cause of persistent imbalance in
patients whose BPPV is in remission? One possibility is
the age of the patient. Those patients who improved in
the Di Giralamo study were younger (P .05).40 No difference was found between groups for time from onset of
BPPV, history of falls, or patient ratings of the intensity
of vertigo, although the difference between groups in
patients subjective rating of the intensity of disequilibrium approached significance. Therefore, the increased
postural sway in some individuals on these tests may be
due to a separate, pre-existing problem with balance that
occurs in the elderly, such as disuse disequilibrium,
which would not improve after CRT.
Alternatively, it is possible that it takes time for
the otoliths to recover fully after CRT. This latter explanation is supported by the study of Giacomini and
coworkers,59 who found that balance on a static platform
did not fully recover in patients with BPPV until 12
weeks after CRT. This finding has significant implications for the rehabilitation of patients with BPPV. If balance does not improve with treatment of the BPPV, then
patients should be reexamined to rule out vestibular
hypofunction or some other cause for imbalance. If
appropriate, patients should then be referred for specific
exercises to improve balance.
Contraindications to
the Assessment and
Treatment of BPPV
Because the Dix-Hallpike test and CRT require that
the head be rotated 45 degrees and extended 20 to 30
degrees, they should not be performed in patients with
certain types of neck disorders. Humphriss and colleagues62 consider the following disorders to be
absolute contraindications to performing the DixHallpike test, and presumably the treatment: history of
neck surgery, recent neck trauma, severe rheumatoid
arthritis, atlantoaxial and occipitoatlantal instability, cervical myelopathy or radiculopathy, carotid sinus syncope,
Chiari malformation, and vascular dissection syndromes.
They state that the test is otherwise safe and can be done
without causing injury in individuals who do not have
these disorders. They recommend that the following
parameters be met in every patient before the DixHallpike test is performed:
1. With the patient seated, can the head be rotated
45 degrees to the right for 30 seconds and then
to the left for 30 seconds without pain?
255
2. With the patient seated, can the head be rotated

45 degrees to either side and extended back for
30 seconds without pain?
Injury of patients during testing for BPPV is virtually nonexistent. However, clinicians must be cautious in
performing the Dix-Hallpike test and should follow the
parameters discussed by Humphriss and colleagues.62
In patients who cannot extend the head backward
owing to neck disease, we perform the side-lying test
(described previously) instead of the Dix-Hallpike test.37,54
We also perform this alternative test in elderly patients
who cannot extend the head backwards and in patients
with low back pain or recent back surgery. In patients for
whom rotating or extending the head is contraindicated, a
modified side-lying test can also be done. In these patients
we use a soft neck collar to help stabilize the neck.
1. To test the right posterior SCC, we sit the
patient on the side of a table and then rotate the
body and head together 45 degrees to the left.
2. We then lay the patients body and head down
together to the right to reach a side-lying
position.
This modification avoids moving the head independent of the body. To test the left posterior SCC, we rotate
the body and head 45 degrees to the right before laying
the patient down to the left. This whole-body movement
method has also been used to treat BPPV in patients with
orthopedic problems in the neck and spine.63
We published a small study on the complications
of the CRT.39 Of 85 consecutive patients treated with
CRT for posterior SCC BPPV, we found that two patients
developed anterior SCC and 3 patients developed horizontal SCC BPPV at testing 7 days later (Table 17-8).
Others have also noted the conversion of posterior SCC
BPPV to horizontal SCC BPPV after CRT.42,44,48 Another
complication was a stiff neck from keeping the head
upright. Finally, some patients experienced severe vertigo and nausea within 1020 minutes after CRT or the
Liberatory maneuver had been performed.
To reduce these complications, we now take the following measures: To avoid conversion of BPPV from
posterior SCC to anterior and horizontal SCC, we always
now use a tilt table to be certain that the patients head is
tilted at least 30 degrees down from horizontal during
CRT. Since we began doing this, none of our patients
experienced such conversions except for occasional
patients who performed the treatment themselves at
home. We believe that if the head is not tilted down
enough during CRT, otoconia may enter into one of these
other SCCs instead of the utricle. To avoid a stiff neck
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Table 17-8 COMPLICATIONS OF

CRT FOR POSTERIOR
SCC BPPV IN 85
Complication
No. of Patients
Affected
Percentage of
Patients Affected
Neck pain
5.8
Conversion to
anterior
SCC BPPV
2.3
Conversion to
horizontal
SCC BPPV
3.5
Emesis
1.2
after CRT, we instruct all patients to move the head horizontally a few times every hour while they awake for at
least 24 hours. To avoid severe vertigo, nausea, and vomiting, we instruct all patients to sit still for a couple of
minutes after the treatment and for 10 minutes longer in
the waiting room before leaving the clinic. Also, in
patients with a history of severe nausea from BPPV, we
perform the Dix-Hallpike test slowly; if BPPV is found,
we immediately stop all further testing and perform the
CRT slowly.
Unraveling Complicated Cases

Unfortunately, not all patients with BPPV have obvious signs and symptoms. The following case studies
illustrate some of the more confusing presentations.
All patients in these case studies were tested with
Frenzel lenses or infrared goggles. Figure 17.17 presents an algorithm that may provide some assistance
is making decisions when confronted by difficult cases
of BPPV.
BPPV, benign paroxysmal positional vertigo; CRT, canalith

repositioning treatment; SCC, semicircular canal.
Adapted from Herdman and Tusa, 1996.39
Results in
Do
Results in
Do
Up-beating and
torsional nystagmus
with vertigo
Dix-Hallpike to
symptomatic side
Up-beating and
torsional nystagmus
with vertigo
Treat for
bilateral PC
BPPV
No nystagmus
no vertigo
Test using
sidelying test
Nystagmus is
appropriate and
with vertigo
Treat for BPPV
History of
Episodic vertigo
Clear neck
Perform Dix-Hallpike
to asymptomatic side
No nystagmus
no vertigo
Dix-Hallpike to
symptomatic side
Nystagmus but no
vertigo
Stalwart patient
Not BPPV
Downbeating and
torsional nystagmus
mild vertigo
Dix-Hallpike to
symptomatic side
Vertical nystagmus only

with or without vertigo
Possible
central
No nystagmus
complains of vertigo
Fear, anxiety
conditioned
response
Strong upbeating and

torsional nystagmus
with vertigo
False bilateral;
treat PC BPPV
No nystagmus
no vertigo
Treat AC BPPV
Figure 17.17 Algorithm for assessing, interpreting, and treating complicated cases of benign
paroxysmal positional vertigo.
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CASE STUDY 1
The patient has a persistent right-beating nystagmus
without vertigo when in the right Dix-Hallpike position, and an upbeating and leftward torsional nystagmus with vertigo when in the left Dix-Hallpike
position. This latter nystagmus resolves in 25 seconds,
and then a persistent right-beating nystagmus (without vertigo) is again observed.
Explanation
The patient may have a left vestibular neuritis affecting the superior branch of the vestibular nerve. This
would result in horizontal canal hypofunction and
would explain the presence of the right-beating nystagmus without vertigo in both the right and left DixHallpike positions. The superior branch of the
vestibular nerve also supplies the utricle and anterior
canal but not the saccule or posterior canal. Thus, the
patient could have degeneration of the utricle with

release of otoconia, which could then move into the
still functioning posterior SCC, causing the posterior
canal canalithiasis form of BPPV.
Resolution
Treat the left-sided BPPV first. When the patient
comes back and there is remission of BPPV, ask the
patient whether the treatment has resolved all of the
symptoms. If it has not and the patient reports imbalance or vertigo with quick head movements, ask
whether any episode of vertigo has lasted for a day or
longer (consistent with vestibular neuritis). Then perform the head-thrust test to confirm horizontal canal
hypofunction, and refer the patient for a caloric test.
If the patient has unilateral vestibular hypofunction,
begin vestibular rehabilitation.
CASE STUDY 2
The patient has no vertigo when moved into the left
Dix-Hallpike position but does have a persistent
downbeat nystagmus. When moved into the right
Dix-Hallpike position, the patient has an upbeating
and rightward torsional nystagmus (with vertigo) that
decreases over 15 seconds but then becomes a persistent downbeat nystagmus. The vertigo lasts only
15 seconds.
Explanation
The upbeat and torsional nystagmus with vertigo lasting only 15 seconds is consistent with the posterior
SCC canalithiasis form of BPPV. The downbeat nystagmus observed after the upbeat and torsional nystagmus resolves is not simply a reversal of the primary
nystagmus of BPPV. First of all, it is persistent and if
it were a reversal of the BPPV nystagmus, it would
last only seconds. Second, it was observed when the
patient was in both the right and the left Dix-Hallpike
positions. The persistent downbeating nystagmus in
this case suggests a central problem in addition to the
BPPV. If the patient has a spontaneous downbeating
nystagmus when sitting as well as when in the DixHallpike positions, the physician must be informed.
257
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CASE STUDY 3
In the left Dix-Hallpike position, the patient has a
vigorous upbeating and leftward torsional nystagmus
associated with intense vertigo lasting 25 seconds. In
the right Dix-Hallpike position, there is a downbeating and rightward torsional nystagmus with mild vertigo lasting 15 seconds.
the PC BPPV on the left side. The orientation of the

labyrinth when the patient is in the right Dix-Hallpike
position is such that it causes the otoconia in the
left posterior canal to drift toward the cupula. False
bilateral BPPV is more common than true bilateral
BPPV.
Explanation
There are two possibilitieseither the patient has
posterior canal (PC) BPPV on the left side and anterior canal BPPV on the right side, or this is an example of false bilateral BPPV. In the latter situation, the
patient actually has PC BPPV on the left side; the
mild downbeating and torsional nystagmus with
mild vertigo that occurs when the patient is in the
right Dix-Hallpike position is actually produced by
Resolution
The patient should be treated for left PC BPPV. If the
nystagmus and vertigo resolve on both sides, the
patient had false bilateral BPPV. If, after resolution of
the PC BPPV on the left, the patient still has downbeating and rightward torsional nystagmus when in
the right Dix-Hallpike position, the patient has true
bilateral BPPV, and so should be treated for the anterior canal BPPV.
CASE STUDY 4
In the right and left Dix-Hallpike positions, the
patient has no nystagmus but complains of dizziness
and becomes diaphoretic.
Explanation
It is quite possible that the patient had BPPV but it
has already resolved. The patient, however, has
become fearful and has a conditioned autonomic
nervous system response when moved into a position
that previously provoked the vertigo. It is also possi-
ble that the patient is being histrionic; he or she

should be given the benefit of the doubt, however.
Resolution
The patient still needs to be able to tolerate lying
down. This is a situation for which the habituation
approach would be appropriate. The patient can begin
by moving into a semi-supine positionone that elicits very mild symptomsand gradually works toward
becoming more comfortable when lying down.
CASE STUDY 5
You have been treating a patient for BPPV for 3
weeks but her signs and symptoms have not yet been
resolved. CRT was performed on two visits during
the first week, and she also performed the treatment
at home. When you asked the patient to demonstrate
how she is doing the treatment, you noticed that she
lifted her head when rolling from the initial DixHallpike position to the opposite side. You corrected
this problem, but after a week of performing the CRT
at home, she was still not better. You then performed

the Liberatory maneuver and taught the patients husband how to do the treatment at home. This approach
was tried daily for another week without success. The
husband was able to demonstrate the treatment correctly, so faulty performance was not the problem.
You then had the patient perform the Brandt-Daroff
habituation exercise at home for another week, still
without resolution.
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Explanation
Failure to respond to treatment for BPPV should be a
red flag that something else may underlie the
patients signs and symptoms. The literature shows
that 90% or more of patients with BPPV have complete resolution in one or two treatments.
Summary
Based on several randomized, controlled trials, both CRT
and the Liberatory maneuver are effective treatments for
posterior canal BPPV. CRT and the Dix-Hallpike test can
be modified in patients with neck disease that prevents
neck rotation and/or extension. There is no need to have
patients sleep upright after the treatment is completed.
Instead, they may need to sit upright for only 20 minutes,
which is best done in the clinic. Because BPPV is a
chronic disease (recurrences do occur), teaching the
patient how to perform the treatments at home
is an effective way to reduce repeat visits. The few
complications of the treatments can be avoided through
careful attention to the technique used for CRT and posttreatment instructions. Some patients have persistent
imbalance after treatment; therefore, all patients should
be questioned about persistence of imbalance, and appropriate testing and physical therapy given to those in
whom imbalance persists.
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APPENDIX 17A
Differential Diagnosis:
Mimicking BPPV
A number of causes of positional dizziness and positional nystagmus may be confused with benign paroxysmal
positional vertigo (BPPV) (Appendix Table 17-1).
Episodic Signs and Symptoms (Benign)
head rotation5 or in individuals with cervical spondylosis.6 Transcranial Doppler ultrasonography can be used to
demonstrate decreased posterior circulation flow in
symptomatic individuals.7 In our experience, vertebral
artery compression during Dix-Hallpike testing and
canalith repositioning treatment is extremely rare, most
likely because the extent of rotation is relatively small
(maximum 45 degrees horizontal rotation and 30 degrees
head extension).
Central positional vertigo (CPV) that occurs as spells is

usually due to migraine or a migraine equivalent spell.
Nystagmus may be vertical or horizontal. The nystagmus
is usually sustained. See the Appendix Case Study.
Central Positional
Nystagmus without Vertigo
Central Positional
Vertigo with Nystagmus
Persistent Signs and

Symptoms (Pathological)
Injury near Cerebellar Nodulus
Persistent CPV is a rare entity that has been attributed to
cerebellar tumor1 or to hemorrhage dorsolateral to the
fourth ventricle.2,3 It produces a position-induced nystagmus (downbeat) and vertigo that (1) usually persists as
long as the head position in maintained, (2) does not
fatigue, and (3) does not habituate with repeated testing.
The nystagmus in CPV does not have a torsional component. In addition, CPV is induced in all position changes
(supine, left ear down, right ear down).
Vertebral Artery Compression

Vertigo and nystagmus can occur during head rotation
from vertebral artery insufficiency4 either from extreme
There are various types of central positional nystagmus

(CPN) that are usually not associated with vertigo. In
these cases, nystagmus is usually sustained and is not
suppressed by visual fixation. Unidirectional nystagmus
(vertical, horizontal, or torsional) is more commonly
associated with a central lesion than with a peripheral
cause. These patterns of nystagmus are usually due to
lesions in central vestibular pathways.
CPN Present Only When

Patient Is Supine (Benign)
Usually in elderly patients, downbeating or upbeating
nystagmus may be elicited only when the patient is
supine and there are no other abnormalities on examination. The etiology of this condition is unknown. Perhaps
it represents mild trauma to the craniocervical junction
from arthritis.
261
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Appendix Table 17-1 DIFFERENTIAL DIAGNOSIS FOR BENIGN

PAROXYSMAL POSITIONAL VERTIGO
Category
Circumstance
Most Common Cause(s)
Central positional
vertigo with nystagmus
Episodic signs and symptoms during position

testing
Usually benign: Migraine
Persistent signs and symptoms during position

change
Usually pathologic: Tumor or stroke

near cerebellar nodulus, or vertebral
artery compression
Present only when patient supine
Usually benign: Nothing seen on

magnetic resonance imaging of head
Present when patient supine or seated

(pathologic)
Usually pathologic: Abnormality

within central vestibular pathways
(cerebellar or brainstem disorders)
Dizziness induced during Dix-Hallpike testing,

but also usually induced by pressure changes
between inner and middle ear (Valsalva maneuver, Henneberts sign, Tullio phenomenon)
Perilymphatic fistula, superior canal

dehiscence, hypermobile stapes
Persistent, mild vertigo in certain head positions

while patient is supine
Labyrinthine hypofunction
Dizziness induced when patient bends over, sits

up, or stands; never when patient is lying down
Orthostatic intolerance
Dizziness usually when patient sits or stands with

head pitched or turned to an extreme position
Head extension dizziness or extreme

rotation dizziness
Central positional nystagmus without vertigo
Peripheral positional
vertigo with nystagmus
other than BPPV
Positional dizziness
without nystagmus
CPN Present When Patient Is Supine

and When Sitting (Pathological)
In some cases, downbeating or upbeating nystagmus
occurs while the patient is seated and is usually enhanced
while the patient is supine. The patient may also have
mild cerebellar signs. The etiology depends on whether
the nystagmus is downbeat or upbeat, as follows.
Upbeating Nystagmus
Upbeating nystagmus in both supine and sitting positions
is due to increased activity of central posterior SCC pathways relative to the anterior SCC. This occurs with
lesions involving the brachium conjunctivum in the midbrain or ventral tegmental tract in the dorsal pontomedullary junction, including multiple sclerosis,
tumor, and stroke.9
Downbeating Nystagmus
Downbeating nystagmus in both supine and sitting positions can occur from increased activity of central anterior
semicircular canal (SCC) pathways relative to the posterior SCC.8 This occurs with cerebellar degeneration,
Chiari malformation, and selective lesions involving the
cerebellar flocculus or the medial longitudinal fasciculus
in the floor of the fourth ventricle, such as multiple sclerosis, tumor, and stroke.
Peripheral Positional Vertigo with

Nystagmus Other Than BPPV
Pressure-Induced Disorders
As in BPPV, perilymphatic fistula (PLF), SCC dehiscence, and hypermobile stapes can cause positional vertigo and nystagmus. Unlike BPPV, these disorders are
usually associated with hearing loss. Valsalva maneuver,
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Appendix 17A
change in pressure to the external ear (Henneberts sign),

mechanical movement of the tragus of the external ear, or
loud noises (Tullios phenomenon) may induce vertigo
and nystagmus in these disorders.
A perilymphatic fistula is a hole between the inner and
middle ear caused by trauma, a cholesteatoma, otic
syphilis, or displaced middle ear prosthesis.10,11 As in
BPPV, it can cause positional vertigo and nystagmus;
unlike BPPV, it is usually associated with hearing loss.
Valsalva maneuver or a change in pressure to the external
ear frequently induces vertigo and nystagmus.

SCC dehiscence is congenital thinning of the roof of the
superior SCC.12 During mild head trauma or Valsalva
maneuver, the bony canal wall may erode and the superior SCC then comes in contact with the dura above the
petrous bone. This results in a third membranous window into the inner ear that is susceptible to any pressure
changes within the labyrinth.
Hypermobile Stapes
The stapes may become hypermobile following head
trauma or a stapes prosthesis may become dislodged and
move into the oval window.13
Labyrinthine Hypofunction
Direction-changing, static, positional nystagmus may
occur in individuals with chronic unilateral vestibular
hypofunction.14 The nystagmus may either be geotropic
(left-beating with the left ear down and right-beating with
the right ear down) or apogeotropic (beats away from the
earth). Individuals with this type of nystagmus may have
mild vertigo during the position change, but the vertigo is
much less than that found in BPPV.
Positional Dizziness
without Nystagmus
Orthostatic Hypotension
The history of orthostatic hypotension consists of transient dizziness when the patient gets out of bed, stands up
quickly, or bends over quickly. The patient may report
episodic lightheadedness, weakness, impaired cognition,
DIFFERENTIAL DIAGNOSIS: MIMICKING BPPV
263
visual blurring, tremulousness, and vertigo that are

aggravated by prolonged standing, or exercise, or that
that occurs 15 to 45 minutes after eating (postprandial
hypotension). Chronic fatigue may be present.
The physical examination in a patient with such a
history should include a blood pressure check as follows.
Supine blood pressure should be measured after 10 minutes. In a patient with orthostatic hypotension, the systolic blood pressure drops by at least 20 mm Hg within
3 minutes of standing up, and the patient is symptomatic.
A tilt table test should be performed in individuals in
whom results of the bedside blood pressure check is not
clear (may be helpful in young individuals with syncope). Treatment consists of elimination of diuretics,
nitrates, calcium-channel blockers, and beta-blockers if
possible. If this step is not successful, the patient should
drink at least 20 oz water and should salt food excessively during each meal. If necessary, fludrocortisone
(Florinef) up to 0.6 mg/day can be prescribed. If this
treatment is not effective, midodrine 10 mg up to three
times a day can be tried. The patient should be instructed
to sleep on a 30-degree wedge pillow to avoid supine
hypertension.
Head Extension Dizziness

and Extreme Rotation Dizziness
The otoliths are outside their optimal functioning range
when the head is pitched back.15 This head position can
cause dizziness in individuals when they are seated or
standing. Normal individuals who rotate the head to an
extreme position laterally also may experience vague
dizziness. This unusual posture may be due to a sensory
mismatch16 or to a disturbance in spatial localization.
When the Dix-Hallpike test result is negative in a patient
complaining of consistent positional dizziness, it is useful to ask the patient to demonstrate the head posture that
most commonly causes the dizziness. This can help confirm the diagnosis of head extension or extreme rotation
dizziness.
Appendix References
1. Harrison MS, Ozsahinoglu C: Positional vertigo. Arch
2. Brandt T: Positional nystagmus in normals. Adv
3. Brandt T: Positional and positioning vertigo and nystagmus. J Neurol Sci 1990;95:3.
4. Strupp M, Planck JH, Arbusow V, et al: Rotational
vertebral artery occlusion syndrome with vertigo
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CASE STUDY
The patient is a 45-year-old woman with a 3month history of positional vertigo (getting out of
bed), blurred vision, oscillopsia, imbalance, and
throbbing headache. She has had migraine
headaches since age 27. Clinical findings are normal. Magnetic resonance imaging and caloric test
results are both normal. She visits the clinic on
the day of her next spell. Physical findings are
normal except during positional testing using a
video infrared camera to block fixation.
The video shows sustained left-beating nystagmus with the left ear down and sustained rightbeating nystagmus with the right ear down. She
also has transient upbeat and right torsional nystagmus with the right ear down. She had mild vertigo during the sustained portions of nystagmus,
and moderate vertigo during the transient upbeat
nystagmus.
Comment
This patient has sustained geotropic nystagmus
and right posterior canal BPPV. The sustained
geotropic nystagmus does not fit the pattern for
horizontal canal BPPV; therefore, it is most likely
due to migraine aura and represents central positional vertigo (benign). She undergoes treatment
for the BPPV and is started on a migraine program (see Chapter 12). On the follow-up visit in 2
days, she has no positional nystagmus or vertigo.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
due to labyrinthine excitation. Neurology 2000;

54:1376.
Toole JF, Tucker SH: Influence of head position upon
cerebral circulation. Arch Neurol 1960;2:616.
Sheehan S, Bauer RB, Meyer JS: Vertebral artery compression in cervical spondylosis. Neurology 1960;
10:968.
Sturzenegger M, Newell DW, Douville C, et al: Dynamic
transcranial Doppler assessment of positional vertebrobasilar ischemia. Stroke 1994;25:1776.
Baloh RW, Spooner JW: Downbeat nystagmus: a type
of central vestibular nystagmus. Neurology 1980;
31:304.
Fisher A, Gresty M, Chambers B, Rudge P: Primary position upbeating nystagmus: a variety of central positional
nystagmus. Brain 1983;106:949.
Pyykko I, Ishizaki H, Aalto H, Starck J: Relevance of the
Tullio phenomenon in assessing perilymphatic leak in
vertiginous patients. Am J Otol 1992;13:339.
Kohut RI, Hinojosa R, Ryu JH: Update on idiopathic
perilymphatic fistulas. Otolaryngol Clin North Am 1996;
29:343.
Minor LB, Solomon D, Zinreich JS, Zee DS: Soundand/or pressure-induced vertigo due to bone dehiscence
of the superior semicircular canal. Arch Otolaryngol Head
Neck Surg 1998;124:249.
Pickuth D, Brandt S, Berghaus A, et al: Vertigo after
stapes surgery: the role of high resolution CT. Br J Radiol
2000;73:1021.
Lin J, Elidan J, Baloh RW, Honrubia V: Directionchanging positional nystagmus: incidence and meaning.
Brandt T, Krafczyk S, Malsbenden I: Postural imbalance with head extension: improvement by training as
a model for ataxia therapy. Ann N Y Acad Sci 1981;
374:636.
Brandt T: Vertigo: Its Multisensory Syndromes. London:
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CHAPTER
18
Hypofunction
Normal Vestibulo-Ocular Reflex
Normal activities of daily life (such as running) can be

associated with head velocities of up to 550 degrees per
second (deg/sec), head accelerations of up to 6000
degrees/sec2, and frequency content of head motion from
1 to 20 Hz.1,2 Only the vestibular system can detect head
motion over this range of velocity, acceleration, and frequency. Additionally, the latency of the vestibulo-ocular
reflex (VOR) has been reported to be as short as 5 to
7 msec.3,4 In contrast, ocular following mechanisms, such
as smooth pursuit, generate slower eye velocities (~60
deg/sec), have relatively long latencies (up to 100
msec),5,6 and fail at frequencies exceeding 1 Hz.7 For subjects with vestibular loss that has not been compensated
adequately, head movements can significantly limit participation in activities of daily life.
Individuals with vestibular loss use different compensatory strategies to improve their ability to see clearly during a head rotation.16 Compensatory mechanisms include
substitution or modification of a saccade, increased gain
of the cervico-ocular reflex (COR), the use of a centrally
preprogrammed eye movement, and, perhaps, enhancement of the smooth pursuit system.
The substitution of a saccade in the direction of the
deficient VOR (preprogrammed saccades [PPSs]) during
ipsilesional whole-body and head-only rotations has been
identified in persons with loss of vestibular function.14,15
Recently, it has been reported that these saccades are
unique in that they occur with reduced latencies of 50 to
150 msec from the onset of a head rotation (Fig. 18.1),15,17
occur during both predictable and unpredictable head
movements,14,17 and have been hypothesized to be of vestibular origin.14
It appears that PPSs also function to improve gaze
stability associated with ipsilesional head rotations. The
influence of the PPS in reducing gaze instability was initially reported in 1988. Segal and Katsarkas18 studied the
VOR using unpredictable whole-body rotations in three
persons with unilateral vestibular hypofunction (UVH) as
a result of an VIIIth cranial neurectomy for removal of a
vestibular schwannoma. The investigators described a
type of saccade that corrected for 28% to 59% of the
slow-component error associated with ipsilesional head
thrusts. Later, Bloomberg and colleagues19 reported a
Abnormal Vestibulo-Ocular Reflex

People who sustain vestibular damage typically experience vertigo, disequilibrium, head motioninduced
oscillopsia, spontaneous nystagmus, and postural instability.811 In particular, when a subject with loss of vestibular function makes rapid head rotations in the direction of
the damaged labyrinth, the eyes do not remain fixated on
a visual target, reflecting a deficient VOR. As a result,
visual acuity during head rotation is degraded.12,13 As a
form of compensation, the brain can generate surrogate
eye rotations that compensate for the VOR.14,15
265
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A. Unpredictable Ipsilesional Head Rotation

160
120
Velocity (d/s)
80
40
0
-40
-80
-160
-200
Preprogrammed Saccades
-240
20
40
60
80
100
120
140
160
180
200
120
140
160
180
200
B. Unpredictable Contralesional Head Rotation

160
120
Normal VOR
Velocity (d/s)
80
40
0
-40
-80
-160
-200
-240
20
40
60
80
100
Time (msec)
Figure 18.1 Preprogrammed saccades vs. normal vestibular-ocular reflex (VOR) in a person with
unilateral vestibular hypofunction (UVH). Black traces reflect head velocity, and gray traces eye velocity. The vertical line marks the onset of the head rotation. (A) The slow eye velocity is deficient in relation to the head velocity (low VOR gain), and preprogrammed saccades (PPSs) are recruited. Note
that the direction of the PPSs is the same as that of the slow velocity. (B) The slow eye velocity is
similar to the head velocity for a normal VOR gain.
similar synergistic relationship between slow-component

vestibular and saccadic eye movements for the purpose of
improving gaze stability.
The translational VOR (tVOR; otolith-mediated)
has also been shown to benefit from the symbiotic relationship between VOR and saccades. Shelhamer and
associates20 adaptively increased the gain of the tVOR in
human subjects by exposing them to lateral sinusoidal

translations and target motion for 20 minutes. These
researchers showed that saccades occurred in the direction of the slow eye movements and accounted for 32%
of the tVOR after adaptation. On the basis of these previous studies, saccades not only have been shown to occur
in the direction of the vestibular slow component but also
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Chapter 18 COMPENSATORY STRATEGIES FOR VESTIBULO-OCULAR HYPOFUNCTION
appear to require little time for their recruitment and utility in reducing gaze instability.
Saccadic Modifications
A variety of modifications to the saccadic oculomotor
system have been reported for patients with vestibular
hypofunction when the experimental paradigms have
involved a head rotation (a condition that normally
requires a VOR). Three are described here.
Kasai and Zee16 reported that when patients were
asked to follow a target with the eyes and head, they were
found to generate an initial saccade to the target of
decreased amplitude (undershoot). The researchers
hypothesized that the brain intentionally undershoots the
target, anticipating the inability of the VOR to keep the
eyes still during the head rotation. Through the use of a
saccade of insufficient amplitude, the eyes then drift to
the target with the head motion.
Several studies have established that during an
ipsilesional unpredictable head rotation (yaw) away from
a centrally positioned visual target, a saccade is generated
in the opposite direction to the head rotation, back toward
the target.14,1819,2123 Most of the investigators agree that
these types of saccades (preprogrammed saccades):
Are recruited for the purpose of stabilizing gaze,
though incompletely.
Improve gaze stability, although they do not
completely match the velocity of head motion.
Are inversely correlated with VOR gain.14,18,19,23
May occur more than once during a single head
rotation.14,21,2324
The studies also demonstrate a great deal of variability in use of preprogrammed saccades. Some patients
appear to use PPSs only for high-acceleration or largeamplitude head motions.14,16,19,2324
It has also been shown that the latency to generate a
preprogrammed saccade during an ipsilesional unpredictable head rotation (yaw, away from a centrally located visual target) is much shorter than visually guided
saccade latencies, 70 to 130 msec versus 200 msec,
respectively.14
Cervico-Ocular Reflex
The COR parallels the VOR and is thought to contribute
a slow-component eye rotation in the direction opposite
to head movement in the place of the deficient vestibular
system. The difference, however, is that the eye motion
from the COR is generated from receptors in the joints
and ligaments of the upper cervical vertebrae.25 For eye
movements to be discerned as being generated from the
267
cervical spine and not the vestibular system, the head

must remain still. The COR is quantified from the ratio
between eye and trunk velocities (absolute value of peak
eye velocity peak trunk velocity). As a compensatory
mechanism for vestibular loss, the COR should move the
eyes in a direction opposite to the head position. When
the trunk is rotated to the left under a still head, the relative head position (static) is the same as if the head had
rotated to the right. A rightward static head position
would therefore elicit a leftward eye motion. Although
the COR is well described in animal models, its presence
in humans is controversial.
In 1906, Barany first demonstrated eye motion in
rabbits when the trunk was rotated beneath a still head.26
In later studies, various researchers demonstrated that
sectioning the dorsal roots from C1 to C4 or injecting
anesthetic into the cervical joints of rabbits produced
nystagmus.27,28 Recording from cat abducens motor neurons, Hikosaka and Maeda25 showed in 1973 that stimulating the second or third cervical dorsal roots caused
facilitation of the ipsilateral abducens motor neurons and
increased firing rate from the contralateral vestibular
nucleus. Additionally, contralateral abducens motor neurons were inhibited. Stimulation below the fourth cervical joints did not generate the same facilitation and
inhibition responses. These researchers demonstrated
synapses between second and third cervical vertebral
joints and abducens oculomotor neurons and vestibular
nuclei. As a form of control, the second or third cervical
joints were anesthetized with lidocaine injection, after
which the nystagmus could not be elicited.
A later study by Gdowski and McCrea,29 in the
squirrel monkey, yielded further evidence of the influence of neck proprioceptive information on the vestibular
nuclei. The investigators compared firing rates (sensitivity) recorded from secondary afferents of the horizontal
semicircular canals while the primates trunk was rotated
beneath a still head (passive neck rotation) with those
during whole-body rotation (each rotation parameter was
measured at 0.5 Hz, 40 deg/sec and at 2.3 Hz, 20
deg/sec). They reported the gain of the COR was similar
regardless of frequency of the test (0.4 0.04 for 0.5 Hz
and 0.33 0.05 for 2.3 Hz). This study showed that neurons in the vestibular nuclei are sensitive to neck rotation
in primates. More importantly, these results appear to
support the earlier study in cats concluding that the COR
serves as a compensatory mechanism.
The identification of a COR as a means of gaze
stabilization in humans is controversial. Part of the
controversy is due to the methods used to study the
COR, and part to the great variability in reported function of the COR. See Chapter 29 for a review of cervical vertigo.
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Subjects with Vestibular Hypofunction

The majority of studies that have investigated the role of
the COR as a compensatory strategy have done so in
patients with bilateral vestibular hypofunction (BVH).16,
22, 3033 Kasai and Zee16 first reported that COR gain varied from 0.27 to 0.5 in three subjects with complete loss
of vestibular function. Others have reported similar COR
gain values.22, 3033 Of particular interest was a case study
involving a subject in whom complete loss of vestibular
function was diagnosed from caloric irrigation.32 The
investigators reported that the COR gain decreased from
0.51 to 0.17 as the central vestibular system demonstrated recovery of the VOR gain (both VOR and COR measured at 0.2 Hz, 40 deg/sec). This finding implies that the
COR was a compensatory mechanism transiently useful
until the gain from the VOR recovered.
30
Evidence for the existence of a COR in a person

with UVH was recently reported in an 81-year-old
woman. 34 The authors described a COR gain of 0.1
0.04 during 0.3-Hz trunk rotation. In this patient, the
COR gain was increased to 0.32 0.13 after 5 weeks of
gaze stabilization exercises (Fig. 18.2). Oddly, the direction of the COR was not compensatory. This evidence
suggests that the COR can be potentiated, although its
functional relevance is still uncertain.
Effects of Prediction
When individuals with vestibular hypofunction can
predict head movement, gaze stability improves. This
process has been shown in two ways. First, VOR gain
(eye velocity head velocity) is larger during predictable
A. Pre Gaze Stabilization Exercises

Chair velocity trace
Mean eye velocity
Mean head velocity
Right
10
Mean head velocity = 0.23 d/s
-10
Velocity (deg/sec)
Mean Eye velocity = 2.8 d/s

Left
-30
30 B. Post Gaze Stabilization Exercises
A. Post
Exercises
Chair Gaze
velocityStabilization
trace
Right
Mean eye velocity

Mean head velocity
10
Mean head velocity = 0.6 d/s
-10
Mean Eye velocity = 7.8 d/s
Left
-30
0
1.5
Time (sec)
3.0
Figure 18.2 Cervico-ocular reflex (COR) in a

patient with unilateral vestibular hypofunction (UVH).
The chair, eye, and head velocities are plotted. The
subjects head was fixed to a post to prevent head
motion. (A) The COR gain (eye velocity/chair velocity)
was at 0.1 before the patient started a gaze stabilization exercise program. After the program, the COR
gain had increased to 0.32. Note the very low head
velocity, demonstrating that this eye velocity is not
from the vestibular system.
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head movements toward the defect than during unpredictable head movements toward the defect in individuals
with vestibular hypofunction.15,17,3539 Second, visual acuity during head motion (dynamic visual acuity [DVA]) is
better during predictable head rotations than during
unpredictable head rotations.12,40 Enhancement of gaze
stability and DVA with predictable head movement is
believed to be due to mechanisms such as central preprogramming and efference copy of the motor command.
269
We have found evidence that individuals with

vestibular hypofunction can generate a high-velocity
slow phase (HVSP) for ipsilesional predictable head rotations (Fig. 18.3A).15 These unique eye rotations occur
with velocities greater than the velocity limit imposed by
inhibitory cutoff (@ 100 deg/sec). Additionally, we have
evidence that the HVSPs occasionally occur before the
onset of the head rotation and, therefore, are not a
vestibular-generated eye rotation (Fig. 18.3B).
A. Velocity Plot
100
Head Velocity
Gaze Velocity
Eye Velocity
93 deg/sec
Right
Velocity (deg/sec)
50
Onset of
Head Thrust
0
Head = 0
46 deg/sec
-50
Left
-100
124 deg/sec
0
100
200
300
400
500
600
Time (msec)
B. Acceleration plot of same head thrust

Head Acceleration
Gaze Acceleration
Eye Acceleration
Right
Figure 18.3 Velocity and acceleration plots of

a high-velocity slow phase during a predictable
head thrust in a subject with BVH. (A) The head is
thrust to the left at 124 deg/sec, above the level of
inhibitory cutoff, yet the subject generates a slow
eye velocity of 93 deg/sec, for a gain of 0.74. (B)
The acceleration plot reveals that the slow eye
velocity precedes the head rotation, demonstrating
that this type of eye response is not generated
from the vestibular system.
Acceleration (deg/sec/sec)
1000
Onset of
Eye Acceleration
500
15 msec
0
-500
Onset of
Head Thrust
-1000
Left
-1500
100
200
Time (msec)
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Enhanced Smooth Pursuit

Smooth pursuit eye movements are used to track a moving visual target, typically without head rotation. Smooth
pursuit gain is the ratio of eye velocity to target velocity
(eye velocity target velocity). Like the vestibular system, smooth pursuit is highly modifiable.41,42 Generally,
smooth pursuit functions best at frequencies within 1 to 2
Hz7 and at velocities within 60 deg/sec. However, for
motivated individuals, smooth pursuit has been demonstrated to function well at velocities of 90 deg/sec.43
Subjects with vestibular hypofunction may be able
to use smooth pursuit as a means of substitution for the
deficient VOR, although limited data are available to support this possibility. In a study by Bockisch and associates,44 subjects with BVH were reported to have smooth
pursuit gains that were, on average, 9% greater than those
in healthy controls. The researchers also documented that
these patient subjects were able to generate higher
smooth pursuit velocities (peak velocity 40 deg/sec).
They concluded that smooth pursuit may be a useful
compensatory mechanism for a deficient VOR. More
research regarding smooth pursuit and VOR interaction is
needed to discern whether smooth pursuit may be a useful oculomotor mechanism to adapt for people with
vestibular hypofunction.
Summary
Evidence strongly supports the notion that people with
vestibular hypofunction use different strategies for gaze
stabilization. These data demand that rehabilitation
approaches be customized to meet the unique adaptive
strategies and capacities of each patient.
References
1. Grossman GE, Leigh RJ, Abel LA, et al: Frequency and
velocity of rotational head perturbations during locomotion. Exp Brain Res 1988;70:470476.
2. Das VE, Zivotofsky AZ, DiScenna AO, Leigh RJ: Head
perturbations during walking while viewing a head-fixed
target. Aviat Space Environ Med 1995;66:728732.
3. Minor LB, Lasker DM, Backous DD, Hullar TE:
Horizontal vestibuloocular reflex evoked by highacceleration rotations in the squirrel monkey, I: Normal
responses. J Neurophysiol 1999;82:12541270.
4. Huterer M, Cullen KE: Vestibuloocular reflex dynamics
during high-frequency and high-acceleration rotations of
the head on body in rhesus monkey. J Neurophysiol
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5. Krauzlis RJ, Miles FA: Release of fixation for pursuit and
saccades in humans: evidence for shared inputs acting on
different neural substrates. J Neurophysiol 1996;76:
28222833.
6. Krauzlis RJ, Lisberger SG: Temporal properties of visual

motion signals for the initiation of smooth pursuit eye
movements in monkeys. J Neurophysiol 1994;72:
150162.
7. Leigh RJ, Zee DS: The Neurology of Eye Movements,
2nd ed. Philadelphia: FA Davis; 1991.
8. Gillespie MB, Minor LB: Prognosis in bilateral vestibular
hypofunction. Laryngoscope 1999;109:3541.
9. Telian SA, Shepard NT, Smith-Wheelock M, Hoberg M:
Bilateral vestibular paresis: diagnosis and treatment.
10. Belal A Jr: Dandys syndrome. Am J Otol 1980;1:
151156.
11. Bhansali SA, Stockwell CW, Bojrab DI: Oscillopsia in
patients with loss of vestibular function. Otolaryngol
Head Neck Surg 1993;109:120125.
12. Herdman SJ, Schubert MC, Tusa RJ: Role of central preprogramming in dynamic visual acuity with vestibular
loss. Arch Otolaryngol Head Neck Surg 2001;127:
12051210.
13. Herdman SJ, Schubert MC, Das VE, Tusa RJ: Recovery
of Dynamic Visual Acuity in Unilateral Vestibular
Hypofunction. Arch Otolaryngol Head Neck Surg
2003;129:819824.
14. Tian JR, Crane BT, Demer JL: Vestibular catch-up saccades in labyrinthine deficiency. Exp Brain Res 2000;
131:448457.
15. Schubert MC, Das VE, Tusa RJ, Herdman SJ: Gaze stability during predictable and unpredictable head thrusts.
Program No. 266.1 [CD ROM]. Washington, DC: Society
for Neuroscience; 2002.
17. Della Santina CC, Cremer PD, Carey JP, Minor LB:
Comparison of head thrust test with head autorotation test
reveals that the vestibulo-ocular reflex is enhanced during
voluntary head movements. Arch Otolaryngol Head Neck
Surg 2002;128:10441054.
18. Segal BN, Katsarkas A: Goal directed vestibulo-ocular
function in man: gaze stabilization by slow-phase and saccadic eye movements. Exp Brain Res 1988;70:2632.
19. Bloomberg J, Melvill Jones G, Segal B: Adaptive plasticity in the gaze stabilizing synergy of slow and saccadic eye
movements. Exp Brain Res 1991;84:3546.
20. Shelhamer M, Roberts DC, Zee DS: Dynamics of the
human linear vestibulo-ocular reflex at medium frequency
and modification by short-term training. J Vestib Res
2000;10:271282.
21. Cremer PD, Halmagyi GM, Aw ST, et al: Semicircular
canal plane head impulses detect absent function of individual semicircular canals. Brain 1998;121:699-716.
22. Maurer C, Mergner T, Becker, et al: Eye-head coordination in labyrinthine-defective humans. Exp Brain Res
1998;122:260274.
23. Segal BN, Katsarkas A: Long-term deficits of goal directed vestibulo-ocular function following total unilateral loss
of peripheral vestibular function. Acta Otolaryngol
(Stockh) 1998;106:102110.
24. Segal BN, Katsarkas A: Goal directed vestibulo-ocular
function in man: gaze stabilization by slow-phase
and saccadic eye movements. Exp Brain Res 1988;
70:2632.
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25. Hikosaka O, Maeda M: Cervical effects on abducens

motor neurons and their interaction with vestibulo-ocular
reflex. Exp Brain Res 1973;18:512-530.
26. Brandt T: Cervical vertigoreality or fiction? Audio
Neurootol 1996;1:187196.
27. Biemond A, de Jong JMBV: On cervical nystagmus and
related disorders. Brain 1969;92:437458.
28. Gresty MA: A reexamination of neck reflex eye movements in the rabbit. Acta Otolarygol (Stockh) 1976;81:
386394.
29. Gdowski GT, McCrea RA: Neck proprioceptive inputs to
primate vestibular nucleus neurons. Exp Brain Res
2000;135:511526.
30. Bronstein AM, Hood JD: The cervico-ocular reflex in normal subjects and patients with absent vestibular function.
Brain Res 1986;373:399408.
31. Huygen PLM, Verhagen WIM, Nicolasen MGM:
Cervico-ocular reflex enhancement in labyrinthinedefective and normal subjects. Exp Brain Res 1991;
87:457464.
32. Bronstein AM, Morland AB, Ruddock KH, et al:
Recovery from bilateral vestibular failure: implications for
visual and cervico-ocular function. Acta Otolaryngol
(Stockh) Suppl 1995;520:405407.
33. Heimbrand SA, Bronstein AM, Gresty MA, et al:
Optically induced plasticity of the cervico-ocular reflex in
patients with bilateral absence of vestibular function. Exp
Brain Res 1996;112:372380.
34. Schubert MC, Das V, Tusa RJ, Herdman SJ: Cervicoocular reflex in normal subjects and patients with
unilateral vestibular hypofunction. Otol Neurotol
2004;25:6571.
35. Collewijn H, Martins AJ, and Steinman RM. Compensatory eye movements during active and passive head
36.
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movements: fast adaptations to changes in visual magnification. J Physiol 1983;340:259286.

Demer JL, Oas JG, Baloh RW: Visual vestibular interaction in humans during active and passive vertical head
movement. J Vestib Res 1993;3:101114.
Hoshowsky B, Tomlinson D, Nedzelski J: The horizontal
vestibulo-ocular reflex gain during active and passive high
frequency head movements. Laryngoscope 1994;104:
140145.
Jell RM, Stockwell CW, Turnipseed GT, et al: The influence of active versus passive head oscillation, and mental
set on the human vestibulo-ocular reflex. Aviat Space
Environ Med 1988;59:10611065.
Halmagyi GM, Black RA, Thurtell MJ, Curthoys IS: The
human horizontal vestibulo-ocular reflex in response to
active and passive head impulses after unilateral vestibular
deafferentation. Ann N Y Acad Sci 2003;1004:325336.
Tian JR, Shubayev I, Demer JL: Dynamic visual acuity
during passive and self-generated transient head rotation
in normal and unilaterally vestibulopathic humans. Exp
Brain Res 2002;142:486495.
Fukushima K, Tanaka M, Suzuki Y, et al: Adaptive
changes in human smooth pursuit eye movement.
Neuroscience Res 1996;25:391398.
Scheurer W, Ditterich J, Straube A: Adaptation of initial
smooth pursuit eye velocity in humans. Neuro-ophthalmology 1999;21:223-231.
Meyer CH, Lasker AG, Robinson DA: The upper limit
of human smooth pursuit velocity. Vision Res 1985;25;
561563.
Bockisch CJ, Straumann D, Hess K, Haslwanter T:
Enhanced smooth pursuit eye movements in patients
with bilateral vestibular deficits. Neuroreport 2004;15:
26172620.
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19
Physical Therapy
Assessment of Vestibular
Hypofunction
Patients with peripheral vestibular hypofunction differ

with respect to the onset and clinical course of their disability as well as to the final level of recovery, depending
on the type and extent of vestibular deficit. Despite these
differences, such patients have many of the same symptomsdizziness, lightheadedness, vertigo, nystagmus,
blurred vision, postural instability, fear of movement, gait
disturbances, and occasional falling.1 In addition, these
patients may experience anxiety, depression, and fear
related to their disability.26 In fact, people with vestibular
dysfunction report that they are significantly impaired by
their disability.79 As a result of one or more of these
symptoms, patients with peripheral vestibular hypofunction often cope with their disability by avoiding certain
movements and decreasing their activity level.10 This
habit, if not treated, will lead to the unfortunate results of
physical deconditioning and an alteration of the patients
lifestyle.10,11
The purpose of this chapter is to provide an
overview of patient problems and the key components of
the clinical examination as well as the more comprehensive examination. We use the International Classification
of Functioning, Disability and Health (ICF) scheme for
the organization of this chapter.12 The ICF was developed
by the World Health Organization specifically to provide
a framework for the description of health-related states
that includes both positive experiences and negative consequences of disease.12 This scheme consists of three
272
domains that can be used to describe the effect of different disorders or diseases on a persons health, with a
number of environmental and personal factors that affect
each of those domains (Box 19-1).
The ICF model differs from other models of disablement in that it provides a more comprehensive depiction of the health of an individual. The model shifts the
emphasis away from impairment and disability to a more
balanced perspective that includes health.
Normal Structure and Function

versus Impairment
Patients with vestibular hypofunction may express a multitude of symptoms. These symptoms emerge from functional deficits in vestibulo-ocular and vestibulospinal
systems (Box 19-2) and from the results of sensory mismatch and physical deconditioning.13
Vestibulo-Ocular
Function and Dysfunction
The vestibulo-ocular reflex (VOR) is the primary mechanism for gaze stability during head movement. During
movements of the head, the VOR stabilizes gaze (eye
position in space) by producing an eye movement of
equal velocity and opposite direction to the head move-
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Chapter 19 PHYSICAL THERAPY ASSESSMENT OF VESTIBULAR HYPOFUNCTION
273
Box 19-1
HEALTH CONDITION12
Activities
Versus
Limitations
(individual level)

versus
Impairment
(body level)
Participation
Versus
Restriction
(societal level)
Contextual Factors
Environmental Factors:
Personal Factors:
e.g. Natural environment

Attitude of family
Attitude of society
e.g.
ment. The ratio of eye velocity to head velocity is referred

to as the gain of the VOR. The ideal gain in a normal subject would equal 1. VOR gain has been shown to be
reduced to 25% in human beings immediately after uni-
Gender, age
Co-morbidities
Social background
Past experience
Coping and character style
lateral labyrinthine lesions for head movements toward

the affected side.14,15 During the acute stage, VOR gain is
also reduced to 50% for head movements toward the
unaffected side.
Box 19-2
QUESTIONS TO ASK A PATIENT WITH A VESTIBULAR DISORDER

1. Do you experience spells of vertigo (a sense
of spinning)? If yes, how long do these spells
last?
2. When was the last time the vertigo occurred?
3. Is the vertigo spontaneous, induced by motion,
induced by position changes?
4. Do you experience a sense of being off-balance
(disequilibrium)? If yes, is the feeling of being
off-balance constant, spontaneous, induced by
motion, induced by position changes, worse with
fatigue, worse in the dark, worse outside, worse
on uneven surfaces?
5. Does the feeling of being off-balance occur
when you are lying down, sitting, standing, or
walking?
6. Do you stumble, stagger, or side-step while
walking?
7. Do you drift to one side while you walk? If yes,

to which side do you drift?
8. At what time of day do you feel best?
____________ worst? ____________
9. How many times per day do you experience
symptoms?
10. Do you have hearing problems?
11. Do you have visual problems?
12. Have you been in an accident (e.g., motor
vehicle)?
13. What medications do you take?
14. Do you live alone?
15. Do you have stairs in your home?
16. Do you smoke? If yes, please indicate how much
per day.
17. Do you drink alcohol? If yes, please indicate
how much.
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Other eye movements, such as saccades and pursuit,

are not affected by vestibular loss. Saccadic eye movements are rapid voluntary movements that allow
refoveation of stationary targets. Pursuit eye movements
enable the individual to visually follow a moving object
across the visual field (smooth pursuit) without making
compensatory head movements. Normally, the vestibuloocular, pursuit, and saccade systems work cooperatively
to stabilize gaze during head movements.16
Perception of Head
Movement and Position
Normally, signals from the labyrinth provide accurate
information concerning head movement and position.
These vestibular signals are synchronized with visual and
somatosensory inputs, and the nervous system is able to
appropriately interpret the combination of signals.
Whenever there is an acute or sudden asymmetry of
vestibular function, of course, the brain interprets this
abnormal signal as continuous movement of the head,
and the patient experiences a spinning sensation even
when he or she is not moving at all. In patients with a
chronic vestibular dysfunction, the asymmetry becomes a
problem only with actual movement of the head.
According to Norr,17 the disturbed vestibular function
produces a sensory input different from the one expected
under normal conditions. This abnormal vestibular signal
is in conflict with normal signals provided by the visual
and somatosensory systems, and the resultant sensory
conflict is thought to produce the symptoms associated
with motion misperception.17 Clinically, patients complain of lightheadedness or dizziness associated with particular head or body movements. Norr17 has referred to
this condition as provoked vertigo, which is attributable to the asymmetry in the dynamic vestibular responses following a unilateral vestibular lesion.
Postural Instability
Independent and safe ambulation depends on the ability
to successfully perceive the relevant features of ones
environment.18 In addition, information about the orientation of the body with respect to the support surface and
gravity is essential to postural control. Information necessary for postural control is derived from an integration
of sensory inputs from the visual, somatosensory, and
vestibular systems.19
Impairment in the function of vestibulospinal reflex
(VSR) itself is believed to contribute to postural disturbances in patients with peripheral vestibular disorders.
Lacour and associates20 showed that producing a unilateral vestibular neurotomy in baboons induces asymmetrical
excitability in ipsilateral and contralateral spinal reflexes.
Similarly, Allum and Pfaltz,21 using support surface rotations, reported that tibialis anterior responses in patients
with unilateral peripheral vestibular deficits are enhanced
contralateral to and reduced ipsilateral to the side of the
lesion. These patients also had reduced neck muscle
activity and greater-than-normal head angular accelerations during response to the support surface rotations.
Cervical Range of Motion

Limitations in cervical range of motion can be a common
clinical finding in patients with vestibular hypofunction,
perhaps because of the head movementinduced symptoms and instability.22,23
Changes in a patients overall general physical condition
(deconditioning) can be considered the most potentially
disabling consequence of vestibular dysfunction. This
finding may be associated with a patients tendency to
restrict movements that potentially provoke symptoms.
Activities versus Limitation

The loss or reduction of the VOR and vestibulospinal
function translates into changes in function at the level of
the individual. Poor VOR gain means that the person will
have difficulty seeing clearly during head movements,
especially unpredictable ones. Poor VSR results in
changes in the persons confidence in balance, diminished
gait speed, and an increased risk for falling. Patients with
unilateral peripheral vestibular hypofunction frequently
experience gait instability in situations that require them
to move their heads while walking, to turn, or to stop
quickly.2427 Walking with head movement appears to be
particularly complex for persons with vestibular dysfunction,28 and limited activity is often the result. In addition,
clinical observation of their gait commonly reveals deviations such as veering left or right, a widened base of support, decreased gait speed, shortened step lengths,
decreased arm swing, a diminished ability to perform
multiple tasks while walking, occasional head or trunk
tilting, an impaired perception of vertical, and decreased
head and trunk motion.2931 For some patients, the use of
an assistive device such as a cane reduces gait instability
by acting as an additional proprioceptive cue. Work by
Jeka and Lackner3234 seems to support this concept.
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Participation versus Restriction
Physical Therapy Evaluation
As a result of many factors, including fear of falling, embarrassment about staggering while walking, personality,
and the uncomfortableness of head movementinduced
symptoms, patients may adopt a more sedentary lifestyle,
frequently abandoning premorbid exercise routines or
recreational activities.10,35 If untreated, such changes could
lead to more serious physical and psychosocial consequences, with significant restrictions in the persons participation in activities at the level of the society.
The inclusion of different measurement tools to assess

outcome in the ICF domains Normal/Abnormal Structure
and Function (organ/body level), Activity/Limitation
(person level) and Participation/Restriction (societal
level) ensures that all possible problems associated with
a patients vestibular dysfunction are considered in
planning the treatment program and in determining
whether the treatment has been effective. Table 19-1 lists
a variety of measurement tools according to ICF domain.
Table 19-1 MEASUREMENT TOOLS USED ACCORDING TO ICF DOMAIN

ICF Domain
Tool
Normal/Abnormal
Structure and
Function
Head-thrust test
Dix-Hallpike test
Strength
Range of motion
Endurance
Millon Behavioral Medicine Diagnostic
Vestibular Coping Questionnaire
Balance confidence (ABC scale)
Activity/
Limitation
Participation/
Restriction
Gait speed
Fall risk (Dynamic Gait Index)
Dynamic Visual Acuity
Physical Activities Scale for the Elderly
Medical Outcomes Study 36-Item ShortForm Health Survey
Sickness Impact Profile
Vestibular Disorders Activities of

Daily Living Scale
Disability Score
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These tools are discussed in the context of the full examination.
History
Medical History
Physical therapy is usually initiated after vestibular laboratory testing and the physicians determination of the
patients diagnosis. The diagnosis, vestibular laboratory
test results, other diagnostic test results, and the patients
current and past medical histories are important pieces of
information that should be obtained by the therapist at the
initiation of the physical therapy evaluation. Such information may assist in the identification of problems that
could ultimately affect the patients rehabilitation prognosis and outcome. For example, concurrent disease
processes, such as peripheral vascular disease and peripheral neuropathy, could affect and prolong the patients
functional recovery. Diabetes, heart disease, old neck and
back injuries, a history of migraines, and preexisting or
long-term visual dysfunction are examples of disorders
that affect the ability of the person to compensate for the
vestibular loss.
Obtaining a complete medication history from the
patient is vital because many medications can produce or
enhance dizziness (see Chapters 7 and 11). Certain medications act to reduce the patients symptoms by depressing the vestibular system. These medications may also
delay vestibular adaptation and therefore may prolong
the recovery period. The therapist should consult with the
physician to determine the possibility of reducing the
dose of such a medication or even eliminating it completely. Some people need medication in order to proceed
with rehabilitation, especially those with anxiety and persons with central vestibular dysfunction. Persons with
central vestibular disorders who have constant dizziness
complaints may benefit from a central vestibular suppressant so that their symptoms, especially severe nausea, are better under control.36,37 They may not be able to
tolerate rehabilitation efforts without such medication to
control their dizziness.
Subjective History
The subjective history of the patients condition is critical
in the evaluation of the patient with a peripheral vestibular problem. Questions that go beyond those usually
asked by a physical therapist should be considered (see
Box 19-2). The use of a questionnaire that the patient can
fill out prior to the initial visit is often helpful and saves
time (see Appendix 19-A). A complete description of the
patients symptoms should be documented, so that func-
tional progress can be later assessed. Knowing what positions, movements, or situations aggravate the patients
symptoms may be of importance in treatment planning.
In addition, the patient should be asked questions about
the type, frequency, duration, and intensity of symptoms
as well as whether symptoms are of a fluctuating nature.
Knowing the type of onset and frequency of the symptoms is very helpful in determining the physical therapy
diagnosis and prognosis.
Intensity of symptoms like vertigo and dysequilibrium can be measured by means of a visual or verbal analog scale similar to that used in the assessment of pain.38,39
Some therapists use a 0 to 10 scale, and others use a 0 to
100 scale.39,40 It is very helpful to have patients rate their
symptoms, yet not all patients are able to provide a number. Those who are confused have great difficulty rating
their symptoms, and family members often attempt to
help the patient rate their sensation of dizziness, which
is not useful. When it is impossible for the patient to provide a numerical rating, a little, medium, or lot of dizziness rating scale can help guide intervention.
Questions related to the patients perceived disability and psychosocial status should also be included in the
initial assessment. Many different tools can be used to
measure perceived disability, and most of them include
items that assess function at the activity/limitation and
participation/restriction levels. Using the Medium
Outcomes Study 36-Item Short-Form Health Survey (SF36) is one method that could be used to determine
whether the patient is doing more in the home or community after therapy.4146 Other therapists may use the
Sickness Impact Profile or other health status measures.47
These tools help the therapist determine whether the
patient is feeling better and is more active. Use of health
status inventories is an excellent way to learn whether the
patient has actually improved.48
Many patients believe they have a psychological
problem rather than a physical one. The patients condition is one that cannot be seen by family and friends.
Often, the condition is not well understood and has been
misdiagnosed by the medical community.49 When interacting with such a patient, the therapist must reassure
him or her that others share the disorder. This reassurance
is essential, because in some cases, stress or emotional
trauma magnifies symptoms (see Chapter 15). Showing
the patient brochures from the Vestibular Disorders
Association (VEDA) often validates the condition, and
the patient begins to understand that many other people
have a similar impairment.
Several tools that have been developed to define the
patients subjective symptoms of dizziness in an objective manner.50 The Dizziness Handicap Inventory (DHI)
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is a useful clinical tool that can clarify the patients symptomatic complaints and perceptions of his or her functional abilities (see Appendix 19-A).9,5054 Items relate to
functional, emotional, and physical problems that the
patient may have, and these items reflect all three
domains of the IFCfunction, activity, and participation.
This inventory can be administered quickly during the
initial and discharge visits, to quantify whether or not the
patient thinks he or she has improved. The DHI is consistent with high test-retest reliability (r = 0.97).49
Responses to various items on the DHI can lead the clinician to suspect benign paroxysmal positional vertigo
(BPPV).55 The DHI has been shown to be correlated to
the Activities-specific Balance Confidence (ABC) Scale
in persons with vestibular disorders.5 The ABC scale is a
16-item tool that quantifies balance confidence.56 In addition, the DHI may also help the therapist identify persons
who may be at risk for falling.9 Scores higher than 60
have been related to reported falls in persons with
vestibular dysfunction.9
Shepard and colleagues57 have suggested the use of
a disability scale to objectively document a patients perceived level of disability (Table 19-2). Test-retest reliability is high (ICC 1.057a). This 6-point Disability Scale
has descriptors that range from having no disability to
having long-term disability. Long-term disability is
defined as the inability to work for more than 1 year.57
The Disability Scale can be incorporated into the initial
and discharge physical therapy evaluations, to document
Table 19-3 POST-THERAPY

SYMPTOM SCALE
Criterion
Score
No symptoms remaining at the end

of therapy
Marked improvement remaining

at the end of therapy
Mild improvement, definite persistent

symptoms
No change in symptoms relative

to therapy
Symptoms worsened with therapy

activities on a persistent basis relative
to pre-therapy period
Adapted from Shepard NT, et al: Habituation and balance retraining: a

retrospective review. Neurol Clin 1990;8:459.
treatment outcome. As an alternative, the Post-Therapy

Symptoms Scale, also developed by Shepard and colleagues,57 can be used at discharge to determine whether
the patient perceives a change in disability (Table 19-3).
The Disability Scale is also useful in predicting treatment
outcome; Shepard and colleagues57 found that patients
who rated their disability as a 4 or 5 were less likely to
show significant improvement with rehabilitation.
Table 19-2 DISABILITY SCALE
Fall History
Criterion
Score
Negligible symptoms
Bothersome symptoms
Performs usual work duties but symptoms interfere with outside activities
Symptoms disrupt performance of both

usual work duties and outside activities
Currently on medical leave or had to

change jobs because of symptoms
Unable to work for over 1 year or established permanent disability with compensation payments
Adapted from Shepard, NT, et al: Habituation and balance retraining:

A retrospective review. Neurol Clin 8:459, 1990.
Some patients with vestibular dysfunction fall.1,25,5860

Taking a history of falls is very important because individuals often misinterpret the question Have you fallen? When asked, the patient answers no, but with
probing, it is common to find out that the patient has fallen. A fall is defined as involuntarily moving to the ground
or floor. Carefully defining what a fall is with the patient
provides the therapist better data to interpret the patients
condition. People who have fallen two or more times in
the last 6 months are at high risk for falling again.61 The
patient can also be asked about having near falls. Near
falls are be defined as (1) taking several steps to hold
onto a wall, table, or top of a chair or (2) being caught or
supported by another person.61,62 Other important issues
include: (1) whether the patient has been injured during a
fall, (2) the conditions under which the fall(s) occur, (3)
how the patient has modified his or her lifestyle after a
fall or fall-related injury, and (4) whether the patient
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sought medical intervention as a result of the fall.

Unexplained falls are always of concern. The treating
physician should be notified immediately if the person is
falling with no known provocative cause. Fortunately,
certain exercises programs can reduce fall risk, even in
the frail older adult.63 Hall and associates64 have demonstrated that fall risk is reduced after vestibular rehabilitation in persons with unilateral hypofunction.
sedentary lifestyle. Occasionally patients develop phobias associated with their symptoms, including fears of
elevators and of heights. Whitney and colleagues68 have
reported that 50% of the people referred to the investigators tertiary physical therapy clinic stated that they were
always wary of heights.
Functional History
At the beginning of the assessment, the patient should be

asked about expectations of physical therapy and functional goals.69 After the assessment is complete, the therapist and the patient should discuss whether these goals
are realistic and attainable. Many times, the patients
goals may have to be mutually modified by the therapist
and the patient. The final level of recovery for most
patients with unilateral vestibular hypofunction (UVH),
without other complications, should be a return to full
activities. Conditions that may make recovery more difficult and so need to be recognized in the setting of goals
include the patients premorbid physical condition and
personality profile.6 Occasionally patients with significant vestibular dysfunction make remarkable functional
gains but still experience significant symptoms at the
conclusion of rehabilitation.
To obtain a complete picture of functional status, the therapist should question the patient about previous and current activity levels (Box 19-3). A history of the patients
activity level is an important component of the assessment, which often characterizes the extent of the patients
disability. Cohen and coworkers10,65 Vestibular Activities
of Daily Living Scale is an excellent example of a tool
that will assist the therapist in identifying functional limitations.
Some patients avoid leaving their homes because
exposure to highly textured visual stimulation, such as
light flickering through trees or walking in stores,
increases their disequilibrium.66,67 This common experience is referred to as the shopping aisle syndrome.
These patients may have a limited ability to interact with
their environment and, over time, tend to adopt a more
Box 19-3
CURRENT FUNCTIONAL STATUS

Are you independent in self-care activities?
Can you drive:
In the daytime?
In the nighttime?
Are you working? If yes, occupation:
________________________
Are you on medical disability?
Can you perform all your normal parenting activities?
Do you have difficulty:
Watching TV?
Reading?
Being in stores or malls?
Being in traffic?
Using a computer?
Do you have difficulty walking up and down
ramps, stairs, walking on grass?
Patient Goals
The clinical examination of a patient with vertigo and
disequilibrium is usually comprehensive (Box 19-4) and
therefore is time-consuming. Discretion should be used
as to which portions of the examination must be performed on each patient. The full examination is described
here with indications, where possible, for which conditions different portions of the examination would be
unnecessary. Many of the elements of the therapists
assessment are also discussed in Chapter 7. Key elements
of the clinical examination are listed in Box 19-5.
Oculomotor and Vestibulo-Ocular Testing

The oculomotor examination is one part of the overall
assessment of the dizzy patient that may have been performed by a neurologist or otolaryngologist prior to
referral for physical therapy. It is therefore not always
included in the physical therapy assessment.
First, the patient is observed for the presence of
spontaneous nystagmus in room light. In patients with
unilateral peripheral vestibular hypofunction, spontaneous nystagmus will be observable in room light during
the acute stage after onset of the lesion. Spontaneous nystagmus occurs because of an imbalance in the tonic or
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Box 19-4
SUMMARY OF THE CLINICAL EXAMINATION OF THE DIZZY PATIENT

Oculomotor Examination (in room light)
Non-vestibularextraocular movements, pursuit,
saccades, VORc, diplopia.
Vestibularskew, spontaneous and gaze-evoked nystagmus, VOR to slow and rapid head thrusts, visual acuity test with head stationary and during
gentle oscillations of the head.
With Frenzel lensesSpontaneous and gaze-evoked
nystagmus, head shaking-induced nystagmus, tragal pressure-induced nystagmus, hyperventilationinduced nystagmus, and positional nystagmus.
Sensation
Somatosensationproprioception, light touch, vibration; quantified tests: vibration threshold, tuning
fork test.
Visionvisual acuity and field.
Coordination
Optic ataxia/past pointing, rebound, diadochokinesia,
heel to shin, and postural fixation.
Range of motion (active and passive)
Upper and lower extremity, neck (rotation, extension,
flexion, lateral flexion).
Strength (gross)
Grip, upper extremity, lower extremity, trunk.
Postural Deviations
Scoliosis, kyphosis, lordosis
resting firing rate of the vestibular neurons. Within a few

days of onset, the patient should suppress the nystagmus
with visual fixation. Patients in this acute stage often complain of having difficulty reading and watching television.
Smooth pursuit is tested by asking the patient to
track a moving object with the eyes while the head is stationary. This tracking test should assess the patients
entire visual field. Typically this test also assesses the
motor function of cranial nerves III, IV, and VI. Inability
to perform downgaze is not a sign of vestibular deficits
but can occur with other neurological problems (e.g.,
progressive supranuclear palsy). Patients with this problem may have difficulty seeing objects on the ground as
Positional Testing
Hallpike-Dix test, side-lying test, roll test
Motion Sensitivity
Motion- and position-induced dizziness
Sitting Balance (active or passive, anteriorposterior, and lateral)
Weight shift, head righting, equilibrium reactions,
upper and lower extremity, ability to recover trunk
to vertical
Static Balance (performed with eyes
open and closed)
Romberg test, Sharpened Romberg test, single leg
stance, stand on rail, force platform
Balance with Altered Sensory Cues
Eyes open and closed, foam.
Dynamic Balance (self-initiated movements)
Standing reach (Duncan), functional (Gabell and
Simons), Fukudas stepping test
Ambulation
Normal gait, tandem walk, walk while turning head,
singleton to right and left, Dynamic Gait Index,
Timed Up & Go
Functional Gait Assessment
Obstacle course, double-task activities, stairs, ramps,
grass, sand
they walk and with descending steps. During the test of

smooth-pursuit eye movements, the presence of gazeevoked nystagmus and the quality of the eye movement
should be noted. Saccadic pursuit, especially in younger
individuals, or asymmetric pursuit should be noted.
For the patient with nystagmus, however, determining the quality of pursuit eye movements may be difficult. Care must be taken to distinguish gaze-evoked
nystagmus from end-point nystagmus. Gaze-evoked nystagmus occurs when the eyes are 30 degrees eccentric.
Direction-changing, gaze-evoked nystagmus is a sign of
a central lesion. End-point nystagmus, which is normal,
occurs when the eyes are at the extreme end of their range
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Box 19-5
KEY ELEMENTS OF THE

CLINICAL EXAMINATION
Oculomotor
In room lightskew deviation, spontaneous and
gaze-evoked nystagmus, VOR head-thrust test,
visual acuity test with head stationary and during gentle oscillations of the head
With Frenzel lensesSpontaneous nystagmus,
positional nystagmus
Range of Motion
Neck (rotation, extension, flexion, lateral flexion)
Positional Testing
Hallpike-Dix test, side-lying test, roll test
Motion Sensitivity
Motion- and position-induced dizziness (motion
sensitivity test)
Static Balance (performed with
eyes open and closed)
Romberg test, sharpened Romberg test, single-leg
stance
Eyes open and closed, foam
Ambulation
Normal gait, tandem walk, walk while turning
head, singleton to right and left, Timed Up &
Go
Functional Gait Assessment
Obstacle course, double-task activities, stairs,
ramps, grass, sand
Fall Risk
Dynamic Gait Index
Activity Level
Physical Activities Scale for the Elderly
Quality of Life
Medical Outcomes Study 36-Item Short-Form
Health Survey, Dizziness Handicap Inventory,
Vestibular Disorders, Activities of Daily Living
Scale, Disability Score
of motion. It is also important to determine, in the initial

patient history, whether the patient has any premorbid
eye disorder, including asking about a history of strabismus. Patients with lazy eye disorders may have difficulty with smooth pursuit, which can confound the
results of the testing.
Patients can also be tested for ocular alignment, particularly for skew deviations that can occur during the
acute stage of a unilateral vestibular loss. Skew deviations, in which the eye opposite the side of the lesion is
elevated, occur because of the loss of the tonic otolith
input from one side. Normally, the tonic input holds the
eyes level within the orbit; when there is a unilateral
vestibular loss, the eye on the side of the lesion drops in
the orbit, and the patient complains of vertical diplopia.
By convention, the skew is named according to the side
of the elevated eye (e.g., right hypertropia means the
right eye is elevated, although in reality the left eye has
dropped). As with spontaneous nystagmus from UVL,
skew deviations from UVL should resolve within 37
days after onset.
Saccadic eye movements are tested by simply asking the patient to look back and forth between two horizontal or two vertical targets. In healthy individuals, the
target can be reached with a single eye movement or with
one small corrective saccade.
The patient can then be asked to voluntarily fixate
on a moving target while the head is moved in the same
direction. This procedure tests vestibulo-ocular cancellation (VORc) and is a function of the parietal lobe. Results
should agree with the observations made during the
smooth-pursuit test.
Next, the VOR itself is tested. The head-thrust or
head impulse test is one test that an experienced physical
therapist can perform to assess the function of the vestibular system itself. The test involves an unpredictable,
high-acceleration, small-amplitude head thrust in the horizontal plane.70,71 The patient sits with the head pitched in
30 degrees of cervical flexion (using an imaginary line
from the inferior rim of the ocular orbit to the external
acoustic meatus). The patient is instructed to maintain
visual fixation on the examiners nose. The patients head
is then gently grasped, and a small-amplitude (5-10 d)
but high-acceleration (30004000 deg/sec2) thrust is
applied horizontally. When the head impulse stops, the
eyes are observed for a corrective saccade, a rapid eye
movement that returns the eyes to the target. If the head
impulse test at near distance is abnormal (corrective saccade is present), the test is repeated with the participant
looking at a target place more than 2 m away. Repeating the test with a distant target helps reduce the falsepositive results seen in some older individuals because of
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poor ability to accommodate to a near target. Testing is

always performed with appropriate visual correction
(glasses) for the distance tested. The sensitivity of the test
has been reported to be 54%, and specificity to be
100%.72 People without vestibular disease will be able to
maintain fixation during both slow and rapid head movements. People with vestibular deficits often are able to
maintain fixation during slow head movements using the
pursuit eye movement system but make corrective saccades to regain the target with rapid head movements.
During the acute stage or with severe deficits, corrective
saccades occur even with slow head rotations.
Another evaluation of VOR function is to measure
the degradation of visual acuity that occurs with head
movement.73,74 We use a modified ETDRS chart with
SLOAN letters (Lighthouse Distance Visual Acuity Tests,
Long Island City, New York) for this test. A hand-held
Snellen card is not as appropriate because it measures the
patients vision at a distance of only 18 inches, at which
distance older patients in particular have difficulty
accommodating. In the clinical Dynamic Visual Acuity
(DVA) test, the patient is first asked to read a wall eye
chart with the head stationary. Then the patient is asked
to read the chart while the head is gently oscillated at 2
Hz. Using a metronome helps standardize the test. In normal individuals, visual acuity changes at most by one
line. In patients with uncompensated, unilateral vestibular loss, visual acuity degrades by three or four lines. A
computerized system for measuring visual acuity during
head movement is now available (see Chapter 8). Brandt75
suggests that distance acuity poorer than 20/50 has a significant effect on postural stability. Additionally, visual
field loss can also affect balance,76 and patients with
monocular vision may have particular difficulty with
depth perception, which would affect their ability to walk
up and down stairs.
Eye movements can also be observed with the use of
Frenzel lenses or video oculography (VOG). Frenzel lenses magnify the eyes, with light inside them to help with
visualization, enabling the clinician to observe eye movements and greatly decreasing the patients ability to stabilize the eyes with visual fixation. The VOG systems
permit the examiner to visualize the eyes in all positions,
via infrared cameras that record eye movements and
transmit the image to either a computer or television monitor. Either one or both eyes may be visualized, depending
on the system used. Clinical assessment of oculomotor
function using Frenzel lenses should include spontaneous
and gaze-evoked nystagmus, head shakinginduced nystagmus,77 tragal pressureinduced nystagmus, hyperventilation-induced nystagmus, and positional nystagmus (see
Chapter 7).
281
During this assessment, the patient is asked to report

any symptoms of blurred vision or dizziness. Tests that
involve repeated head movements (VOR, head shaking
induced nystagmus) may exacerbate the patients symptoms. If there is a significant increase in symptoms, the
patient may be unable or may refuse to continue with the
testing. Explaining the importance of the information to
be gained from the test, and acknowledging the patients
symptoms often helps the patient to accept the discomfort
caused by the test.
Sensory Evaluation
Sensation of the extremities can be tested to rule out
concurrent pathology and assist in treatment planning.
Perhaps the most important of these is the assessment
of kinesthesia and proprioception, although profound
sensory loss affecting touch and pressure sensitivity would also affect postural stability and raise the risk
of a fall.78,79 These tests may not be performed in all subjects but should be considered especially in older individuals.
Proprioception can be assessed by having the patient
close the eyes and then moving the patients great toes
either up or down and asking the patient to identify the
position of the toe. Care must be taken to make these relatively small movements or the test becomes too easy.
The patient must also be instructed not to guess at the
answer. This traditional test of proprioception does not
appear to be very sensitive, and patients are quite accurate
in perceiving whether the toe is up or down even when
other tests indicate sensory deficiencies. Kinesthesia can
be tested by slowly moving the toe either up or down and
asking the patient to state the direction of the movement
as soon as he or she first perceives movement. Again, the
patient should be instructed not to guess. Perception of
the direction of the movement should occur before the toe
is moved more than 10 to 15 degrees, although each clinician must develop his or her own internal standard for
what is normal. Vibration can be tested with application
of a tuning fork to a bony prominence. One method is to
ask the patient to identify when the vibratory sensation
stops, and then to dampen the tuning fork unexpectedly.
Another method is to let the vibration diminish naturally
and to time the difference between when the patient and
the clinician stop feeling the vibration. Again, each clinician must develop his or her own sense of normal.
Devices are also available that quantify vibration thresholds. These devices enable the clinician to compare the
patient with age-matched normal subjects and to follow
changes over time. Diminished sensation in the toes may
not affect postural stability; if a patient appears to have no
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sensation in the toes, then the clinician should perform

the same tests on the ankles.
The visual, vestibular, and somatosensory systems
all show decrements with age, and the clinician should be
familiar with these normal changes to differentiate them
from pathological changes.80 Furthermore, certain disorders that can affect perception, such as cataract formation, are more likely to occur in the older person. There
is some evidence that a decrease in the gain of the VOR
occurs with aging, at least at higher frequencies, as well
as a more limited adaptive capability.14,15
Multisystem involvement can impede the patients
functional progress. A patient with reduced vestibular
function and a deficit in somatosensory cues is likely to
compensate by using visual mechanisms. This patient is
limited functionally if placed in a situation devoid of
visual information. For example, many patients with
reduced somatosensory cues and a peripheral vestibular
deficit have difficulty walking in the dark. A treatment
plan that does not consider the patients sensory loss may
be ineffectual, and the patients functional independence
could suffer.
range of motion increases, there appears to be an associated decrease in dizziness symptoms.23 A detailed examination of extremity strength and range of motion is often
unnecessary; however, a quick screen indicates whether
more detailed testing would be appropriate. It is not
uncommon in the elderly patient to see distal weakness,
which can be recognized in this quick screening and dealt
with through use of a home exercise program to tune
up the system and reduce the patients risk of falling.
Postural Examination
In addition to assessment of range of motion, the patients
posture should be evaluated. Predisposing orthopedic
conditions or postural deviations may complicate the
rehabilitation prognosis. Anterior-posterior and mediallateral views of both the patients sitting and standing
postures should be assessed. Typically, posture is not
affected in people with peripheral vestibular dysfunction.
Postural abnormalities are more commonly seen in people with central disorders of the nervous system.
Positional and Movement Testing

Coordination
Vestibular deficits per se do not result in poor coordination or in limb ataxia. Assessment of coordination is
especially important, however, as part of the preoperative
and postoperative examination of patients with cerebellar
angle tumors. Finger-to-nose and heel-to-shin movements as well as the ability to perform rapid alternating
movements of fingers or feet are gross tests that may be
used to subjectively assess the patients coordination.
Other tests of cerebellar function include truncal stability and tests of tone, such as postural fixation and the
rebound phenomenon.
Range of Motion and Strength

The patients range of motion and strength must be
assessed in the initial evaluation. Although the neck,
trunk, and extremities can be included in this assessment,
special attention should be paid to the necks range of
motion. Patients in whom head movement exacerbates
symptoms may voluntarily restrict active neck motion
and may eventually lose that range of motion.
Furthermore, many of the other assessments involve passive movement of the neck (VOR during rapid head
thrusts, head shakinginduced nystagmus, positional
testing), and any limitations in movement or pain associated with neck movement should be identified before
those tests are attempted. In some patients, when neck
Clinically assessing the positions and movements that

provoke the patients symptoms is important. In this portion of the evaluation, attempts are made to replicate the
various positions and movements experienced by the
patient throughout the day (Table 19-4). The activities are
rated by the patient as to whether they provoke no symptoms or mild, moderate, or severe symptoms. In some situations, the patient may be unable, or unwilling, to
perform the task. This reluctance is especially apparent in
the patient who experiences severe dizziness early in the
evaluation. In addition, a patient may refuse to move into
or out of a specific posture because of the fear of eliciting symptoms.
The most important positional test is the DixHallpike test (Fig. 19.1).82 This test is most commonly
utilized in patients who complain of vertigo only when
they move into certain positions, but it should be included in almost all assessments. Vertigo and nystagmus
occurring when the patient is moved into the DixHallpike position is used to diagnose BPPV (see Chapter
17). In the Dix-Hallpike maneuver, the patient typically
sits with the head turned to one side. The patient then is
moved backward so that the head is extended over the
end of the table approximately 30 degrees below horizontal. The maneuver is performed to both the right and
left sides. The patient should be cautioned in advance that
the maneuver can cause dizziness or vertigo but nonetheless should be performed. Two variations of the Dix-
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Table 19-4 TYPICAL POSITIONS AND MOVEMENTS THAT PROVOKE SYMPTOMS*

Baseline Symptoms
Intensity
Duration
Score
1. Sitting to supine
2. Supine to left side
3. Supine to right side
4. Supine to sitting
5. Left Hallpike-Dix position
6. Return to sit from left Hallpike-Dix position
7. Right Hallpike-Dix position
8. Return to sit from right Hallpike-Dix position
9. Sitting, head tipped to left knee
10. Head up from left knee
11. Sitting, head tipped to right knee
12. Head up from right knee
13. Sitting, turn head horizontally 5 times
14. Sitting, move head vertically 5 times (pitch)
15. Standing, turn 180 degrees to the right
16. Standing, turn 180 degrees to the left
*See Chapter 20 for further information.
Hallpike test, the side-lying test and the roll test, should
also be performed (see Chapter 17). It is also important
to perform the Dix-Hallpike test because some patients
will not have a specific diagnosis but rather a diagnosis
of dizziness or vertigo. After the Dix-Hallpike test is performed, it may become obvious that these patients have
benign paroxysmal positional nystagmus. There are also
people who have subjective BPPV, as reported by
Haynes and associates,83 who describe symptoms typical
of BPPV yet do not exhibit the typical nystagmus during
the Dix-Hallpike maneuver. Haynes and associates
reported that 86% of those with subjective BPPV
reported significant improvement in symptoms after
treatment with the Semont maneuver.83 Recognizing
benign paroxysmal positional nystagmus and providing
the proper intervention can significantly enhance the
patients quality of life.84
Benign paroxysmal positional vertigo is a common
cause of vertigo.85 This peripheral vestibular deficit is
easily and effectively treated with physical therapy.86, 87 In
contrast, vertebral artery compression is relatively rare. It

often causes similar, yet somewhat different symptoms to
those of BPPV. Occlusion of blood flow with compression of the vertebral artery produces neurological symptoms, such as numbness, weakness, slurred speech, and
mental confusion, as well as vertigo and nystagmus.
Persons with BPPV do not experience neurological
symptoms such as slurred speech, mental confusion,
weakness, or numbness.
Examples of other movements that can be tested are
rolling, supine to sit, reaching in sitting toward the floor,
and sit to stand. All of these movements should be tested
at various speeds and with the patients eyes open and
closed. The therapist should exercise care when having
patients perform these maneuvers while standing with the
eyes closed because this is often very difficult for patients
and may cause them to lose their balance. A more formalized assessment of what positions and movements induce
symptoms in patient is the Motion Sensitivity Quotient
(see Chapter 20). The speed of the activity often affects
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the patients symptoms. For example, a quickly performed

movement could increase the patients symptoms, whereas the same movement done at a slower speed may not.
Varying the speed and the conditions under which the
patient performs the task may affect the patients functional ability. Positional and movement testing is limited
only by the imagination of the therapist. For one patient
seen in our clinic, the only position that increased her
symptoms was the all-fours position, which she would
assume for looking under the bed (Fig. 19.2)!
In addition to testing positions and movements that
incorporate multiple body segments, the patient is asked
to perform head movements. The head movements are
typically tested with the patient sitting. These movements
are performed at various speeds and with the eyes open
and closed. The patient is asked to report whether these
movements provoke symptoms and whether the symptoms are of a mild, moderate, or severe intensity. Verbal
and visual analog scales have also been used in an attempt
to better quantify the patients symptom intensity.38,39 The
same movements are tested in the standing position or
during gait, if the patient can tolerate further testing.
Balance Assessment
Sitting Balance
Figure 19.1 Hallpike-Dix test used primarily to evaluate for
benign paroxysmal positional vertigo. The head is turned to one
side and the patient is moved from sitting into a supine position
with the head hanging over the end of the table. The patient is
then observed for nystagmus, and complaints of vertigo are
noted. The patient is then returned to the upright position.
(From Herdman, 1990.81)
Many patients with chronic vestibular disorders do not

have difficulty with balance in sitting, but for some
patients, including an assessment of sitting balance may
be appropriate. Patients should be tested while they are
leaning anteriorly and posteriorly as well as right and
left; tests should be performed both actively and passive-
Figure 19.2 Patients may experience dizziness or vertigo in positions other than those
normally tested. Shown here is the provoking
position for one patient who experienced
vertigo only when bending over and turning
her head.
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ly. The patient can be observed for weight-shifting ability, head righting, equilibrium reactions in the upper and
lower extremities, and the ability to recover to a trunk
vertical position. Having the patient reach in sitting in all
directions without support is also valuable information
that can be gained in the clinical examination.
Static Balance
Static balance tasks have been used clinically to objectively document balance function.8892 Single-leg stance
(SLS), Romberg, and Sharpened or tandem Romberg
tests are often included in a static balance test battery and
can be performed with the patients eyes open or
closed.9294 Traditionally, the variable of interest in this
testing has been the time that the patient maintains the
position. Normative data for different ages have been
established for SLS, Romberg, and sharpened Romberg
tests.92 The Romberg test has been shown to have low
intrasubject variability when measures are repeated over
a 5-day period.93
Patients with vestibular deficits may have normal
performance on these tests.94 Tests of static balance, such
as the Romberg, are fairly easy. Patients may have diffi-
285
culty with this test only during the acute stage after onset
of the vestibular deficit. It is also important to remember
that patients with balance disorders other than from
vestibular dysfunction may have difficulty with these
tests. Having difficulty maintaining stance with the
Romberg test does not necessarily mean the subject has
vestibular dysfunction. Table 19-5 lists the expected
results for static and dynamic balance tests in patients
with acute and compensated unilateral vestibular loss.
Measures of Sway
During performance of static balance tasks, mediallateral or anterior-posterior stability can be objectively
documented with the use of high-tech tools such as
force platforms or of simple tools such as a sway grid.95,96
When one is assessing and attempting to replicate standing sway measures, the distance the subject stands from
a stable visual target, upper extremity positioning, type or
lack of footwear, and foot position of the patient should
be standardized. Brandt75 hypothesizes that one explanation for the variability often found on the Romberg test is
the inconsistent positioning of the patient with respect to
a target used for visual fixation. The distance that the
Table 19-5 EXPECTED TEST RESULTS IN PATIENTS

WITH UNILATERAL VESTIBULAR LOSS (UVL)
Test
Acute UVL
Compensated UVL
Nystagmus
Spontaneous and gaze-evoked in light and

dark; head shakinginduced nystagmus
Spontaneous in dark; may have

head-shakinginduced nystagmus
Vestibulo-ocular reflex (VOR)
Abnormal with both slow and rapid head

thrusts
Abnormal with rapid head thrusts

toward side of lesion
Romberg
Often, but not always positive
Negative
Sharpened Romberg
Cannot perform
Normal with eyes open; cannot

perform with eyes closed
Single-leg stance
Cannot perform
Normal
Clinical Test for Sensory

Interaction in Balance
(CSTIB)foam, eyes closed
Most cannot perform
Normal
Fukudas stepping tets
Cannot perform
Normal
Gait
Wide-based, slow cadence, decreased

rotation, may need help for a few days
Normal
Turn head while walking
Cannot keep balance
Normal; some may slow cadence
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patient stands from the target should be standardized and

should be within 1.5 me. Kirby and associates97 employed
five different foot positions to determine the effect of foot
position on sway. They determined that subjects standing
in double-limb stance were most stable in the 25-degree
toe-out position. In addition, they observed that subjects
had the greatest medial-lateral sway when their feet
closely approximated each other. The standard Romberg
position is with heel and toes together.
Postural sway correlates well with measures of the
DHI.51,53 Of course, both postural sway and the responses
to the DHI questionnaire are under voluntary control,
and what is measured is subject to errors according to
what the patient wants to convey. Sway patterns of
patients with central disorders differ from that of patients
with other vestibular diagnoses. Yoneda and Tokumasu98
reported that sway patterns seem to be different among
patients with Mnires disease, BPPV, and vestibular
neuronitis, and that these patterns differed from those of
a normal comparison group.
Altering Sensory Cues

The modified Clinical Test for Sensory Interaction in
Balance (CTSIB) should be included in the rehabilitation
assessment.26,98100 In some ways this test is an extension
of the Romberg test, which assesses the effect of removing visual cues on postural stability. Referred to formerly as the foam and dome test (Fig. 19.3), the CTSIB
assesses the influence of vestibular, somatosensory, and
visual inputs on postural control. In the modified version,
the dome portion of the test is no longer used. In the
modified CTSIB, standing on the foam surface and closing the eyes alters somatosensory input and eliminates
visual input. In this situation, vestibular input is the most
accurate information about postural stability. Patients
with uncompensated unilateral peripheral vestibular loss
may have difficulty maintaining an upright posture when
both visual and support-surface information are altered.19
Subjects with unilateral peripheral vestibular dysfunction
often lose their balance when standing on foam with the
eyes closed (using the CTSIB protocol).
According to Nashner,19 symmetry and constancy of
vestibular information are critical in providing an
absolute reference for reorganization of senses in conflicting conditions. The inability of the vestibular system
to provide this information may explain why patients
with unilateral vestibular lesions often report postural
instability when riding on an escalator or when walking
on thick carpet across a dimly lit room. If a patient is
unstable when both visual and somatosensory cues are
altered, a treatment plan might be designed to improve
the function of the remaining vestibular system.
Depending on the patient, an alternative treatment strategy may focus on altering the patients environment so
that visual and somatosensory cues are maximized, in an
effort to overcome the vestibular loss.102104.
Self-Initiated Movements
In addition to static tests of balance function, selfinitiated movements and dynamic tests of balance should
be examined. Self-initiated weight shifts performed in
different directions can be assessed to determine whether
Figure 19.3 The modified Clinical

Test of Sensory Integration of Balance:
The subject is standing on a level support surface with eyes open (A) and
with eyes closed (B), and then on a
compliant surface with eyes open
(C) and eyes closed (D). The time
the patient takes to perform each task
is recorded, and the amount of sway
and the patients movement strategy
are documented qualitatively. The
results of this test help determine
whether the patient is dependent on
certain sensory cues.
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Figure 19.4 The distance a patient can

reach is one measure of functional balance.106
(A) The patients acromion is lined up with a
yardstick while the patients arm is held parallel to the yardstick. (B) The patient reaches
forward as far as possible while keeping both
feet flat on the ground.
the patient moves freely and symmetrically.105 Selfinitiated movements should also be tested in functionally
relevant and rich contextsfor example, having the
patient reach to pick an object from the floor or place an
object on a high shelf. Altering the environment so that
there are many visual distractions may also be a way to
make the task more difficult. Reaching for an object on
the floor among many objects on the floor might make
the task more difficult for the patient.
The standing reach test has been developed as a way
to assess the subjects balance and willingness to reach
Figure 19.5 The distance a patient can

reach to the side is another possible functional
measure of balance. (A) The patients acromion
is lined up with the edge of a yardstick. (B) The
patient reaches to the side as far as possible
while keeping both feet flat on the floor.
outside the base of support.51,106111 This test functionally

and reliably documents performance on a self-initiated
task. The subject is asked to reach as far forward as possible. The extent of movement is measured with a simple
yardstick (Fig. 19.4). Duncan and coworkers108 have
shown that functional reach, as a measure of a subjects
margin of stability, correlates well with center of pressure
measures obtained from a force platform. This test might
be modified so that reaches in different directions are
documented (Fig. 19.5).105 Functional reach has also been
shown to be related to falls in older male veterans.107
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Table 19-6 BALANCE CODING

Criterion
Code
Static Stress
Unsafe while seated
Safe while seated, unsafe standing
Steady while standing for 20 sec with aid
Steady while standing, 20 sec, no aid, wide base
Steady while standing, 20 sec, no aid, narrow base
Steady while standing, 20 sec, no aid, long base
Steady while standing, 20 sec, no aid, long base, eyes closed
Rotational Stress
For those who can stand for 20 sec with or without aid
Subject should stand with feet in most stable position
Steady while turning head from right to left
(Tested three times, 5 seconds of rest after each trial)
Can turn 360 without staggering or grabbing onto furniture
Sagittal Stress
Subject can arise from chair (with help if necessary), is immediately steady,
and can stand for 20 sec without help except for aid if uses one
x
(No code given if cannot perform)
Directional Preponderance
Coded if subject tends to fall or overbalance in one direction consistently
during the above tests
Anterior: (A)
Posterior: (P)
Right: (R)
Left: (L)
Modified from Gabell and Simons, 1982.112
Generally, scores of 6 inches or less indicate that the person is at high risk for falling.107 This test has been shown
to have concurrent validity with certain items of the
Functional Independence Measure and is useful in determining the risk of falling in older adults. It has also been
shown to demonstrate change over the course of rehabilitation,109 although Wernick-Robinson and colleagues111
suggest that functional reach measures have less value in
patients with vestibular dysfunction.
Gabell and Simons112 also developed a functional
balance test to assess elderly clients at risk for falling.
Their assessment examines static positions as well as

rotational and sagittal movements (Table 19-6) and
includes criteria for successful performance of each task.
For example, to succeed in one of the rotational stress
tasks, the patient must rotate 360 degrees once without
staggering or grabbing onto furniture.
Fukudas stepping test assesses stability during the
self-initiated movement of marching, which the patient
performs first with eyes open and then with eyes closed.113
The test is easily administered in the clinic and can be
quantified by the use of a polar coordinate grid placed on
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Figure 19.6 Fukudas stepping test assesses balance while

the patient marches in place, first with eyes open and then with
eyes closed. The forward progression of the patient as well as
the amount and direction of turning are recorded. Normal subjects will have moved forward less than 50 cm and turned less
than 30 degrees at the end of 50 steps. Patients with unilateral
vestibular deficits often turn excessively. A polar coordinate grid,
placed on the floor, enables easy scoring of the subjects
response.
the floor (Fig. 19.6). The test is not specific for vestibular
dysfunction, but patients with unilateral vestibular
deficits often turn excessively when stepping with the
eyes closed.113 Bonnani and Newton114 reported that the
50-step test is more reliable than the 100-step test in people without vestibular disease. There appear to be many
false-positives and false-negative results for the Fukuda
stepping test, so it is important to consider the results as
only one aspect of the clinical picture of the patient.113
The standing reach test,101 Gabell and Simons functional assessment,112 and Fukudas stepping test113 are
administered easily and require very little equipment.
Such functional measures of balance can easily be used
in the clinic or home care setting to document whether
the patient has made gains in physical therapy.
Movement Strategy
During the balance assessment, the therapist should
observe and document the patients movement strategy.
Three types of movement strategies have been described
289
for controlling anterior-posterior displacements of the

center of mass.113 The ankle strategy produces shifts in the
center of mass via rotation of the body about the ankle
joints. According to Horak and Nashner,115 the ankle strategy elicits a distal-to-proximal firing pattern of ankle, hip,
and trunk musculature. This activation pattern exerts
compensatory ankle torques, which are believed to correct for small postural perturbations. The hip strategy
controls movement of the center of mass by flexing and
extending the hips. Unlike the ankle strategy, the muscle
activation sequence associated with the hip strategy
occurs in a proximal-to-distal fashion. This strategy produces a compensatory horizontal shear force against the
support surface. The hip strategy occurs in situations in
which the ankle is unable to exert the appropriate torque
necessary to restore balance. This situation arises when
the task of maintaining balance is more difficult, such as
when an individual stands on a small, narrow support surface. Finally, a stepping strategy is used when the center
of mass is displaced outside the base of support. This
strategy is employed in response to fast, large postural
perturbations.
To function safely and independently throughout the
lifespan, humans are required to respond, through their
movements, to a variety of task situations and environmental contexts. Postural strategies may be task-specific,
and therefore categorizing postural strategies can prove
to be difficult. In addition, individuals vary greatly with
respect to body size, proportion, and weight. These considerations, taken together with age-related changes,
make the task of categorizing postural strategies difficult.
Instead, the physical therapist may be more successful in
documenting whether the patients individual strategy is
efficient, safe, and successful with respect to achieving
the task goal. With this approach, the clinicians expectations of the patients responses are not as biased. This
notion also has implications for treatment. Current motor
learning theory suggests that the learner will be more
successful in the task when the learner, not the teacher or
therapist, selects the appropriate movement strategy.116
Gait Evaluation
Evaluation of the patients gait provides a dynamic and
functional assessment of the patients postural control
mechanism. The gait assessment can be obtained through
clinical observation, videotape analysis, or computerized
motion analysis. A videotape record of the patients gait
is easily obtained clinically and can be extremely useful
for documentation and patient education.
The patients gait should be assessed in as many situations as are realistically accessible to the therapist.
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Analysis of the patient walking down a crowded versus a

noncrowded hallway may yield very different information about the patients gait function. Similarly, the
patient should be instructed to walk at a normal speed,
slowly, and quickly. Common clinical observations indicate that patients with vestibular disorders, like other
patients, have greater gait instability when asked to walk
at a nonpreferred speed. They also often have difficulty
changing gait speed while they are walking.
During gait assessment, the physical therapist documents the patients movement strategy, the presence of
gait deviations, and whether the patient reports any
abnormal sensation of movement. The patient with a
peripheral vestibular disorder may select an overall strategy for gait that limits movement of the head and trunk.
Clinically, this gait is characterized as being stiff or
robot-like, and the patient may use excessive visual fixation while walking. Some of the typical gait deviations
demonstrated by these patients include inconsistent step
lengths, veering to the right or left, a widened base of
support, a listing of the head and/or trunk to one side,
decreased rotation through the trunk and neck (and
decreased arm swing), and en bloc117 movements and
slow turns. In addition to observable gait deviations,
patients with a unilateral peripheral vestibulopathy may
associate dizziness with their gait instability.
A complete assessment of the patients gait function
should include having the patient perform a variety of
tasks while walking. Many of these tasks cause the
patient to lose balance; therefore, during this portion of
the gait assessment, the physical therapist may need to
guard the patient but without becoming a part of the
patients postural control system. The goal of this assessment is to learn how the patient, not the therapist, solves
the problem of postural control.
One of the gait tasks performed by the patient is to
walk while moving the head, either to the left and right or
up and down. Head movements up/down and right/left
are components of the Dynamic Gait Index (DGI),118 a
very helpful tool for use in the quantification of gait dysfunction. The therapist documents whether the patient
experiences symptoms (dizziness, lightheadedness, etc.),
loss of balance, or an exaggeration of gait deviations.
Such a detailed assessment facilitates documentation of
the patients progress.
Many patients with unilateral peripheral vestibular
loss experience difficulty when asked to perform gait
tasks that require an anticipatory mode of motor control.
One such task requires the patient to walk quickly and
then to stop immediately on the therapists command. To
enhance task difficulty, the patient may be asked to perform the same task with the eyes closed. Another such
task, called the Singleton test, requires the patient to walk

quickly and pivot to the right or left immediately on the
therapists command. To maintain a level of uncertainty,
the patient should not be informed ahead of time of the
required pivot direction. The speed of the pivot is another factor that must be considered. The patient may also
slow gait speed as a strategy to avoid disequilibrium during the task. The patient may also slow gait speed to
avoid the anticipatory requirements of the task. In such
instances, the patient should perform the task at a faster
speed so that the therapist obtains a more complete picture of the patients gait function.
Observing the ability of the patient to negotiate an
obstacle course may also provide valuable information
about his or her functional balance (Fig. 19.7) as well as
the patients ability to function in an anticipatory mode of
control. To assess the patients functional balance, the
patient self-selects the path to negotiate the obstacle
course. In addition, the patient decides whether or not to
pick up or step over an object in the course. The patient
also decides to negotiate the course quickly or slowly. If,
on the other hand, the patients anticipatory control is of
interest, the therapist directs which path the patient should
follow. Task variability and uncertainty are manipulated
by the therapist. For example, the therapist may decide at
which point in the course to throw a ball toward the patient
(Fig. 19.8). A temporal constraint may also be added to
the task. Asking the patient to negotiate the course as
quickly as possible enhances task difficulty and provides
a means to subjectively document the patients progress.
The ability of the patient to perform gait tasks while
manipulating an object with the hands should also be
assessed. Patients with unilateral vestibular loss frequently complain of increased gait instability when carrying a
basket of laundry up a flight of stairs or when carrying a
bag of groceries. Clinically, the patients ability to monitor postural control while manipulating an object can be
tested in a variety of ways. The patient can be asked to
walk, pick up one or more objects off of the floor, and
continue walking. Documenting the strategy used by the
patient to perform this task is important. Many patients
with vestibular loss bend at the knees and avoid flexing
the head or bending at the hips. This strategy may be
selected in an attempt to minimize provocation of symptoms or loss of balance. A patient may also be asked to
negotiate a flight of stairs while carrying objects of varying weight or size. This task is important to include in the
gait assessment, because a patient who demonstrates little difficulty with other gait tasks may express extreme
postural instability with this task.
Other gait tasks that the therapist can assess are sidestepping, backward walking, tandem walking, walking in
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291
Figure 19.7 Patients with vestibular

disorders may have difficulty negotiating
an obstacle course. The patient selects the
path of the course to follow and whether
to step over or pick up objects.
a figure of eight, and marching and/or jogging in place. If

feasible, the patient should be asked to perform these
tasks at various speeds with the eyes open and closed.
Additional tests can be used to assess functional balance in subjects with peripheral vestibular dysfunction.
The DGI, as developed by Shumway-Cook and associates25,28,118121 is very helpful in quantifying gait dysfunction in people with vestibular disease (Box 19-6). This
eight-item test takes less than 10 minutes to perform and
requires little equipment (a shoebox, two cones, and
stairs). Scoring is based on the concept of no, minimal,
moderate, or severe gait dysfunction when performing
Figure 19.8 The obstacle course can

also be used to determine how well the
patient responds to external perturbations.
In this situation, the patient maintains postural control while simultaneously stepping
over a box and catching a ball.
the eight gait tasks. It has been related to scores on the

Berg Balance Scale,119,121 a tool to assess balance. Scores
of 19 or less on the DGI have been related to falls in
community-living elderly adults.119 In patients with
severe vestibular disability, We have seen scores as low as
3 out of 24! The DGI is very useful for quantifying gait
dysfunction in people with vestibular dysfunction and
can be easily used to determine whether the therapy intervention is effective.
The Berg Balance Scale (BBS) is also a useful tool
to use if the patient has balance dysfunction.121124 Not all
patients with peripheral vestibular disorders have balance
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Box 19-6
DYNAMIC GAIT INDEX

1. Gait Level Surface
Instructions: Walk at your normal speed from here to
next mark (20 ft).
Grading: Mark the lowest category that applies:
Normal: Walks 20 ft, no assistive devices, good
speed, no evidence of imbalance, normal gait
pattern.
Mild impairment: Walks 20 ft, uses assistive
devices, slower speed, mild gait deviations.
Moderate impairment: Walks 20 ft, slow speed,
abnormal gait pattern, evidence of imbalance.
Severe impairment: Cannot walk 20 ft without
assistance, severe gait deviations, or imbalance.
2. Change in Gait Speed
Instructions: Begin walking at your normal pace (for
5 ft). When I tell you Go, walk as fast as you can
(for 5 ft). When I tell you Slow, walk as slowly as
you can (for 5 ft).
Normal: Able to smoothly change walking speed
without loss of balance or gait deviation. Shows
a significant difference in walking speeds
between normal, fast, and slow speeds.
Mild impairment: Is able to change speed but
demonstrates mild gait deviations; or has no gait
deviations but unable to achieve a significant
change in velocity; or uses assistive device.
Moderate impairment: Makes only minor adjustments to walking speed; or accomplishes a
change in speed with significant gait deviations;
or changes speed but has significant gait deviations; or changes speed but loses balance, but is
able to recover and continue walking.
Severe impairment: Cannot change speeds; or
loses balance and has to reach for wall or be
caught.
3. Gait with Horizontal Head Turns
Instructions: Begin walking at your normal pace.
When I tell you to Look right, keep walking
straight, but turn your head to the right. Keep looking
to the right until I tell you to Look left; then keep
walking straight and turn your head to the left. Keep
your head to the left until I tell you to Look
straight; then keep walking straight but return your
head to the center.

Normal: Performs head turns smoothly with no
change in gait.
Mild impairment: Performs head turns smoothly
with slight change in gait velocity (i.e., minor
disruption of smooth gait path or uses walking
aid).
Moderate impairment: Performs head turns
with moderate change in gait velocity, slows
down, staggers but recovers, can continue to
walk.
Severe impairment: Performs task with severe
disruptions of gait (i.e., staggers outside 15degree path, loses balance, stops, reaches for
wall).
4. Gait with Vertical Head Turns
When I tell you to Look up, keep walking straight,
but tip your head and look up. Keep looking up until
I tell you Look down. Then keep walking straight
and turn your head down. Keep looking down until I
tell you to Look straight; then keep walking
straight, but return your head to the center.
Normal: Performs head turns with no change
in gait.
Mild impairment: Performs task with slight
change in gait velocity (i.e., minor disruption to
smooth gait path or uses walking aid).
Moderate impairment: Performs tasks with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.
Severe impairment: Performs task with severe
disruption or gait (i.e., staggers outside 15degree path, loses balance, stops reaches for
wall).
5. Gait and Pivot Turn
When I tell you Turn and stop, turn as quickly as
you can to face the opposite direction, and stop.
Normal: Pivot turns safely within 3 seconds and
stops quickly with no loss of balance.
Mild impairment: Pivot turns safely in >3 seconds and stops with no loss of balance.
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Box 19-6 (continued)

Moderate impairment: Turns slowly, requires
verbal cuing, requires several small steps to
catch balance after turn and stop.
Severe impairment: Cannot turn safely, requires
assistance to turn and stop.
6. Step Over Obstacle
Instructions: Begin walking at your normal speed.
When you come to the shoe box, step over it, not
around it, and keep walking.
Normal: Is able to step over box without changing gait speed; no evidence of imbalance.
Mild impairment: Is able to step over box, but
must slow down and adjust steps to clear box
safely.
Moderate impairment: Is able to step over box
but must stop, then step over. May require verbal
cuing.
Severe impairment: Cannot perform without
assistance.
7. Step Around Obstacles
Instructions: Begin walking at your normal speed.
When you come to the first cone (about 6 ft away),
walk around the right side of it. When you come to
the second cone (6 ft past first cone), walk around it

to the left.
Normal: Is able to walk around cones safely
without changing gait speed; no evidence of
imbalance.
Mild impairment: Is able to step around both
cones, but must slow down and adjust steps to
clear cones.
Moderate impairment: Is able to clear cones but
must significantly slow speed to acomplish task,
or requires verbal cuing.
Severe impairment: Unable to clear cones, walks
into one or both cones, or requires physical
assistance.
8. Steps
Instructions: Walk up these stairs as you would at
home (i.e., using the rail if necessary). At the top,
turn around and walk down.
Normal: Alternating feet, no rail.
Mild impairment: Alternating feet, must use rail.
Moderate impairment: Two feet to stair, must
use rail.
Severe impairment: Cannot do safely.
From Shumway-Cook and Woollacott, 1995.118
disorders.87 Scores of 36 and less on this test indicate a

100% risk of falling in older adults.119,125 This scale consists of 14 items that include sitting, standing, and reaching activities with a total point value of 56. It has been
shown to be a reliable and valid test with many different
patient populations and is very useful in assessing change
in a patients balance over time. Concurrent validity of
the BBS and the DGI has been established in a mixed
group of patients with vestibular dysfunction.121
Another tool that might be helpful to assess gait
over time is the Timed Up and Go test.126 This test consists of having the subject rise from a standard height
chair with armrests, walk 3 m, turn, and return to sit in
the chair. It is closely related to speed of gait and is a
quick method to assess gait performance over time in any
physical setting. In people with vestibular dysfunction, it
is often helpful to have the subject turn to the right and
also to the left to detect any asymmetry. The test takes
less than 1 minute to complete and requires only a chair
and a stopwatch. In a mixed group of patients with
vestibular disorders, scores of 11.1 seconds or greater
were 5 times more likely to have reported a fall in the
previous 6 months.28 At 11.1 seconds, the sensitivity of

the test was 80% and the specificity was 56%, suggesting
that the tool may be helpful for use in persons with
vestibular dysfunction.28 The TUG has been modified to
include components that assess an individuals ability to
allocate attention. Although the modified TUG has not
yet been validated in patients with vestibular deficits, it
adds an important component to balance testingthat of
the effect of cognitive impairments on balance.
Red Flags
As the assessment is being performed, certain red flags
may appear. Signs and symptoms of central nervous system pathology must be recognized and reported to the
referring physician (Box 19-7). It is possible for individuals to be referred to a balance and vestibular clinic with
undiagnosed central nervous system disease. Acoustic
neuromas, multiple sclerosis, brainstem transient ischemic attacks (TIAs), cerebellar disorders, and migraines
are but a few of the disorders that have been diagnosed in
patients presenting to our clinics with the diagnosis of
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dizziness. It is very important that individuals who treat

people with vestibular dysfunction become very good at
making a physical therapy diagnosis on the basis of the
patients symptoms and physical findings. The patient
history gathered early in the assessment often guides the
experienced clinician in deciding which path to follow in
further evaluating the patient. Red flags are often identified in the history if the correct questions are asked of the
patient. For example, patients who describe their dizziness as a sensation of being pushed or having sensory
changes associated with their dizziness may actually
be experiencing TIAs.
Transition from Assessment

to Treatment
The following points are offered as guidelines for
the development of a treatment program based on the
assessment.
Is There a Documented
Vestibular Deficit?
The results of the formal vestibular function tests should
be reviewed. If vestibular testing has been performed, it
is very helpful to obtain the results before initiating treatment. If the vestibular function test results are normal,
the therapist may or may not be dealing with a vestibular
deficit. The results of the vestibular function tests confirm the presence of horizontal semicircular canal
deficits. Of course, a patient may have a vertical canal
lesion without a horizontal canal problem, but that is
most likely to occur in BPPV, which is usually easily recognized. Otolith and central vestibular lesions are more
difficult to identify, and the therapist must rely on patient
history or on the presence of other deficits that localize
the problem to the central nervous system. Persons with
normal vestibular test results may still have a vestibular
disorder. Only one fifth of the vestibular apparatus (the
horizontal canal) is typically tested by laboratory vestibular function testing, although utricular and saccular function tests now are available (see Chapters 8, 9).
Box 19-7
RED FLAGS DURING

ASSESSMENT THAT INDICATE
A NEED TO ASK FURTHER
QUESTIONS
Numbness
Tingling
Weakness
Slurred speech
Progressive hearing loss
Tremors
Poor coordination
Upper motor neuron signs and symptoms:
Presence of Babinski sign
Spasticity
Clonus
Loss of consciousness
Rigidity
Visual field loss
Memory loss
Cranial nerve dysfunction
Spontaneous nystagmus in room light after two
weeks
Vertical nystagmus without torsional component
(not benign paroxysmal positional vertigo)
What Type of Vestibular

Problem Does this Patient Have?
The vestibular function test results indicate whether the
patient has a peripheral, unilateral, central, or mixed disorder (both peripheral and central) or a bilateral vestibular deficit as well as the severity of the deficit. Some of
the exercises for patients with vestibular deficits are
designed to improve the remaining vestibular function or
to induce compensatory responses from the central nervous system and therefore are not appropriate for patients
with complete vestibular loss. Similarly, exercises for
benign paroxysmal positional vertigo (see Chapter 17)
will not help the patient with a unilateral vestibular loss
(see Chapter 20).
Not All Dizzy Patients

Have a Vestibular Lesion
Although nystagmus and complaints of dizziness and
vertigo are common in patients with vestibular deficits,
these problems can occur in other, non-vestibular disorders. Nystagmus may be caused by medications or
brainstem or cerebral hemisphere lesions, or may be congenital. Dizziness may occur in patients with peripheral
somatosensory deficits (like patients with peripheral
vestibular deficits, such patients feel dizzy when they are
standing but not when they are sitting), with central nervous system lesions, or with other medical problems such
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as low blood pressure, or as a side effect of medications.

Vertigo, most frequently associated with peripheral
vestibular deficits, can occur with central lesions (often,
patients with central lesions may not complain of vertigo)
and with other medical problems, such as presyncope.
These patients may have balance problems and may need
an individualized exercise program but not necessarily
exercises designed to improve vestibular function. It is
not known what interventions are optimal for persons
with central vestibular dysfunction.
Assess and Reassess

The initial assessment is directed at identifying problems
associated with the vestibular deficit, such as increased
dizziness or decreased visual acuity with head movements, and with the functional limitations of the patient.
The exercise plan, therefore, may include vestibular
exercises but must also address the specific problems and
level of function of the individual patient. Developing a
problem list enables the therapist to set goals and devise
specific exercises for each of those goals. As the patient
responds to the exercises, reassessment is necessary to
allow modification of the treatment program. The participation of the patient is key in developing a plan of care
that is mutually agreed upon and feasible for the patients
lifestyle.
Quantify the Assessment

Although not all components of the assessment yield
quantifiable data, many tests do, such as the patients
subjective complaints, DVA, measures of postural stability, and most of the gait and balance measures. Taking the
time to objectively measure the patients performance is
important in order for the therapist to determine the outcome of the patients intervention, to modify the intervention, to justify further intervention, and to determine
when to terminate intervention.
Determining Whether There

Has Been Improvement
One of the most difficult parts of the assessment is deciding what criteria to use in determining whether the
patients problem has actually improved. Many studies
that examine changes in patients with performance of
vestibular exercises use a statistically significant change
in test score as the criteria for improvement. 31,40,127,128
However, statistically significant change does not necessarily indicate a clinically meaningful change, especially
295
from the patients perspective. Some studies have begun

to define change according to criteria that may be more
clinically relevant, but the criteria can vary considerably
among studies. For example, Brown and colleagues102
defined clinically significant change for the DHI as a
change greater than 18 points, whereas Weiner and associates129 defined it as a change greater than 2 points. In
neither case did the investigators describe how they
arrived at these criteria.
A second method of examining improvement has
been to determine whether the patients performance has
returned to within normal values for age. This information
exists for only some of the outcome measures we use,
such as the computerized DVA test and gait speed.73,130 A
third method would be to use values based on comparisons with other information. For example, the cutoff
value for low risk for falls using the DGI was established
by comparing test scores against the persons history of
falling.118121 A fourth approach has been to combine the
scores for several tests and then define outcome on the
basis of the total or weighted score. For example, Whitney
and colleagues59 used a composite score based on the
ABC, DHI, and DGI scores. Finally, criterion for
improvement can be based on change in score that is
beyond the within-subject variability of the measures.64
Clearly, more research is needed in this important area.
Summary
The physical therapy assessment is multifaceted and
aimed toward identifying the patients specific functional
deficits as well as to quantitatively establish the effects of
the vestibular deficit on the patients vestibulo-ocular and
vestibulospinal systems and subjective complaints of disequilibrium and vertigo. The results of the assessment are
used to identify specific patient problems and to develop
treatment goals for the patient. The results of the assessment also provide the basis for determining whether the
interventions used are successful. The aim of exercise in
the rehabilitation of patients with vestibular disorders is
to promote vestibular compensation and functional
recovery.
Acknowledgments
The authors wish to acknowledge the contribution of
Diane F. Borello-France, Ph.D., P.T., who cowrote this
chapter in the first edition of Vestibular Rehabilitation.
Some of the work described here is supported by NIH
grant DC05384 (SLW) and NIH grant DC03196 (SJH).
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Otolaryngol Head Neck Surg 1995; 113:77.
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determinants. Age Ageing 1997;26:15.
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APPENDIX 19A
Evaluation
Initial: Yes No
Follow-up: Yes No
Date:
Patient:
Medical Record #:
D.O.B.
Age:
Referring physicians and physicians to whom we should send report (please give addresses):
Describe the major problem or reason you are seeing us:

When did this problem begin?
Specifically, do you experience spells of vertigo (a sense of spinning)?
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
If yes, how long do these spells last?

When was the last time the vertigo occurred?
Is the vertigo:
spontaneous:
induced by motion:
induced by position changes:
Do you experience a sense of being off-balance (disequilibrium)?
If yes, is the feeling of being off-balance:
constant:
spontaneous:
induced by motion:
induced by position changes:
worse with fatigue:
worse in the dark:
worse outside:
worse on uneven surfaces:
Does the feeling of being off-balance occur when you are:
lying down
sitting
standing
walking
300
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Appendix 19A
Do you or have you fallen (to the ground)?

If yes, please describe
How often do you fall?
Have you injured yourself?
If yes, please describe:
Yes
No
Yes
No
Do you or have you had near falls?

Do you stumble, stagger or side-step while walking?
Do you drift to one side while you walk?
If yes, to which side do you drift? Right Left
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
EVALUATION
Pertinent Past Medical History

Do you have:
Diabetes:
Heart disease:
Hypertension:
Headaches:
Arthritis:
Migraines
Neck problems:
Back problems:
Pulmonary problems:
Weakness or paralysis:
Hearing problems:
If yes, describe
Visual problems:
If yes, describe
Have you been in an accident?
If yes, please describe
When did it occur?
What medications do you take?
Social History
Do you live alone?
If No, who lives with you?
Do you have stairs in your home? Yes No If yes, how many?
Do you smoke? Yes No If yes, please indicate how much per day
Do you drink alcohol? Yes No If yes, please indicate how much
Do you have trouble sleeping?
Yes
No
Yes
No
PANAS (Positive and Negative Affective Scale)2

The scale below consists of a number of words that describe different feelings and emotions. Read each
item and then mark the appropriate answer in the space next to that word. Indicate to what extent you
301
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generally feel this waythat is, how you feel on the average. Use the following scale to record your
answers:
1
very slightly
or not at all
_____ interested
_____ enthusiastic
_____ ashamed
_____ guilty
2
a little
3
moderately
4
quite a bit
5
extremely
_____ irritable
_____ distressed
_____ afraid
_____ determined
_____ jittery
_____ alert
_____ upset
_____ proud
_____ strong
_____ active
_____inspired
_____ scared
_____ nervous
_____ excited
_____ hostile
_____ attentive
How would you describe your functional level of activities before this problem developed?
Current Functional Status

Are you independent in self-care activities?
Yes
Can you drive: In the daytime? Yes No In the nighttime?
Yes
Have you modified your driving habits? If yes, in what way? ____________________
Are you working? Yes No Not applicable If yes, occupation: ____________________
Are you on Medical Disability?
Yes
Can you perform all your normal parenting activities? Yes No Not applicable
Are you able to:
Watch TV comfortably?
Yes
Read?
Yes
Go shopping?
Yes
Be in traffic?
Yes
Use a computer?
Yes
No
No
No
No
No
No
No
No
Initial Visit
Please pick the one statement from the following list that best describes how you feel1:
Have negligible symptoms
Have bothersome symptoms
Perform usual work duties but symptoms interfere with outside activities
Symptoms disrupt performance of both usual work duties and outside activities
Am currently on medical leave or had to change jobs because of symptoms
Have been unable to work for more than 1 year or have established permanent disability with
compensation payments
Final Visit
Please pick the one statement from the following list that best describes how you feel1:
No symptoms remaining at the end of therapy
Marked improvement remaining at the end of therapy
Mild improvement, definite persistent symptoms at the end of therapy
No change in symptoms in relation to therapy
Symptoms worsened with therapy activities on a persistent basis compared with pretherapy
period
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Appendix 19A
EVALUATION
Assessment
Subjective Complaints
PANAS2 Score/significance:
Rate the following symptoms from 0 (none) to 10 (as bad as it can be):
Vertigo: (010)
Disequilibrium: (010)
What time of day do you feel best:
Oscillopsia (010)
worst:
How many times per day do you experience symptoms?

Major problems:
Disability score:
(pre-therapy)
(post-therapy)
Motion Sensitivity Quotient1:

MSQ = {(Total score) (# of positions with symptoms)} 20.48.
(Dont forget to adjust for baseline intensity so MSQ is based on change in intensity.)
MSQ: 010 = mild; 1130 = moderate; 31100 = severe.
Baseline Symptoms
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Intensity (05)
Duration*
Score (Intensity +
Duration in Points)
Sitting to supine
Supine to left side
Supine to right side
Supine to sitting
Left Hallpike-Dix
Return to sit from left Hallpike-Dix
Right Hallpike-Dix
Return to sit from right Hallpike-Dix
Sitting, head tipped to left knee
Head up from left knee
Sitting, head tipped to right knee
Head up from right knee
Sitting, turn head horizontally 5 times
Sitting, move head vertically 5 times
Standing, turn 180 to the right
Standing, turn 180 to the left
*Duration: 510 sec = 1 point; 1130 sec = 2 points; >30 sec = 3 points.
Oculomotor Examination
Room light:
A. Spontaneous nystagmus
B. Gaze-holding nystagmus
Y
Y
N
N
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C. Smooth pursuit
D. Saccadic eye movements
E. VORc
F. VOR slow
G. VOR rapid head thrusts
H. Visual acuity stationary:
Dynamic
Frenzel/IR (recorded Y or N):

A. Spontaneous nystagmus?
B. Gaze-holding nystagmus?
C. Horizontal head-shakinginduced nystagmus?

D. Vertical head-shakinginduced nystagmus?
E. R Hallpike-Dix maneuver: nystagmus
vertigo
F. L Hallpike-Dix maneuver: nystagmus
vertigo
G. Supine roll head right: nystagmus
vertigo
H. Supine roll head left: nystagmus
vertigo
I. Pressure test
Quantitative Dynamic Visual Acuity (DVA): static

left
Caloric Test:
Stance Postural Control
right
A. Alignment eyes open:
(erect, head still, base of support)
B. Self-initiated weight-shifting:
(strategy)
C. Reactive responses (sternal shove):
(strategy)
Balance Tests (video-taped? Y N)

A. Romberg: eo
ec
Normal/abnormal for age?
B. Sharpened Romberg: eo
ec
C. Single leg stance: eo
ec

(normal 12 inches)
D. Functional reach:
E. Fukudas stepping test: eyes closed
(FP, turn) Normal?
Gait
Assistive devices:
Orthoses?
A. At self-initiated pace:
Speed:
Base of support:
the other)
Normal for age?

Step length:
Cadence:
(equal, each foot passes
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Appendix 19A
EVALUATION
R
Y
L
N
Arm swing:
Head and trunk rotation:
Path:
Straight?
Staggers:
Y
Y
N
N
Swerves:
Side-steps:
B. As fast as possible: Can perform Cannot perform

Speed:
Normal for age?
Base of support:
Cadence:
Step length:
(equal, each foot passes
the other)
Arm swing:
Head and trunk rotation:
Path:
Straight?
Staggers:
Y
Y
N
N
Drifts:
Side-steps:
R
Y
L
N
R
Y
L
N
R
Y
L
N
C. Gait deviations: (20 foot path, 12 inches wide)

D. Walk, turn head: Can perform Cannot perform
Cadence:
Path:
Straight?
Staggers:
Base of support:
Y
Y
N
N
Drifts:
Side-steps:
E. Walk, move head vertically

Cadence:
Path:
Straight?
Staggers:
Base of support:
Y
Y
N
N
Drifts:
Side-steps:
F. Walk, turn head and count backwards out loud by

Cadence:
Path:
Straight?
Staggers:
Base of support:
Y
Y
N
N
Drifts:
Side-steps:
R
Y
G. Walk, turn around rapidly:

Normal:
Has difficulty/loses balance turning right
turning left
H. Singleton test: To right
To left
I. Fall Risk (Dynamic Gait Index):
Functional Gait
Independent: min/mod/max assist
Dependent: slow, cautious
Stairs
Uneven surfaces
Inclines
Carpet
L
N
305
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Subsystems
A. ROM:
Cervical
R-UE
L-UE
R-LE
L-LE
B. Strength: R-UE
L-UE
R-LE
L-LE
C. Soft tissue problems: Y N Location:
Nature: (spasm?)
D. Sensation: (vibration, proprioception, kinesthesia) LEs
E. Muscle tone:UEs
LEs
F. Cerebellar: Finger to nose
R
L
Rapid alternating movement: R
L
Optic ataxia
R
L
Tremor
R
L
Heel to shinlooking
R
L
Heel to shinnot looking
R
L
Rapid alternating movement
R
L
G. Pain: Y N
Location
Appendix References
1. Shepard NT, et al: Habituation and balance retraining therapy: a retrospective review. Neurol Clin
1990;8:459.
2. Watson D, et al: Positive and negative affectivity and their relation to anxiety and depressive disorders. J
Abnorm Psychol 1988;97:346.
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APPENDIX 19B
Dizziness Handicap
Inventory*
Name:
Date:
The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please check Yes, No, or Sometimes for each question. Answer each question as it pertains to your dizziness or
unsteadiness only.
Yes
No
Sometimes
P1. Does looking up increase your problem?

E2. Because of your problem, do you feel frustrated?
F3. Because of your problem, do you restrict your travel for
business or recreation?
P4. Does walking down the aisle of a supermarket increase
your problem?
F5. Because of your problem, do you have difficulty getting
into or out of bed?
F6. Does your problem significantly restrict your participation
in social activities such as going out to dinner, the movies,
dancing, or to parties?
F7. Because of your problem, do you have difficulty reading?
P8. Does performing more ambitious activities like sports or
dancing or household chores such as sweeping or putting
dishes away increase your problem?
E9. Because of your problem, are you afraid to leave your
home without having someone accompany you?
E10. Because of your problem, are you embarrassed in front of others?
P11. Do quick movements of your head increase your problem?
F12. Because of your problem, do you avoid heights?
P13. Does turning over in bed increase your problem?
F14. Because of your problem, is it difficult for you to do
strenuous housework or yardwork?
E15. Because of your problem, are you afraid people may
think you are intoxicated?
F16. Because of your problem, is it difficult for you to walk
by yourself?
P17. Does walking down a sidewalk increase your problem?
E18. Because of your problem, is it difficult for you to concentrate?
*From Jacobson GP, Newman CW: The development of the dizziness handicap inventory. Arch Otolaryngol Head
Neck Surg 1990;116:424. Copyright 1990 The American Medical Association.
307
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Yes
No
Sometimes
(24)
(20)
(22)
F19. Because of your problem, is it difficult for you to walk

around your house in the dark?
E20. Because of your problem, are you afraid to stay home alone?
E21. Because of your problem, do you feel handicapped?
E22. Has your problem placed stress on your relationships
with members of your family or friends?
E23. Because of your problem, are you depressed?
F24. Does your problem interfere with your job or household
responsibilities?
P25. Does bending over increase your problem?
Total
Total:
(38)
(36)
(28)
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CHAPTER
20
Interventions for the

Patient with Vestibular
Hypofunction

Vestibular rehabilitation is considered an appropriate and

valuable treatment approach for patients with vestibular
hypofunction. There are now many randomized controlled
studies that have demonstrated the value of vestibular
exercises compared with placebo exercises,14 general
exercise,5,6 no exercise,7 and other vestibular exercises.8 In
addition, numerous observational studies report patient
outcomes before and after vestibular rehabilitation, and
although these studies lack a control group, they provide
information about what factors may affect recovery and
the effect of vestibulopathy at the participation/restriction
level of function.915 New information about how the nervous system works and about the mechanisms of recovery
after vestibular loss has led to the development of more
specific exercises than those proposed by Cawthorne and
Cooksey in the 1940s.16,17 This chapter provides the reader with the background necessary to treat patients with
vestibular hypofunction. The similarities and differences
among the various treatment approaches are examined.
Case studies are provided to illustrate the decisionmaking process in the development of exercise programs.
Several different mechanisms are involved in the recovery of function after unilateral vestibular loss (UVL).
These mecahnisms include cellular recovery, spontaneous reestablishment of the tonic firing rate centrally,
vestibular adaptation, the substitution of other strategies,

and habituation.
Cellular Recovery
Cellular recovery suggests that the receptors or neurons
that were damaged and initially stopped functioning may
recover. This has been demonstrated for vestibular hair
cells in nonprimate mammals after aminoglycosideinduced loss.18,19 There appears to be some functional
recovery related to the anatomic recovery, although there
is also a persistent deficit.20 It is unclear at this time
whether recovery of hair cells is a significant factor in
recovery of vestibular function in human beings.
Reestablishment of Tonic Firing Rate

Asymmetrical disturbances of static vestibular function
(nystagmus, skew deviation, and postural asymmetries in
stance) recover spontaneously.21,22 These symptoms and
signs are caused by the disruption of tonic vestibuloocular and vestibulospinal responses. In the normal individual, when the head is stationary, the tonic firing of the
neurons in the vestibular nuclei on each side of the brainstem is balanced. Unilateral loss of the input from the
semicircular canals (SCCs) results in an asymmetry in
that activity. That asymmetry is interpreted as head
movement. For example, loss of the signal from the SCCs
309
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on one side results in a slow-phase eye movement away

from the intact side as if the intact side were excited by
movement. The slow-phase eye movement is interrupted
by a quick-phase eye movement in the opposite direction.
This quick-phase eye movement resets the eye position,
creating a spontaneous nystagmus. Unilateral loss of
utricular inputs results in a skew deviation in which the
eye on the side of the lesion drops in the orbit. Patients
with skew deviations complain of a vertical diplopia.23
Disruption of the tonic vestibulospinal responses
produces an asymmetry in the muscle activity in the
lower extremities, as measured electromyographically,
while the patient is standing,24 and in a postural asymmetry, which can be detected clinically.25 These signs and
symptoms resolve within 3 to 14 days after onset of the
unilateral vestibular deficit. The timing of the disappearance of the symptoms parallels the recovery of the resting firing rate of the vestibular nucleus neurons.26
Although visual cues can also be used to suppress spontaneous nystagmus and the postural asymmetry, several
studies have demonstrated that recovery of spontaneous
nystagmus does not depend on visual inputs per se.27
Nystagmus decreases at the same rate in animals kept in
the dark immediately after unilateral labyrinthectomy as
in animals kept in a lighted environment. Spontaneous
recovery is probably due to the development of denervation supersensitivity and to axonal sprouting.
head movement. This results in a dramatic decrease in

vestibulo-ocular reflex (VOR) gain during head movements. During the acute stage, the gain of the VOR is
decreased by as much as 75% for head movements
toward the side of the lesion and by 50% for head movements away from the side of the lesion in patients with
unilateral vestibular deficits.28 Disturbances of the
dynamic vestibulo-spinal response are distinguished by a
gait ataxia. Typically, patients ambulate with a widened
base of support, frequently side-step, and may drift from
one side to another while walking. They decrease trunk
and head rotation while walking because these rotations
would make them less stable. Head movement would
result in an asymmetrical vestibular signal that increases
their sense of disequilibrium and the ataxia.
There is a wealth of evidence that recovery from the
dynamic disturbances of vestibular function requires both
visual inputs and movement of the body and head.22,2932
VOR gain does not recover when cats or monkeys are kept
in the dark after unilateral labyrinthectomy.22,31 Recovery
of VOR gain begins when the animals are returned to a
lighted environment. Similarly, if animals are prevented
from moving after unilateral vestibular nerve section,
there is a delay in the onset of the recovery of postural stability, and the recovery period is prolonged (Fig. 20.1).32
Recovery of the Dynamic Component
It was initially believed that the recovery of the dynamic

vestibulo-ocular responses were due to the adaptive capability of the vestibular systemthat is, the ability of the
vestibular system to make long-term changes in the neuronal response to input. VOR adaptation can be induced
UVL also results in disequilibrium and visual blurring,

especially during head movements. These symptoms
are due to the disruption of the vestibular response to
Figure 20.1 Effect of restricting mobility

on rate of recovery after unilateral transection of vestibular nerve. Baboons that were
restrained after unilateral vestibular nerve
section had a delayed onset of recovery and
a more prolonged recovery than those animals that were allowed free movement.
(From Lacour et al, 1976.32)
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INTERVENTIONS FOR THE PATIENT WITH VESTIBULAR HYPOFUNCTION
after unilateral labyrinthectomy in cats as early as the

third day after surgery.33 The vestibular system in human
beings can also be adapted during the acute stage after
UVL. Pfaltz34 found an increase in the VOR gain in
patients with UVL stimulated optokinetically compared
with untreated patients. More recently, Szturm and colleagues8 reported greater VOR gain in patients after a
course of vestibular adaptation exercises but not in a control group.The signal for inducing vestibular adaptation
is retinal slip, or the movement of a visual image across
the retina.35 This slip results in an error signal that the
brain attempts to minimize by increasing the gain of the
vestibular responses.
Although retinal slip induces adaptation of the
VOR, it may not be the mechanism behind recovery in
patients with vestibular hypofunction. Research now suggests that the substitution of alternative strategies may be
behind functional recovery or at least contributes significantly to recovery.
Substitution
The final mechanism involved in recovery after vestibular lesions is the substitution of other strategies to replace
the lost function. Enhancement of gaze stability and
dynamic visual acuity during predictable head movement
is believed to be from either central preprogramming or
efference copy of the motor command. For example,
patients with vestibular hypofunction make a saccade
during the head thrust itself. These preprogrammed saccades occur at a latency that is too short to be voluntary
or reflexive36,37 and are not present in normal subjects.38
Another mechanism that has been described is anticipatory slow-phase eye movements. These slow-phase eye
movements are initiated more than 5 msec before the initiation of predictable head thrusts, are in the appropriate
direction for the direction of the head movement, and are
initiated centrally. Other slow-phase eye movements are
probably initiated by the intact vestibular system, on the
basis of the latency to onset of these eye movements (less
than 10 msec after the head thrust), which is within the
range of the VOR.39
Recovery of postural stability may be due to the use
of visual and somatosensory cues instead of remaining
vestibular cues. Although the substitution of visual or
somatosensory cues as a strategy may provide sufficient
information for postural stability in many situations, the
patient is at a disadvantage if trying to walk when those
cues are inaccurate or not available, such as in the dark.
At an extreme, some patients may modify their behavior
to avoid situations in which visual or somatosensory cues
are diminished, such as going out at night.
311
These mechanisms do not adequately substitute for

the lost vestibulo-ocular functionfunctions across frequencies of up to 20 Hz40,41 for activities such as walking
and runningand must stabilize gaze during both unpredictable and predictable head movements (Fig. 20.2).
Preprogrammed saccades and anticipatory eye movements occur primarily with predictable head movements
and not during unpredictable head movements. Other
type of eye movements do not function across the necessary frequency range. For example, pursuit eye movements are limited to less than 1 Hz and a maximum eye
velocity of 60 degrees per second (deg/sec).42 Saccadic
eye movements would not be a particularly useful alternative for a poor VOR, because patients would not be
able to see the target clearly during the actual eye movements.43 The cervical ocular reflex also does not operate
in the appropriate frequency range, and well-controlled
studies have failed to identifiy a cervico-ocular reflex, in
which the eye movements are in the compensatory direction.44,45 Similar limitations exist for the substitution of
somatosensory and visual cues for lost vestibular function (Fig. 20.3). Again, the vestibular system operates
through a wider frequency and velocity range than do
vision and somatosensation.4041,4648
Patients may also restrict head movements as a
means of seeing clearly or maintaining their balance.
This strategy is not particularly desirable, because it
Figure 20.2 Frequency range over which the cervicoocular reflex (COR), smooth-pursuit eye movements, and the
vestibulo-ocular reflex (VOR) can contribute to gaze stability
compared with the frequency and velocity ranges for daily activities, walking, and running. Only the normal VOR operates over
the frequency and velocity ranges of normal activities. (Modified
from Herdman, 1998.49)
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Figure 20.3 Frequency ranges over which somatosensory,

visual, SCC, and otolith inputs contribute to postural stability.
This information has been determined only for stability during
quiet stance and after sudden perturbations. (Modified from
Herdman, 1998.49)
would result in limited activity but would not provide a

mechanism for seeing clearly or for maintaining balance
during head movements.
Habituation
Habituation refers to a reduction in symptoms produced
through repetitive exposure to the movement and presumably is a central process. The mechanism and neural
circuitry are not well known.
Evidence that Exercise

Facilitates Recovery
The use of exercises, especially if supervised, adds to the
health care costs of the patient. It is necessary, therefore,
to be able to demonstrate the effectiveness of these exercise approaches in the rehabilitation of patients with
vestibular hypofunction. Animal studies support the concept that visuomotor experience facilitates the rate of
recovery and improves the final level of recovery after
vestibular dysfunction.3032 Several animal studies have
suggested that exercise may facilitate the process of
vestibular compensation. Igarashi and associates30 found
that, following unilateral labyrinthectomy, squirrel monkeys exercising in a rotating cage had less spontaneous
nystagmus than a nonexercise control group. In another
similar study, Igarashi and associates50 found that locomotor equilibrium compensation occurred faster in a
group of squirrel monkeys exercising in a rotating cage
(7.3 days) than in a nonexercise group (13.7 days).
Similar findings have been observed in cats after unilateral labyrinthectomy.29
Several randomized, controlled studies support the

benefits of vestibular exercises in the rehabilitation of
patients with vestibular disorders.18 Horak and colleagues5 compared the effectiveness of vestibular rehabilitation (customized programs consisting of gaze stability,
habituation, and balance exercises), general conditioning
exercises, and vestibular suppressant medications on
dizziness and imbalance in patients with chronic vestibular dysfunction. In this prospective, blinded study,
patients were randomly assigned to one of the groups and
were followed up for 6 weeks. Dizziness was assessed
through a calculation of movement sensitivity based on
intensity and duration of symptoms provoked by specific
movements and positions, and by indicating whether the
symptoms had improved, worsened, or were unchanged.
Postural stability was assessed by measuring peak-topeak anterior-posterior (AP) sway under different sensory
conditions. A functional balance measure, single-leg
stance (SLS), was also used. These investigators found a
significant decrease in dizziness only in the group of
patients receiving vestibular rehabilitation. Similarly, only
the vestibular exercise group had a significant improvement in postural stability, as indicated by decreased AP
sway and increased SLS time. It is understandable that the
group receiving medications did not show improvement;
both meclizine and diazepam are vestibular suppressants.
A later study has shown that long-term use of these medications actually prolongs the recovery period.51 One criticism of the Horak study is that it did not use an untreated
group of patients for comparison with the group performing vestibular exercises. An untreated group, however,
would not be an appropriate control, because the subjects
would clearly know they were not being treated and
they would not have parallel contact with the physical
therapists.
In another study of patients with chronic vestibular
deficits, Shepard and Telian52 compared the efficacy of
customized vestibular exercise programs with that of a
more generic exercise program. They did not use a control group but instead used a delayed treatment paradigm.
All subjects were assessed at baseline and again at 1
month before initiating any exercises, to serve as a control for spontaneous recovery. Subjects who did not show
spontaneous recovery were then stratified according to
age and pretreatment disability levels to ensure that the
two groups were similar. After 3 months of therapy, both
groups showed a decrease in self-reported levels of dizziness, with 85% of those in the vestibular rehabilitation
group and 64% in the generic exercise group reporting
complete or dramatic improvement. Only the vestibular
rehabilitation group, however, showed a significant
reduction in dizziness during routine daily activities. The
vestibular rehabilitation group also showed a significant
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improvement on both static and dynamic posturography

scores, a reduction in motion sensitivity, and a decrease
in asymmetry of vestibular function. The generic exercise
group improved only in their performance of static balance tests.
Herdman and coworkers1 examined whether patients
with acute UVL after resection of acoustic neuroma
would benefit from vestibular rehabilitation. This
prospective, double-blinded study compared the effect of
vestibular adaptation exercises with those of exercises
designed to be vestibular neutral (smooth-pursuit eye
movements performed with the head still). Both groups
were instructed in safe ambulation every day. Exercises
were initiated on postoperative day 3 in both groups.
These researchers found no difference in subjective complaints of vertigo between the groups over the course of
the study. This finding was expected, because vertigo
occurs as a result of the asymmetry in the tonic firing rate
of the vestibular system and recovers spontaneously.
There was, however, a significant difference in the complaints of disequilibrium by postoperative days 5 and 6.
As a group, patients performing the vestibular adaptation
exercises had significantly less disequilibrium than
patients in the control group. Differences between the
groups were also noted for gait pattern, especially with
horizontal head movement. All of the control subjects had
increased ataxia or developed some ataxia when asked to
turn the head while walking. In contrast, only 50% of the
vestibular exercise group showed this gait disturbance.
One criticism of this study is that the extent of
vestibular dysfunction and vestibular compensation prior
to surgery was not known. There was no difference, however, between the two groups on the basis of clinical
examination preoperatively. A second criticism is that the
study involved only a small number of subjects who
might not be representative of patients with recent
removal of acoustic neuromas. More recently, however,
another randomized controlled trial with a larger cohort
of subjects (n = 65) confirmed the findings.4 Even this
result is somewhat controversial, because a third study
found no difference in outcome between patients performing vestibular exercises and a placebo group during
the acute stage after removal of an acoustic neuroma.3
There were differences, however, in the outcome measures and the exercises used, which may explain the different conclusions; clearly, however, more research is
needed on the effect of time from onset on recovery.
The original Cawthorne-Cooksey exercises, developed to treat patients with vestibular deficits, were not
customized for the individual patient.16,17 These exercises
are often given as a handout to patients who are simply
instructed to go home and do them. Szturm and colleagues8 compared the effectiveness of an unsupervised
313
program of Cawthorne-Cooksey exercises and of a customized, supervised program of vestibular adaptation

exercises. They found that a greater percentage of patients
improved in the vestibular adaptation exercise group than
in the Cawthorne-Cooksey exercise group.
All of the studies described here are important
because they provide the first evidence that vestibular
exercises result in better function than a placebo treatment. As with many investigations, the studies are limited in certain ways as follows:
1. In none of these studies was the exercise
approach described in sufficient detail to
allow replication of the exercises used.
2. Although the study designs included analysis
of group data, typically no information was
provided on the individual levelfor instance,
the number of participants within a group who
showed no improvement.
3. With few exceptions, these randomized controlled trials did not examine the effect of specific factors, such as exercise approach, gender,
time from onset, comorbidities, and environment, on recovery.
Goals of Treatment
The goals of physical therapy intervention in vestibular
hypofunction are to (1) decrease the patients disequilibrium (sense of being off-balance) and oscillopsia (visual
blurring during head movement), (2) improve the
patients functional balance, especially during ambulation, (3) improve the patients ability to see clearly during head movement, (4) improve the patients overall
general physical condition and activity level, (5) enable
the patient to return to a more normal level of participation in society, and (6) reduce the patients social isolation. Patients are usually seen by the physical therapist on
an outpatient basis, although, in some cases, the initial
treatments occur while the patient is still in the hospital.
An important part of the rehabilitation process is the
establishment of a home exercise program. The physical
therapist must motivate the patient and obtain compliance. To do so, the physical therapist must identify the
patients own goals and clarify for the patient the treatment goals as well as the potential effects of exercise.
Treatment Approaches
Several different approaches have been advocated in the
management of patients with vestibular hypofunction.
Four different approaches are presented here, although
there are elements common to all. Table 20-1 provides a
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Table 20-1 COMPARISON OF DIFFERENT EXERCISE APPROACHES

FOR THE PATIENT WITH A PERIPHERAL VESTIBULAR DISORDER
Feature
Adaptation
Exercises
Substitution
Exercises
CawthorneCooksey
Exercises
Habituation
Exercises
Incorporate head and neck exercises

into the treatment approach
Use a functional evaluation to assess

the symptoms of the patient
Incorporate principles of motor control

and learning into designing a treatment program
Practice mental exercises to increase

concentration
Have the patient work in a variety of environments and task contexts
summary and comparison of the different approaches.

Two case studies are used to demonstrate the basis for
specific exercises used in treatment and the progression
of the patients exercise program.
Adaptation Exercises
Vestibular adaptation refers to the long-term changes that
occur in the response of the vestibular system to input.
Adaptation is important during development and maturation as well as in response to disease and injury. Although
adaptation of residual vestibular function may not underlie recovery, the use of exercises based on generating a
retinal slip error signal does appear to induce recovery.
Guidelines for Development

of Adaptation Exercises
The following points should be considered in the development of exercises based on adaptation for the patient
with a unilateral peripheral lesion.
As mentioned before, the best
stimulus to induce adaptation is one producing an error
signal that the central nervous system attempts to reduce
by modifying the gain of the vestibular system. The best
stimuli appear to be those that incorporate movement of
the head and a visual input. Optokinetic stimulation
(movement of visual world only) by itself also can increase the gain of the vestibular system although perhaps
not as effectively as head movement combined with a
Consider the Stimulus.
visual stimulus.35,5355 Figure 20.4 shows two simple exercises that can be used as the basis for an exercise program
for patients with unilateral vestibular lesions. In each, the
patient is required to maintain visual fixation on an object
while the head is moving.
The early studies on
vestibular adaptation used paradigms in which the stimulus was present for several hours or more.57,58 This situation would not be appropriate for patients, especially
during the acute stage. We now know that vestibular adaptation can be induced with periods of stimulation as brief
as 1 to 2 minutes.34,59 During the time in which the brain is
trying to reduce the error signal, the patient may experience an increase in symptoms and must be encouraged to
continue to perform the exercise without stopping. Each
exercise shown in Figure 20.4, for instance, should be performed for 1 minute without stopping. The time for each
exercise can then be gradually increased to 2 minutes.
Response to Exercise Takes Time.
Adaptation of the Vestibulo-Ocular System is ContextSpecific. Therefore, for optimal recovery, exercises
must stress the system in different ways.46 For example,

adaptation of the vestibular system is frequency dependent.60,61 If the system is adapted at a specific frequency,
gain will improve most at that frequency. Because normal
movement occurs over a wide range of frequencies of
head movement, the patient should perform the head
movement exercises at many different frequencies for
optimal effects. Different head positions can also be used
to vary the exercise.
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315
Figure 20.4 Exercises to increase the

gain of the vestibular system can include a
1 viewing paradigm (A) and a 2 viewing
paradigm (B). In the 1 viewing paradigm,
the visual target is stationary and the subject
moves the head back and forth while trying
to maintain visual fixation on the target. In
the 2 viewing paradigm, the target and the
head move in opposite directions while the
subject again keeps the target in focus.
These exercises are performed with
a small visual target (foveal stimulus) and
a large visual target (full-field stimulus)
with the head moving either horizontally or
vertically. (Modified from Tusa et al, 1993.56)
VOR
gain can be increased even in the dark if the subject simply imagines looking at a stationary target on the wall
while the head is moving. Although not increasing the
gain as much as head movement plus vision combined,
these results suggest that mental effort will help improve
the gain of the system. Patients should be encouraged to
concentrate on the task and should not be distracted by
conversation and other activities.62,63
Adaptation is Affected by Voluntary Motor Control.
Patients Should Always Work at the Limit of Their Ability.
Although patients morale can be lifted through activities

that they can perform relatively easily, most exercises
should stress their ability. For example, with the eye-head
exercises, the speed of the head movement should be

increased as long as the patient can keep the visual target
in focus.
Substitution Exercises
Mechanisms other than adaptation are involved in recovery and should be included in a well-rounded exercise
program. Exercises should synthesize the use of visual
and somatosensory cues with the use of vestibular cues
as well as the possibility of central preprogramming to
improve gaze and postural stability. For example, balance exercises should stress the system by having the
patient work with and without visual cues or should alter
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somatosensory cues by having the patient stand on foam.

Removing or altering cues forces the patient to use the
remaining cues. Thus, if the patient is asked to stand on
foam with eyes closed, the use of vestibular cues will be
fostered.
Cawthorne-Cooksey Exercises
The Cawthorne-Cooksey exercises were developed in the
1940s.16,17 At the time, Cawthorne was treating patients
with unilateral vestibular deficits and postconcussive disorders. In conjunction with Cooksey, a physiotherapist,
Cawthorne developed a series of exercises that addressed
their patients complaints of vertigo and impaired balance. The Cawthorne-Cooksey exercises include movements of the head, tasks requiring coordination of eyes
with the head, total body movements, and balance tasks
(Box 20-1).
Guidelines for Development of

Cawthorne-Cooksey Substition Exercises
The following points should be considered when one is
using the Cawthorne-Cooksey exercises in the treatment
of the patient with a unilateral peripheral lesion.
Cawthorne and Cooksey recommended that the
exercises be performed in various positions and
at various speeds of movement.
Patients were required to perform the exercises
with the eyes open and closed. According to
Cawthorne and Cooksey, performing the exercises with the eyes closed decreased the patients
reliance on visual information and possibly
forced more effective compensation by vestibular
and somatosensory mechanisms.16,17
Cawthorne and Cooksey also recommended that
patients be trained to function in noisy and
crowded environments. These situations may be
very difficult for patients with vestibular disorders to manage.
To encourage active participation, Cawthorne
and Cooksey had patients exercise together in
daily group sessions. They believed that a group
exercise format would be more economical and
more fun for patients and also that it would facilitate identifcation of any malingerers. Hecker
and colleagues,65 utilizing Cawthorne-Cooksey
exercises to treat a group of patients with
vestibular disorders, reported that 84% of the
patients responded favorably. They also emphasized the importance of performing the exercises
Box 20-1
CAWTHORNE-COOKSEY
EXERCISES FOR PATIENTS WITH
VESTIBULAR HYPOFUNCTION
A. In bed
1. Eye movementsat first slow, then quick:
a. Up and down.
b. From side to side.
c. Focusing on finger moving from 3 ft to
1 ft away from face.
2. Head movements at first slow, then quick;
later with eyes closed:
a. Bending forward and backward.
b. Turning from side to side.
B. Sitting (in class):
1. As above.
2. As above.
3. Shoulder shrugging and circling.
4. Bending forward and picking up objects
from the ground.
C. Standing (in class):
1. As A1, A2, and B3.
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 ball from hand to hand under
knee.
5. Changing from sitting to standing and turning around in between.
D. Moving about (in class):
1. Circle around center person, who will
throw a large ball and to whom it will be
returned.
2. Walk across room with eyes open and then
closed.
3. Walk up and down slope with eyes open
and then closed.
4. Walk up and down steps with eyes open
and then closed.
5. Any game involving stooping, stretching,
and aiming, such as skittles, bowling, or
basketball.
Diligence and perseverance are required, but the
earlier and more regularly the exercise regimen is
carried out, the faster and more complete will be
the return to normal activity.
From Dix, 1979.64
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regularly.65 In addition, they noted that emotional

stress seemed to affect a patients progress.
Cooksey17 stressed that patients should be encouraged to move into positions that provoke symptoms. She
believed that with repeated exposure to a stimulus, the
patient would eventually tolerate the position without
experiencing symptoms. This treatment philosophy is
remarkably similar to the philosophy supported by many
physical therapists today who use habituation exercises.
Most physical therapy clinics that treat patients with
vestibular deficits use some component of the
Cawthorne-Cooksey exercises.
Habituation Exercises
The habituation exercise approach is based on the concept
that repeated exposure to a provocative stimulus will
result in a reduction in the pathological response to that
treatment. In the 1980s, Norr66,67 proposed the use of
vestibular habituation training for the treatment of
patients with unilateral peripheral vestibular loss. According to these investigators, an asymmetry in labyrinth
function results in a sensory mismatch. The disturbed
vestibular signal produces an input to the brain that conflicts with information received from intact visual and
somatosensory systems. This conflict, they believed, produces the symptoms experienced by patients with unilateral peripheral vestibular loss.
The Motion Sensitivity Test, developed by Shepard
and Telian, uses a series of movements and positions as
the basis for establishing an individualized exercise program for patients with chronic unilateral vestibular hypofunction (UVH) (Table 20-2).51,52,68 The patient rates the
intensity of the symptoms and indicates the duration of
symptoms.
Guidelines for Development

of Habituation Exercises
The following points should be considered when one is
developing exercises based on habituation for the patient
with a unilateral peripheral lesion.
Up to four movements are chosen from the test
results to form the basis for these exercises. The
patient performs these movements two or three
times twice a day.
It is important that the patient perform the movements quickly enough and through sufficient
range to produce mild to moderate symptoms.
As habituation occurs, the movements can be
performed more rigorously.
317
The patient should rest after each movement

until the symptoms stop. The symptoms should
decrease within a minute after each exercise or
within 15 to 30 minutes after all exercises have
been performed.
It may take 4 weeks for the symptoms to begin
to decrease. The exercises are usually performed
for at least 2 months and then can be gradually
decreased to once per day.
This treatment approach is not advocated for all
patients. The elderly especially should not perform movements in which they rise quickly.
Precautions include orthostatic hypotension and
orthostatic intolerance.
If treatment fails and the patient still experiences
debilitating symptoms during leisure or work
activities, counseling is advisable regarding
changing those activities or reorganizing the
work area.
Expectations for Recovery

Recovery from unilateral vestibular lesions is usually
quite good, and patients should expect to return to normal
activities. Several factors can affect the final level of
recovery, and the therapist should keep them in mind
when talking to patients about their progress and anticipated recovery.
Do all subjects improve? Most studies on treatment
of patients with vestibular hypofunction examine outcomes for the entire group and focus on those patients
who show improvement with intervention. However, several studies on treatment of patients with vestibular hypofunction clearly state the reality that some patients do not
experience improvement.2,6,15,69,70 Between 10% and 30%
of reported subjects with UVH do not experience
improvement, depending on what outcome measure is
used.2,70 Of patients with BVH, outcome is worse, with
between 25% and 66% of patients failing to have
improvement (SJ Herdman, personal communication,
2006). Identifying and assessing these nonresponding
patients is extremely important, because we clinicians are
obliged to identify these patients, seek the reasons for
poor outcome, and develop methods to reverse it.
Factors Affecting Outcome

An important part of treatment is the education of the
patient about the possible final level of recovery. This
process enables the patient (and the therapist) to set realistic goals. As one might expect, patients with less initial
disability and those seen earlier after onset of vestibular
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Table 20-2 MOTION SENSITIVITY QUOTIENT TEST

FOR ASSESSING PATIENTS WITH DIZZINESS*
Baseline Symptoms
Intensity (05)
Duration+
Score
1. Sitting to supine
2. Supine to left side
3. Supine to right side
4. Supine to sitting
5. Left Hallpike-Dix position
6. Return to sit from left Hallpike-Dix position
7. Right Hallpike-Dix position
8. Return to sit from right Hallpike-Dix position
9. Sitting, head tipped to left knee
10. Head up from left knee
11. Sitting, head tipped to right knee
12. Head up from right knee
13. Sitting, turn head horizontally 5 times
14. Sitting, move head vertically 5 times (pitch)
15. Standing, turn 180 degrees to the right
16. Standing, turn 180 degrees to the left
*MSQ = {(Total score) (# of positions with symptoms)} 20.48. MSQ score 010 = mild; 1130 = moderate; 31100 = severe.
+
Duration: 510 sec = 1 point; 1130 sec = 2 points; 30 sec = 3 points.
From Shepard and Telian, 1995.52
hypofunction have better recovery.12,52 Patients with stable

unilateral vestibular deficits, or patients with partially
compensated deficits whose symptoms are provoked
only by movement, also have a better prognosis.68
Only one randomized controlled study has examined the influence of multiple factors on the outcome
measured, and only a few factors could be examined
because of the small number of subjects in the study.2 As
a group, patients who performed vestibular exercises
showed a significant improvement in visual acuity during
head movements (P = .00001), whereas those performing
placebo exercises did not (P = .07). Stepwise regression
analysis showed the leading factor contributing to
improvement to be vestibular exercises, which accounted
for 42% of the variance in visual acuity during head
movement. Age, time from onset, initial visual acuity

during head movement, oscillopsia, and duration of treatment did not contribute to recovery of visual acuity during head movement. However, observational studies
provide additional insight about factors that may influence outcome in patients with vestibular disorders.
Although these results are limited because of the small
numbers of participants studied, or because they included patients with both vestibular and non-vestibular causes of dizziness, they provide some idea of individual
relationships that affect outcome.
Results from several studies
have identified the fact that age is not a factor in achieving improvement in subjective complaints, visual acuity
Subject Age and Gender.
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during head movement, gait speed, and fall risk in patients

who undergo a course of vestibular exercises.2,10,12,71,72 Less
is known about the role of gender in recovery. Within the
group of patients who underwent surgical removal of
acoustic neuroma, gender was a significant factor in the
patients postoperative perception of handicap, with male
patients reporting a greater perception of handicap at 3
months, but there was no gender effect at 1 year after surgery.71 In patients with a variety of diagnoses, male
patients reported worse disability scores.51
Relatively little is known about
the effect of comorbid problems on outcome in patients
with vestibular hypofunction. Those studies examining
specific comorbidities have shown that for some comorbidities (e.g., migraine), patients have an equivalent
improvement in physical activities but have greater perceived handicap than patients without the comorbidity.7375 Similar findings have been reported by Betchen
and associates,76 who found that persistent headache lowered quality of life and affected return to work in patients
who had had resection of acoustic neuroma. Patients with
vestibular symptoms after head injury were unlikely to
show significant improvements in subjective complaints
or balance with vestibular rehabilitation.12 Patients with
cerebellar dysfunction and dizziness also seem to demonstrate less improvement after vestibular rehabilitation
than those with other central nervous system conditions
(Whitney et al, personal communication, 2006). Perhaps
the best guideline now is that patients with multiple
comorbidities do not show as great an improvement as
those with only one other etiological factor.77
Physical Comorbidities.
Psychiatric and Psychological Factors. With any chronic

illness, quality of life is an important outcome variable.
One would hope that improvements in functional status
would lead to meaningful changes in quality of life for a
given patient. However, quality of life is complicated by
several factors, including anxiety, depression, and locus
of control/coping strategies (i.e., internal vs. external control or active vs. passive coping). In some populations, the
variable most likely to influence quality of life is depression (e.g., see Jia and associates78). However, Grunfeld
and colleagues79 noted that the presence of a vestibular
lesion per se is not associated with depression. Somewhat
in contrast, Yardley and coworkers80 found that negative
mood, rather than true depression, was a factor contributing to self-perceived handicap in patients with dizziness.
Although there may be no direct association
between vestibular deficits and depression, the presence
of depression can have a serious effect on the potential for recovery. Krebs and associates6 observed that
319
some patients with vestibular hypofunction experienced

depression that prevented their participation in vestibular
rehabilitation. This observation is supported by others,
who noted that patient adherence is low for treatments
that appear to decrease quality of life81 whereas better
outcomes and improved quality of life are associated
with greater treatment adherence.82 Factors that have been
identified as contributing to the self-perception of handicap or disability in patients with dizziness include somatization, negative mood, satisfaction with social support,
self-esteem, and anxiety.83,84 Psychiatric/psychological
factors also help predict outcome. Symptoms of somatic
anxiety predict an increase in handicap over a 7-month
study of people with recurrent dizziness.84
Several studies have documented that
maladaptive coping strategies are associated with
decreased quality of life and with greater depression in
patients with chronic medical illness.85,86 One study of
patients with episodic vertigo identified the following
four primary strategies for coping with vertigo: problemfocused information-seeking, distraction, denial, and
relinquishing responsibility.84 The investigators found that
relinquishing responsibility predicted handicap even
when the analysis controlled for other factors such as
emotional distress. Because of the nonepisodic nature of
the symptoms in patients with vestibular hypofunction,
the relationship of coping strategies and psychological
factors with outcome may be different from what has
been already reported.
Coping Strategies.
There appears to be a difference in final level of recovery (at the activity and participation level) between patients with UVH and patients
with bilateral vestibular hypofunction (BVH).12,69,87 The
extent to which the severity of deficit (e.g., incomplete or
complete) and the rate of development of the problem
(e.g., sudden unilateral, simultaneous bilateral, or
sequential bilateral) affect the final level of recovery is
not clear. Some evidence points to the importance of the
underlying etiology to the outcome. For instance, within
the group of subjects who had had surgical removal of
acoustic neuroma, tumor size and degree of preoperative
canal paresis were significant factors in the patients
postoperative perception of handicap.71 In contrast,
patients with surgically induced vestibular loss have a
similar level of recovery to that of patients with unilateral vestibular neuritis or labyrinthitis.12
The Vestibular Deficit Itself.
Two studies of patients with acute

UVH have suggested that delaying the initiation of
vestibular exercises results in a delay in the initiation
Time from Onset.
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of recovery or slows compensation.1,4 In two studies

of patients with acute loss of vestibular function after
resection of acoustic neuroma, those who started a
vestibular rehabilitation program 3 days postoperatively
and had better postural stability and less disequilibrium
than a control group who performed placebo exercises.1,4
However, a third study found no difference in outcome
between patients performing vestibular exercises and a
placebo group.3 Differences in the outcome measures and
the exercises used may explain the different conclusions.
A different issue is whether there is a critical period
during which exercises must be initiated. The evidence
seems to suggest that there is no critical periodthat
vestibular exercises are beneficial even for patients with
chronic problems.5,8,86,88 This has been shown directly
through analysis of time from onset as a factor that might
be involved in recovery.6,12 Up to 30% of patients with
chronic vestibular hypofunction, however, do not experience improvement during a course of vestibular exercises.2,6 This fact raises the suspicion that time from onset
combined with other factors may affect the potential to
benefit from these exercises
Medication. Several investigators have suggested that
vestibular suppressant medications such as diazepam
may delay or slow recovery,51,89 but few studies have actually examined the influence of medication on the level of
recovery. One randomized controlled study found that
patients taking meclizine did not show an improvement
in symptoms or in balance, whereas patients performing
vestibular exercises did.5 Patients who are treated with
steroids for vestibular neuritis, on the other hand, appear
to have less perception of handicap after treatment than
patients who are not.90
If the patient restricts head

movement or if visual inputs are minimized during
vestibular rehabilitation, recovery may be delayed or limited.27,3132 Patients with vestibular lesions often prefer to
keep their eyes closed and their heads still to minimize
symptoms. Another factor that may delay recovery or
may limit the final level of recovery may be the use of
medications that suppress vestibular function.89
Limit or Delay of Recovery.
Is Recovery Sustained after Rehabilitation is Stopped?
Both anecdotal evidence and systematic studies suggest

that recovery after vestibular loss may be fragile.
Symptomatic relapse may occur with extreme fatigue or
stress, prolonged periods of inactivity, illness, or even a
change in medication.52 Patients need to be aware of this
possibility and should understand that it does not indicate
a worsening of the underlying disease. Little is known as
to whether patients who have improved function after
vestibular rehabilitation need to continue with exercises

in order to sustain that improvement. Krebs and associates6 examined patients with UVH and BVH at 1 year
after a course of vestibular rehabilitation. They found that
frequency of performing a home exercise program over
the course of that year correlated with sustaining
improvements in gait speed.6
Treatment
General Considerations
First, treatment should begin early. As mentioned, when
visuomotor experience is prevented during the early
stages after UVL, there is a delay in recovery.27,31
Furthermore, the initiation of the recovery of postural
responses is delayed, and the course of recovery prolonged, when motor activity is restricted.32
Second, exercise can be done for brief periods initially. Pfaltzs study34 is also important for showing that
even brief periods of stimulation can produce VOR gain
changes that would be particularly useful in the treatment
of patients during the acute stage of recovery.
Third, although patients with chronic vestibular
deficits often do not have vertigo or vomiting (the exception being patients with episodic vestibular disorders,
such as Mnires disease), they frequently have limited
their movements, or at least their head movements, in an
attempt to avoid precipitating the symptoms of disequilibrium and nausea. Head movements must be encouraged in
these patients both to induce compensation (and thereby
improve the function of the remaining vestibular system)
and to habituate the symptoms provoked by movement.
Fourth, many of the exercises provided to the patient
may, at first, worsen the patients symptoms. The reason
is that the exercises involve head movement, which the
patient has been avoiding because moving the head provokes the dizziness. This situation may be threatening to
patients who are extremely fearful of experiencing their
symptoms. Nevertheless, patients should be told that during physical therapy, there might be a period when they
may feel worse before they feel better. To help the patient
through this period, the physical therapist should be accessible. For example, the patient should be instructed to
telephone the therapist if the symptoms become severe or
long-lasting. In such instances, the physical therapist determines whether the exercises can be modified or should
be discontinued until the patient is formally reevaluated.
Excessive exacerbation of the patients symptoms
can also be avoided through careful exercise prescription.
Initially, the patient may be provided with only a few key
exercises. The patient is instructed to attempt the exercises three to five times per day; the number of repetitions is
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based on the therapists assessment of the patients exercise tolerance. It is a good idea to have the patient perform all exercises completely during the clinic visit in
order to assess the response to the exercises. Patients who
become excessively dizzy while performing the exercises may think that the exercises are making them worse
and may refuse to continue with rehabilitation. On subsequent visits, patients are reevaluated and the exercise
program is expanded so that all of the physical therapy
goals are addressed.
Fifth, it is reasonable to expect improved function
within 6 weeks in patients who are compliant with the
exercises, but anecdotally at least, the longer the problem
has existed, the longer the time needed to see improved
function. Once the patient is able to perform the initial
vestibular exercises, it may be necessary to take the
patient with chronic vestibular deficit through more complex movements in order to habituate the response to
movement or at least to make the patient less fearful that
movement will precipitate vertigo. Cawthornes exercises, such as moving from sitting to standing and turning
around in between, and the habituation exercises can be
useful at this stage (see Box 20-1 and Table 20-2).
Problem-Oriented Approach
In a problem-oriented treatment approach, the physical
therapy program is based on (1) the problem areas identified during the evaluation, (2) the patients diagnosis, and
(3) the patients medical history. For example, the physical therapy program for a patient with Mnires disease
would differ from that for a patient with vestibular neuronitis. Specifically, the treatment program for a patient
with Mnires disease would not address the symptom of
vertigo. Compensation of vertigo in Mnires disease is
difficult to achieve because of the fluctuating nature of the
disease process itself. Instead, the physical therapy program would focus on improving any persistent imbalance
in a variety of task and environmental situations, preventing physical deconditioning, and, if indicated, education
in environmental modification and safety awareness.
A problem-oriented treatment approach can incorporate adaptation, substitution, habituation, and the
Cawthorne-Cooksey exercises according to what is needed. In addition, it should incorporate functional activities
and contemporary principles of motor learning and motor
control. As with many of the other approaches, the general treatment progression includes the following:
Increasing and alternating the speed of the
exercises
Performing exercises in various positions and
activities (i.e., head movements performed while
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sitting, then standing, during walking, and during

walking with upper extremity manipulation)
Performing exercises in situations of decreasing
visual and/or somatosensory input (i.e., balance
exercises with eyes open and eyes closed)
Exposing the patient to a variety of task and
environmental situations and contexts (i.e., walking in the home to walking at a shopping mall)
Problem: Visual Blurring and Dizziness

When Performing Tasks that Require
Visual Tracking or Gaze Stabilization
Visual blurring and dizziness when performing tasks that
require visual tracking or gaze stabilization during head
movements are most likely due to decreased VOR gain
resulting in visual blurring during head movement and
also visual-vestibular sensory mismatch. Adaptation
exercises can be used to improve the gain of the VOR and
therefore improve gaze stabilization.
Some caution should be taken with the use of adaptation exercises during the acute stage after UVL. In this
stage, the patient may complain of severe vertigo and may
be nauseated and vomiting. Head movement will make
these symptoms worse, and the patient usually prefers to
lie quietly, often in a darkened room or with eyes closed.
At this stage, the patient may also be taking medications
to suppress these vegetative responses and may be receiving intravenous fluid replacement. Slow, easy head movements, such as turning the head to look at someone,
should be encouraged. Good visual inputs (bright room
lights, curtains open) also should be encouraged during
the first days after the acute onset of a vestibular deficit.
After 1 to 3 days, the symptoms of nausea and vertigo should resolve, and the spontaneous nystagmus
should be decreasing as the resting state of the vestibular
system readjusts centrally. Patients can begin exercises to
facilitate adaptation of the vestibular system (compensation) as early as 1 or 3 days after the onset of the vestibular loss, using gentle, active head movement. Horizontal
head movement while fixating on a small (foveal), stationary target is performed for only 1 minute, followed
by a period of rest ( X1viewing; see Fig. 20.4 and Box
20-3). The exercise is then repeated using vertical head
movements. As patients improve, they should try to perform the exercises for up to 2 minutes each. Although
patients may complain of increased vertigo or disequilibrium with head movements, neither is a reason to stop the
exercises. Vomiting and significant nausea, however, are
reasons for modifying the exercises.
VOR gain in the acute stage after UVL is poor (0.25
to 0.5), and relatively slow head velocities and low fre-
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Box 20-2
EXERCISES TO IMPROVE POSTURAL STABILITY

Many different balance exercises can be used. These
exercises are devised to incorporate head movement
(vestibular stimulation) or to foster the use of different sensory cues for balance.
1. The patient stands with the feet as close together
as possible and with both or one hand helping
maintain balance by touching a wall if needed.
The patient then turns the head to the right and to
the left horizontally while looking straight ahead
at the wall for 1 minute without stopping. The
patient takes the hand or hands off the wall for
longer and longer periods while maintaining balance. The patient then tries moving the feet even
closer together.
2. The patient walks, with someone to assist if needed, as often as possible (acute disorders).
3. The patient begins to practice turning the head
while walking. This will make the patient less stable, so the patient should stay near a wall while
walking.
4. The patient stands with the feet shoulder-width
apart with eyes open, looking straight ahead at a
target on the wall. The patient progressively narrows the base of support from feet-apart to feettogether to a semiheel-to-toe position. The
exercise is performed first with arms outstretched,
then with arms close to the body, and then with
arms folded across the chest. Each position is held
for 15 seconds before the patient does the next
most difficult exercise. The patient practices for a
total of 5 to 15 minutes.
5. The patient stands with the feet shoulder-width
apart with eyes open, looking straight ahead at a
target on the wall. The patient progressively narrows the base of support from feet-apart to feettogether to a semiheel-to-toe position. The
exercise is performed with eyes closed, at first
intermittently and then for longer and longer periods. The exercise is performed first with arms
outstretched, then with arms close to the body,
and then with arms folded across the chest. Each
position is held for 15 seconds, and then the
patient tries the next position. The patient practices for a total of 5 to 15 minutes.
6. A headlamp can be attached to the patients

waist, shoulders, or head and the patient can
practice shifting the weight to place the light
into targets marked on the wall. This home
biofeedback exercise can be used with the feet
in different positions and with the patient standing on surfaces of different densities.
7. The patient practices standing on a cushioned
surface. Progressively more difficult tasks
might involve hard floor (linoleum, wood),
thin carpet, shag carpet, thin pillow, sofa
cushion. Graded-density foam can also be
purchased. Backward walking can be attempted
cautiously.
8. Make walking more difficult by asking the
patient to count backwards while walking. This
can be made progressively more difficult by having the patient perform the exercise while walking on different surfaces.
9. The patient practices walking with a more narrow base of support. The patient can do this first
touching the wall for support or for tactile cues,
then gradually touching only intermittently, and
then not at all.
10. The patient practices turning around while walking, at first making a large circle but gradually
making smaller and smaller turns. The patient
must be sure to turn in both directions.
11. The patient can practice standing and then walking on ramps, either with a firm surface or with
more cushioned surface.
12. The patient can practice maintaining balance
while sitting and bouncing on a exercise ball
or while bouncing on a trampoline. This exercise can be incorporated with attempting to
maintain visual fixation of a stationary target,
thus facilitating adaptation of the otolith-ocular
reflexes.
13. Out in the community, the patient can practice
walking in a mall before it is open, and therefore
quiet. The patient can practice walking in the
mall while walking in the same direction as the
flow of traffic or walking against the flow of
traffic.
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quencies should be used so that the patient can keep the

visual target in focus at all times. As the patient improves
(within a few days to a week or more), the exercises can
be expanded to include use of a full-field stimulus
(checkerboard) in addition to the small target used previously. Within 1 or 2 weeks after onset, patients can begin
the vestibular adaptation exercises that require them to
maintain fixation on a visual target that is moving in the
opposite direction as the head movement (X2 viewing;
see Fig. 20.4 and Box 20-3). This exercise should be performed with somewhat smaller head movements (and
comparably small target movements) because the target
cannot be kept in focus while viewing out of the corner
of an eye. The head movements may have to be slower as
well for the patient to maintain fixation. Both the X1 and
the X2 viewing paradigms should be performed at
increasing head velocities as the patient improves. Within
2 or 3 days after onset, patients can begin to perform the
VOR adaptation exercises while standing, as a preparation for walking and turning the head as well.
Ultimately, the adaptation paradigms should be
incorporated into gait and other functional activities.
Patients with vestibular deficits should also be instructed
to perform functional tasks or games that require visual
tracking or gaze fixation. For example, laser tag requires
the patient to move the head while focusing the eyes on a
moving target. Bouncing and catching a ball may be
another appropriate task for some patients. The patient
could be advised to bounce the ball off the floor, wall,
and/or ceiling in an attempt to vary the task by changing
direction of object motion and/or neck position. Using
multicolored or highly patterned balls may also increase
task difficulty, because the moving pattern or high color
contrast may greatly increase the patients symptoms.
The electronic Simon Says game requires patients to
watch and remember a sequence of lights that flash in
rapid succession in front of them; this task incorporates
Cawthornes suggestion to include mental exercises in
the exercise regimen.
Exposing the patient to highly textured visual environments may also assist in the remediation of visuovestibular interaction deficits. For example, the patient
may be instructed to gradually add tasks, such as grocery
shopping or walking through a shopping mall.
Problem: Exacerbation of Symptoms

If a patient experiences exacerbation of symptoms during
the head movement assessment, habituation exercises are
incorporated into the exercise program. During the physical therapy assessment, positions or movements that
323
provoke the patients symptoms are identified according

to the results of the Motion Sensitivity Test (see Chapter
15). These positions and movements are then incorporated into the patients exercise program.
Movements such as bending forward may exacerbate the patients symptoms (see Table 20-2). If the
patient has significant symptoms, habituation exercises
may be performed initially in an easy poistion, such as
sitting rather than standing. Later, the patient can perform
the exercises while standing or during walking. If
straight-plane movements of the head produce few symptoms, neck diagonal movements, with or without a combination of trunk movement, are prescribed. During the
head movement/position exercises, the patient is instructed to hold each position for at least 10 seconds or until
the symptoms dissipate. In addition, the patient is
instructed to perform each exercise three to five times. It
is particularly important that the initial prescription of
these exercises should avoid those movements/positions
that produce severe symptoms. Many therapists have
found that too aggressive an initial approach may lead to
patient noncompliance. Instead, therapists should select
movements and positions that produce minimal to moderate symptoms.
Attempts are also made to include habituation exercises in the patients daily routine. For example, the
patient is instructed to incorporate neck diagonals into
the task of loading and unloading the dishwasher. This
task requires the patient to focus on the object and move
the body, head, and arm synchronously to either pick up
an object or place it on a high shelf (Fig. 20.5).
Problem: Static and

Dynamic Postural Instability
Balance and gait exercises prescribed for a patient are
based on the problems identified during assessment and
vary considerably according to patient history and medical diagnosis. Recovery from unilateral vestibular neuronitis, labyrinthitis, or a surgical procedure, such as
vestibular nerve section, typically takes 4-6 weeks,
although it may take up to 6 months in some patients.
Patients who have undergone vestibular nerve section, for
example, often return to work within 3 weeks. Recovery
from resection of acoustic neuroma typically takes
longer, although most of the recovery occurs within the
first few weeks. After the first 2 or 3 weeks, the main
complaints are fatigue, instability when turning quickly,
and some greater difficulty walking in the dark. Patients
may also complain of greater instability when walking on
uneven surfaces or when there is a change in light inten-
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Figure 20.5 Neck movements are

incorporated into the patients normal
daily routine. In this example, the patient is
instructed to incorporate a neck diagonal
movement when loading and unloading
the dishwasher.
sity (opening a door to the outside or walking through

intermittent shadows, such as of trees).
Although many patients with peripheral vestibular
hypofunction perform below the norm on static tests of
balance during the acute stage, the most common complaint is imbalance during dynamic activities such as
walking. Rarely do these patients report an inability to
stand on one leg. Instead, they may complain of difficulty walking on an uphill grade, through a cluttered
room, or into a movie theater. Because of the nature of
the patients deficits, balance training should address the
dynamic aspects of gait and should be task directed.
Balance and gait training are inseparable and therefore
considered together in this discussion.
On the basis of the evaluation, the therapist identifies the patients functional balance deficits. Therapeutic exercise prescription should address the patients
specific deficits. For example, a patient may experience
disequilibrium when the opportunity to use visual and/or
somatosensory input for balance is minimized. In this situation, emphasizing exercises and tasks that require the
patient to focus on vestibular, instead of visual or
somatosensory, input is important. Such exercises are
walking backward, sidestepping, and braiding performed
with the eyes closed, marching in place on foam performed with the eyes open and later with the eyes closed
(Fig. 20.6 and Box 20-2), and walking across an exercise
mat or mattress in the dark. It is important that the therapist recognize that there are preparatory exercises the
patient should master before attemping these more difficult exercises.

Another functional deficit is the instability patients
experience when faced with situations that require movements of the head during gait. For instance, many
patients indicate having difficulty shopping for groceries.
To scan the grocery shelves for the desired item, the
patient must walk while moving the head left, right, or
diagonally. At the same time, the patient must continue to
monitor the environment to prevent a collision with
another shopper. As a result, this rather ordinary task creates an overwhelming challenge to the patients postural
control system. To overcome this challenge, the patient is
first instructed to walk down a corridor while moving the
head left and right, or up and down. Later, the patient performs the same task while avoiding objects placed in the
walking path. The most difficult condition would be to
perform this exercise in an area with a complex visual
environment (similar to a shopping aisle with people and
carts). In the grocery store, the patient may try this for
one or two aisles initially, without a cart.
The last deficit to be discussed is the difficulty
patients with vestibular deficits experience when their
gait is unexpectedly disrupted. One seldom walks
through a busy shopping mall without experiencing a
sudden head-on encounter with another person. Such
tasks require the postural control system to respond
quickly. In some cases, the patient may need to improve
the ability to anticipate forthcoming events. As indicated
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325
Box 20-3
EXERCISES TO IMPROVE
GAZE STABILITY
Figure 20.6 Activities that promote use of vestibular information for balance are frequently included in the patients home
exercise program. In this example, the patient marches in place
on a foam cushion with the eyes open or closed. Closing the
eyes maximizes the importance of vestibular information.
in the gait evaluation, an obstacle course can be devised

to assess the patients ability to anticipate or respond
quickly to changes in task context. The obstacle course
can also be used in treatment. The patient should be
instructed to vary the course in as many ways as possible.
Having a family member verbally direct the patient on
the path to follow is helpful. Commands are given at the
moment the patient must encounter or avoid an obstacle,
thereby maintaining a level of task uncertainty. Another
task that requires the patient to respond quickly to externally imposed constraints is walking and pivoting to the
left or right. Again, a family member directs the patient
on when and in what direction to pivot. Family members
can also quickly give the command to stop.
Patients with vestibular disorders can have difficulty with many different balance and gait tasks. This discussion considered only a few. With a thorough
evaluation, the therapist may identify the patients specific motor control problem. In such cases, the therapy program should not be limited to specific balance or gait
exercises. Instead the therapist should provide the patient
Acute and Subacute Stages (also used with

chronic, uncompensated vestibular loss)
1. A business card or other target with words
on it (foveal target) is taped on the wall in
front of the patient so the patient can read
it. The patient moves the head gently back
and forth horizontally for 1 minute while
keeping the words in focus.
2. This is repeated with the head moving vertically for 1 minute.
The patient should repeat each exercise at least
three times a day, gradually increasing to five
times a day.
The duration of each of the exercises is extended
gradually from 1 minute to 2 minutes.
Patients should be cautioned that the exercises
may make them feel dizzy or even nauseated but
that they should try to persist for the full 1 minute
to 2 minutes, resting between exercises.
Chronic Stage
1. Depending on whether this induces any
nausea, the exercise is then repeated using
a large pattern such as a checkerboard
(full-field stimulus) with the head moving
horizontally.
2. The exercise with the checkerboard is then
repeated with the head moving vertically.
3. The patient holds a business card in front
of face so able to read it. The patient
moves the card and the head back and forth
horizontally in opposite directions, keeping
the words in focus, for 1 minute without
stopping.
4. This is repeated with vertical head movements and with a large, full-field stimulus.
The duration is gradually extended from 1 minute
to 2 minutes. The patient should repeat each exercise at least three, preferably five, times a day.
5. The patient fixates on a visual target placed
on the wall in front of the patient while
gently bouncing up and down on a trampoline (otolith stimulation).
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with balance and gait activities that challenge the

patients postural control system in a variety of ways.
Problem: Progression of
Balance and Gait Exercises
Recovery of postural stability occurs more gradually than
recovery of gaze stability. After acute onset of vestibular
loss, patients need assistance to get out of bed for 1 to 2
days after the onset, sometimes longer. They usually,
although not always, need assistance with ambulation for
the first few days. Patients with UVL can usually stand
with the feet together and the eyes closed within 4 to 5
days after onset, although they still have increased sway.
Gait is grossly ataxic for the first week, but patients
should be walking independently, albeit with a widened
base of support, within 1 week. During this initial stage
of recovery, several different balance and gait exercises
are appropriate. Goals include increasing endurance
while walking, improving stability while standing with a
more narrow base of support (Romberg position) with
eyes open and closed, and beginning to turn the head
while walking. Exercises to improve balance in sitting or
other positions are usually not necessary, and for postoperative patients, bending over must be avoided.
Gait exercises can be more challenging for patients
with chronic vestibular disorders, although, as with all
cases, the starting point depends on the problems identified during the assessment (see Box 20-3). Patients can
be taken through a series of exercises that stress their balance by gradually decreasing the base of support or by
altering visual and somatosensory cues. Even if they are
unable to maintain the position successfully for the

required period of time, practicing will improve their balance. Patients with complete UVL, however, rarely perform the Sharpened Rombergs test with eyes closed at
any age. More difficult dynamic balance exercises may
include walking and turning suddenly or walking in a circle while gradually decreasing the circumference of the
circle, first in one direction and then in another. The
patient needs the practice of walking in different environments, such as on grass, in malls (walking in an empty
mall is easier than in a crowded mall; walking with the
crowd is easier than walking against it), and walking at
night. Precautions to prevent falls should always be taken
until the patient no longer needs them, but it is important
to avoid letting the patient become dependent on assistive
devices for walking.
Problem: Physical Deconditioning

Physical deconditioning because of inactivity may be a
significant problem for many patients with UVL. Most
patients are advised to begin a regular walking program,
the purpose of which is two-fold: (1) to prevent deconditioning of the patient and (2) to provide realistic balance
challenges to the patients central nervous system. Tasks
such as walking on uneven terrain, walking through a
shopping mall, and crossing the street challenge the
patient in ways that cannot be simulated by a therapeutic
exercise program (Fig. 20.7). When crossing the street,
the patient must conform to the temporal constraints
imposed by moving vehicles. Specifically, the patient
must determine at what moment to step off the curb to
Figure 20.7 Patients may have difficulty

walking when they must conform to temporal
constraints, such as when crossing a street
before the traffic light changes.
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avoid confronting a vehicle. When crossing the street at a

busy intersection, this requirement becomes more difficult
to fulfill. In addition, the patients postural control system
must make quick adjustments to offset perturbations
caused by changes in terrain or motion of other people.
The initial program requires the patient to walk for
15 to 20 minutes daily. Over subsequent weeks, the
patient is instructed to increase to a 30-minute walk or
longer. Initially, the patient may be advised to walk in a
familiar environment with few challenges. Later, the
therapist encourages the patient to expand the walking
program to other situations and contexts. Walking in a
park and at a shopping mall are frequently recommended. Patients are advised to experience as many challenges
as possible when walking in these situations. For example, riding an escalator in a shopping mall may provide
an interesting challenge. The patient must remain balanced while standing on a moving support surface. In
addition, the motion of other people toward or to the side
of the patient may create a sense of dizziness or imbalance, enhancing the difficulty of the task. Such challenges are necessary to overcome if the patient is to
manage safely in a variety of contexts without experiencing an exacerbation of symptoms.
Patients can also be encouraged to return to other
activities, such as tennis and golf, that will help improve
their overall fitness. These activities need to be added
gradually. Activities such as using a stationary bike,
although it should help improve fitness, will not help
improve postural stability except indirectly by increasing
327
strength or range of motion. Swimming can be safely

performed by patients with UVL and is a good fitness
exercise. If the patients want to return to ocean swimming, they should be advised that they might have some
difficulty initially walking on the sand or standing on the
sand in the water. (Patients with BVL must be more cautious, because without visual cues, they will have difficulty knowing which way is up when under water.
Ocean swimming in particular may not be advisable.
Swimming with goggles will help, but not in murky
water.) For all patients, the precaution all people should
follow needs to be observed: Never swim alone.
Problem: Return to Driving

One of the more commonly asked questions is when the
patient may begin to drive again. The legal ramifications
may vary from state to state, but essentially, patients
should not drive if they cannot see clearly during head
movements or if head movements result in significant
dizziness (or disorientation). One guidelinethat
patients should be able to see clearly when making rapid
and abrupt head movementscan be tested with the
dynamic visual acuity test. If a patient decides to return
to driving, he or she should be encouraged to begin on
quiet, local streets or in an empty parking lot. Driving at
night and driving on high-speed roads should be delayed
until the patient is comfortable with the quieter roads.
Drivers training is often beneficial, and its cost may be
covered through insurance.
CASE STUDY 1
A 56-year-old woman experienced onset of severe
vertigo with nausea and vomiting 6 months ago. At
that time, the vertigo appeared to be positional. She
reports she had to crawl to the bathroom and that she
passed out for an unknown period. She was hospitalized for 8 days, during which time she was treated
for dehydration and worked up for cardiac problems
and stroke. A caloric test performed at that time
showed right canal paresis (63% decrease on right).
She underwent a course of vestibular rehabilitation at
a different site, which she states was not beneficial.
Currently she complains of lightheadedness and
dizziness with head movement. She is using a cane
for ambulation, which she did not need prior to the
onset of the vertigo. Review of records from 6

months ago show that at that time, the patient was
ambulating with a walker and that her clinical visual
acuity was 20/20 with her head stationary but deteriorated to 20/200 during 2-Hz horizontal head oscillations. Additionally, she had restricted participation in
her normal social activities, no longer going to
church function or out to dinner with friends.
Past Medical and Social History
Significant weight gain in last 6 months. No history
of trauma, exposure to ototoxic medications, heart
disease, diabetes, thyroid disorder, hypertension,
arthritis, or treatment by a psychiatrist.
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Comment
UVH developed in this patient 6 months ago (based
on the caloric test); the description of the vertigo as
being positional is misleading but may indicate a
superior vestibular artery lesion resulting in horizontal canal hypofunction and utricular degeneration
with sparing of the posterior canal. This would lead
to horizontal SCC paresis and posterior SCC BPPV.
It is not clear why the patient believes the previous
course of vestibular rehabilitation was not beneficial.
If the exercise program were too aggressive, it may
have provoked excessive dizziness and she may have
not complied with it. Clearly, she has made some
improvement since the onset of the problemshe is
walking now with a cane instead of a walker.
The patient rates her disequilibrium as 6.0 on a visual analogue scale from 0 (normal) to 10 (worst it
could be); she rates her oscillopsia during ambulation
as 8.4 on a similar scale. Her dizziness affects her
activities 80% of the day.
Neurological Examination
Normal findings except as follows:
1. Patient has decreased response to vibration
(125 Hz) and abnormal kinesthesia in her
toes. Ankle jerk responses are absent bilaterally.
2. Muscle strength in anterior tibialis muscle
and in gastrocnemius muscles is 4/5 bilaterally.
3. Unable to perform Romberg test with eyes
open or closed for 30 seconds.
4. Walks slowly with widened base of support;
turns en bloc.
Comment
The peripheral neuropathy, although mild, may affect

the patients postural stability, especially in the dark,
as well as the final level of functional recovery. It is
unusual for the Romberg test result to be abnormal. It
may be due to her peripheral neuropathy (if it is a
profound deficit) or to the combination of peripheral
sensory loss and vestibular hypofunction, and/or
there may be an element of fear of falling. Her gait
pattern is typical of a person with an uncompensated

vestibular deficit.
The oculomotor examination in room light reveals
the following:
Visual acuity is 20/25 4 OU (both eyes
viewing) with head stationary and decreases
to 20/63 3 during 2-Hz horizontal oscillations of the head.
VOR is normal during slow head rotations,
but patient makes large corrective saccades
with head thrusts to the right.
No spontaneous or gaze-holding nystagmus.
Dynamic Visual Acuity testing using the
computerized system could not be performed
because the patient experienced a significant
increase in dizziness with only 20 seconds of
horizontal head movement.
Oculomotor examination using an infrared
recording system to prevent fixation suppression of
nystagmus demonstrates the following:
Horizontal head-shaking resulted in a leftbeating nystagmus; there was no vertical
head shakinginduced nystagmus.
Movement into the Hallpike-Dix position to
the left had negative result, but with same
movement to the right, the patient had a mild
left-beating nystagmus without vertigo.
Comment
The decrease in visual acuity during head movement

is consistent with an uncompensated vestibular
deficit. The presence of corrective saccades with head
thrusts to the right is consistent with a right deficit.
The normal-appearing VOR with slow head movements may be due to the function of the intact left
side, residual function of the right vestibular system,
or substitution of the pursuit eye movement system
for gaze stability. Her inability to tolerate/perform
repeated head movements for more than 20 seconds
will limit her initial exercise program. Head shakinginduced nystagmus is not always present in
patients with unilateral vestibular deficits. The pres-
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ence of a left-beating nystagmus after horizontal head

shaking is consistent with a right-sided lesion. The
left-beating nystagmus, without vertigo, when the
patient was moved into the right Hallpike-Dix position is from the asymmetry in the utricular signal produced by movement into that position and is not
uncommon in patients with UVL. It may explain why
an earlier diagnosis of positional vertigo was made.
Balance and Gait
The patient walks with a slow cadence (0.63
ft/sec; normal for age is 3.59ft/sec) with
and without the cane, a widened base of support, and decreased rotation through the trunk
and neck. She is unable to turn her head
while walking and keep her balance.
Fall risk: Her dynamic gait index is 14/24,
indicating a risk for falling.
Plan for Vestibular Rehabilitation
Problems
Disequilibrium and postural instability

induced by head movement
Decrement in visual acuity with head movement
Limited tolerance for head movement
Ambulation with a cane
Slow gait speed
Is at risk for falling
Decreased participation level
Social isolation
Plan
The patient was started on vestibular adaptation exercises, static and dynamic balance exercises, and some
exercises based on functional activities. The exercises consisted of the X1 viewing paradigm, which the
patient performed for 20 seconds each using a foveal
target held in her hand. Initially, the patient performed these exercises sitting down, and she was
instructed to wait for the symptoms of dizziness to
decrease before starting the next exercise. She used
both horizontal and vertical head movements. This
exercise was to be performed 3 times daily initially
with an increase to 5 times daily in one week if tolerated. The patient was also instructed to gradually
increase the duration of each exercise with a goal of
1 minute each. The goals of these exercises were to
329
increase the gain of the remaining vestibular system,

to decrease the patients symptomatic response to
head movement, and to encourage her to make head
movements. Functionally, the exercises should
improve her visual acuity during head movement and
habituate the dizziness induced by head movement.
She was also instructed in static balance exercises performed with eyes open and then while briefly
closing her eyes. It was made clear to the patient that
she needed to perform the balance exercises in a safe
place in her home, such as in a corner facing out.
Unfortunately, she lives alone, so a family member is
not available to help her. She was instructed to practice walking without her cane and without touching
the furniture or walls. This latter exercise she was to
perform in her house in the hallway for 3 to 5 minutes
twice daily. The goal of these exercises was to
decrease her reliance on her cane while walking. The
patient was also asked to begin a walking exercises
program, increasing her walks to 20 minutes daily.
The patient performed all exercises at least once
during this initial clinic visit to ensure that (1) she
was able to perform them correctly and (2) they did
not make her so dizzy that she would stop performing
them. Follow-up was scheduled for 1 week later, and
the patient was told to call if she had questions or
difficulty performing the exercises. After the initial
follow-up visit, the patient was seen in the clinic
every 2 weeks.
One-Month Reevaluation
The patient rated her disequilibrium as a 3.0 on an

analogue scale from 0 (normal) to 10 (worst it could
be); she rated her oscillopsia during ambulation as a
2.9 on a similar scale. These scores were a marked
improvement over those on the initial visit.
Balance and Gait
She could perform the Romberg test with eyes open

and with eyes closed for 30 seconds but could not
perform the Sharpened Romberg test with eyes open.
She was no longer using her cane. During ambulation, her cadence, base of support, step length, and
rotation through trunk and neck were normal. Her
gait speed had increased to 2.75 ft/sec. When asked to
turn her head from side to side while walking, there
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was a slight decrease in cadence, but the patient could
perform the task with only a slight deviation from a
straight path. She was able to walk safely on ramps,
on stairs, and on grass with and without head rotation. She had resumed local driving during the day
but had not attempted to drive at night. She was able
to go to church but had not yet resumed her evening
social activities.
Comment
This patient is now showing good progress toward

recovery after her UVL. Her inability to perform the
Sharpened Romberg test with eyes open is normal for
age (although some people in her age range can perform this test). A home program of exercises should
be continued until the patients recovery has reached
a plateau.
CASE STUDY 2
A 46-year-old man has complaints of dizziness and
imbalance; he is scheduled for resection of left
vestibular schwannoma within 1 month. Magnetic
resonance imaging (MRI) with gadolinium contrast
showed a 1.5-cm tumor extending into the left cerebellopontine angle with no compression of brainstem
or cerebellum. Facial nerve function appeared to be
symmetrical and normal. He reports that his balance
is worse in the dark and when going up stairs. He
denies falling. Patient appears quite concerned about
the scheduled surgery. He expresses concerns about
dying or being unable to return to work after surgery.
Past Medical History
Headache (sinus or migraine), allergic to hay; no
hearing in left ear, and a minimal high-frequency loss
in right with a speech reception threshold of 35 and
no speech discrimination loss. Medications: none.
Allergies: No known drug allergies. Patient is independent in basic activities of daily living and drives
day and night with no limitations.
He rated his disability as 0/5 (Shepard Disability
Scale), indicating that he has negligible symptoms.
The Positive and Negative Affective Scale (PANAS)
score indicated both anxiety and depression. Head
movement did not induce dizzinessvisual analog
scale (VAS) score 0/10and only slightly increased
his oscillopsia (VAS score 0.1/10) and disequilibrium
(VAS score 2/10).
Positive result of head-thrust test to the left. With
Frenzel lenses, there was no spontaneous or gaze-
evoked nystagmus. After head shaking there was only

a single drift of the eyes to the left and a single corrective saccade. No nystagmus was elicited with vertical head shaking. Visual acuity with the head
stationary was 20/20 corrected. Quantified visual
acuity during active head oscillations between 120
and 180 deg/sec was normal for rightward and leftward head movements.
Balance
Romberg test result was normal, and the patient could
maintain the Sharpened Romberg position with eyes
open for 30 seconds. He could not perform the
Sharpened Romberg test with eyes closed. The
patient ambulated with a normal stride length, base of
support, trunk and neck rotation, and arm swing. His
gait speed was slower than normal for his age (3.25
ft/sec, compared to a normal value of 3.72 ft/sec). He
stated that he normally walks slowly. He did not
appear to use excessive visual fixation to maintain his
balance while ambulating. Fall risk: Dynamic Gait
Index (DGI) = 22/24.
Comments
This patient is typical of many patients with acoustic
neuromas, in that his initial complaint was decreased
hearing. The absence of vertigo or even disequilibrium in such patients is due to the gradual vestibular
loss occurring as the tumor grows rather than an
abrupt onset as would occur with vestibular neuronitis. He has no central signs such as a direction-changing gaze-holding nystagmus. The patient made
corrective saccades with head movements toward
the involved side, indicating an inadequate vestibular
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response. The only abnormal finding in the assessment of his balance was an inability to perform the
Sharpened Romberg test with eyes closed. We have
found that the Sharpened Romberg test with eyes
closed is sensitive to UVL but not specific for
vestibular deficits.
The primary concern expressed by the patient is
that he might die during surgery or might not be able
to work again after surgery.
Intervention
Prior to surgery, the typical postoperative rehabilitation course was discussed with the patient and his
wife. Because of his concerns about the operation, an
appointment was set up with the neurologist, who
prescribed an antianxiety and antidepressant medication for short-term use only.
Surgical resection of the acoustic neuroma was
performed 3 weeks later via a translabyrinthine
approach because the patient had no usable hearing in
the ear on the side of the tumor (see Chapter 14). The
patient did well postoperatively. He had moderate
complaints of vertigo for a few days after surgery but
no diplopia. He did have a complete facial paresis,
but the surgical report noted that the facial nerve was
intact. Initially he had a spontaneous right-beating
nystagmus that worsened when he looked to the right.
He expressed considerable relief that the opertion
was over and no longer appeared to be anxious or
depressed.
On postoperative day 3, the patient no longer
had a right-beating nystagmus. His active neck range
of movement was limited by 50% because of pain at
the surgical site, which he described as a pulling sensation. He was able to ambulate independently but
had a widened base of support and minimized rotation through his trunk. His gait was slow and he occasionally sidestepped. He appeared to use excessive
visual fixation while he walked for balance and
slowed his gait when he turned his head while walking. Romberg test result was negative; Sharpened
Romberg test was not performed.
Vestibular adaptation exercises were initiated on
postoperative day 3. The initial exercise used was the
X1 viewing paradigm, which the patient was to perform both while sitting and while standing. While
standing he was to gradually decrease his base of support and bring his feet closer together. The exercise
was to be performed using a foveal stimulus with horizontal and vertical head movements. The patient was
331
instructed to perform the exercises 3 to 5 times a day

for 1 minute each. In addition, he was to walk, gradually increasing the distance walked.
Comment
This patients postural instability and his performance on the various balance tests are typical of
patients during the acute period after resection of a
vestibular schwannoma. Many patients experience
vertigo immediately after the surgery because of the
sudden asymmetry in vestibuar function with
removal of the tumor. The surgery also accounts for
the spontaneous nystagmus in this patient. His facial
paresis could be a problem when he performs the
adaptation exercises, because he cannot blink to
lubricate his eye.
Early Postoperative Course
By postoperative day 6, the Sharpened Romberg test
result was normal with eyes open but the patient
could not perform the test with eyes closed. He was
ambulating independently but still had a widened
base of support. His gait was less ataxic, and he no
longer used excessive visual fixation to maintain balance. He was independent on stairs with a railing. His
exercise program consisted of the X1 and the X2
viewing paradigms, using both a foveal stimulus and
a full-field stimulus, which he was to perform standing 5 times a day. He also was instructed to begin
practicing turning his head while walking, being
careful because it would make him less stable. Each
exercise period would take approximately 45 minutes. At this stage, patients are still not allowed to
bend over or lift anything weighing more than 5 lb
(risk of cerebrospinal fluid leak). The patient was discharged from the hospital on postoperative day 6.
Comment
Rapid recovery for patients with UVL is typical. The
effect of the vestibular loss is still obvious (e.g. still
has difficulty walking while moving his head). Most
patients with UVL are never able to perform the
Sharpened Romberg test with eyes closed. We typically do not give these patients any kind of assistive
device to use when walking. For some patients, walking with a cane might be helpful for 2 or 3 days while
they are in the hospital. Purchasing a cane for these
patients is difficult to justify, because it will not be
needed at discharge. There are exceptions to this rule,
of course.
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Outpatient Follow-Up
At 4 weeks after resection of left vestibular schwannoma, the patient has complaints of dizziness and
imbalance, which he notes are worse in the dark. He
denies falls. Past medical history is unchanged except
for the recent surgery and facial paresis with left eye
irritation secondary to it. Medications: Ophthalmic
ointment (Puralube) for the eye. He is independent in
basic activities of daily living and drives during the
day but has not resumed driving at night, primarily
because of eye irritation.
He rates his disability as 1/5, indicating that his

symptoms are bothersome. Head movement VAS =
0.1/10; oscillopsia VAS = 0.1/10; disequilibrium VAS
= 0/10. Balance confidence (Activities-specific
Balance Confidence scale) = 82.5%.
Balance
Fall Risk: DGI score = 22/24 (difficulty keeping his

balance when walking with head movements.). Gait
speed = 3.10 ft/sec (normal 3.72 ft/sec).
Visual Acuity
DVA = 0.036 for head movements to the left (normal

< 0.162).
Comment
The patient is doing very well after surgery. Primary
problems are limited to walking on uneven surfaces,
walking with head movement, and difficulties related
to eye irritation. He has an appointment with an ophthalmologist for later in the week. The goal for this
patient is a return to full activities, probably within 6
weeks of surgery. Other patients require a longer
recovery period and may not return to work for 3
months. The full recovery period after this procedure
is 1 year, fatigue being the main problem.
Within 6 months (and usually earlier), patients

should be able to participate in sports such as tennis,
racquetball, and golf, all of which are also good
vestibular and balance exercises. They may have to
change how they play and may have to shift to doubles tennis games. Patients will be aware of a sense of
imbalance when they turn rapidly toward the side of
the deficit but usually do not have any loss of balance.
Some patients complain that they have difficulty
when balance is stressed, such as when walking in the
dark on uneven surfaces or if they have to step backwards suddenly.
Patients who do not do well should be carefully
screened for other problems that would complicate
their recovery, such as the coexistence of visual
changes, sensory changes in the feet, or central nervous system lesions that would prevent vestibular
adaptation. Additionally, screening for psychological
problems may be helpful. Some patients are fearful of
moving the head. These patients may still benefit
from vestibular exercises even several months after
surgery but with a more closely supervised program
to ensure compliance.
This patient also had a facial palsy after surgery.
The potential for recovery is good because the nerve
was intact after surgery. We do not initiate facial exercises until the patient has more than faint voluntary
movements, and even then, patients are cautioned to
practice gentle rather than forceful facial movements.
Another approach would be to send the patient for
electromyography biofeedback instruction. In patients
with significant synkinesis, we use biofeedback training to improve the quality of the facial movements. Of
main concern for patients with facial paresis or palsy
is protection of the eye. If lid closure is absent or poor,
patients may use either a cellophane moisture chamber or an eye patch to prevent drying of the eye and
corneal damage. Patients using either type of patch
should be advised to be careful when walking because
they have only monocular depth perception cues.
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CASE STUDY 3
An 18-year-old woman is referred to physical therapy with a diagnosis of a right peripheral vestibulopathy. Current complaints include imbalance, especially
with head movement, and a sense that her eyes dont
catch up with my head during head movements.
Patient no longer complains of vertigo and denies
falling. She states that she still occasionally staggers,
stumbles, and sidesteps when walking. Past medical
history is noncontributory. Current medications
include prednisone and acyclovir. She is allergic to
penicillin. She is independent in all activities of daily
living. She has not returned to driving or to her parttime job as a housecleaner. She has, however,
returned to college classes.
The general neurological findings were normal
except for the vestibular system. MRI and audiogram
findings were unremarkable. Vestibular laboratory
testing included an oculomotor screening battery,
static positional testing, caloric testing, rotational
testing, and posturography. Test results showed a left
gaze-evoked nystagmus, a left-beating nystagmus on
positional testing, a right vestibular paresis on caloric
testing, a left directional preponderance on rotational
testing, and abnormal posturography (abnormal
response for all six sensory organization conditions,
and abnormal adaptation to toes-up rotation on movement coordination).
ing balance to sudden toes-up rotations of the support

surface may signify a tendency toward retropulsion in
some patients but is a nonspecific finding in many
patients with balance problems. It may indicate that
the patient will have difficulty walking on uneven
surfaces.
Physical Therapy Examination
The patient rates her disability as a 1 on a scale from

0 to 5.68 She rates her dizziness with head movement
as a 1.4/10, her oscillopsia while walking as a 1.4/10,
and her disequilibrium while walking as a 1.9/10 (all
scores represent decrement associated with movement; score of 10 is worse).
Visual Acuity
Head stationary: LogMAR 0.018 (normal); with predictable head movement to the left: LogMAR = 0.076
(normal for age = 0.087); with predictable head
movements to the right: LogMAR = 0.125.
Static Balance
Negative Romberg test result; Sharpened Romberg

eyes open = normal, eyes closed = 4 sec (normal for
age = 60 sec).
Gait
Decreased head movement, occasional stagger.

Fall Risk
Comments
The left-beating, gaze-evoked nystagmus, the leftbeating nystagmus on positional testing, and the
directional preponderance most likely reflect right
vestibular paresis. The greater difficulty experienced
by the patient on all six of the sensory organization
tests is unusual, but not unheard of, during the chronic stage of unilateral vestibular deficit. In some
patients, this finding may reflect a functional component of the patients complaints. Difficulty maintain-
DGI score = 23/24 (increased fall risk indicated by

scores 19/24).
Impression
Subjective complaints of head movementinduced

dizziness, oscillopsia, and imbalance; abnormal visual acuity with 120 deg/sec head movements to right;
abnormal gait pattern (decreased head movement);
decreased activities (driving); all consistent with subacute UVL.
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Treatment Goals
75% decrease in head movementinduced
symptoms (dizziness, oscillopsia, and disequilibrium) in 6 weeks
Normal visual acuity during head movement
to right in 6 weeks
Normal static balance with eyes closed
except for SR
Return to all normal activities in 6 weeks
Comment
The patients complaints of disequilibrium with head
movement, blurred vision, and a gait disturbance as
well as the objective findings are all consistent with
the disturbance of the dynamic vestibular responses.
Intervention
The patient was given a home exercise program that
consisted of head movements while standing with
eyes open, adaptation exercises, and a walking program. She was told to perform the head and adaptation exercises 5 times a day for 2 weeks. She was
Summary
Patients with unilateral vestibular deficits can be expected to recover from the vertigo and/or disequilibrium they
first experience. The final level of recovery should be to
return to all or most activities. Other nervous system disorders can delay or limit the level of recovery. Animal
studies and anecdotal evidence in human beings suggest
that exercises facilitate recovery of vestibular system
function. Early intervention also seems to be important in
optimizing recovery. Restricting movement, preventing
visual inputs, and the use of vestibular suppressant medications may delay the onset of recovery and limit the
final level of recovery.
This chapter has presented treatment strategies
for the physical therapy management of patients with
unilateral peripheral vestibular hypofunction, who may
present with a variety of functional deficits. The physical
therapy treatment program should address all of the
patients functional deficits. The use of exercise in the
rehabilitation of patients with vestibular disorders is
aimed at promoting vestibular compensation. Several
case studies were presented to illustrate the rehabilita-
advised to walk daily. She was seen on two subsequent visits, each 2 weeks apart, upon which she was
reevaluated and given a progression of the home
exercise program. The following exercises were
added to her home program: walking with head movements, walking with pivot turns, and circle walking.
She was also given additional eye/head exercises (see
previous discussion of substitution exercises).
After 4 weeks, the patient was retested in preparation for discharge. The patient no longer complained of symptoms with head movement. Her gait
no longer revealed any abnormalities. She was able to
tandem-walk 15 steps with her eyes open and 3 steps
with her eyes closed. In addition, she had no difficulty walking and moving the head left and right.
At discharge, her activity level had improved.
She was walking for 45 minutes 4 times a week. She
was able to drive and perform housework without difficulty. At discharge, the patient was instructed in a
maintenance home program that consisted of head
movements, eye/head movements, and a walking
program.
tion management of patients with unilateral peripheral

vestibular hypofunction.
Acknowledgment
The work described here was supported by NIH grant DC
03196. The authors also wish to acknowledge the contribution of Diane Borello-France, Ph.D., PT.
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21
Assessment and
Interventions for the
Patient with Complete
Vestibular Loss
Patients with unilateral and bilateral vestibular hypofunction (BVH) typically have subjective complaints of
imbalance, and they frequently complain of oscillopsia
a visual blurring or jumping of the environment during
head movement. These are all serious problems, resulting
in decreased activity level, avoidance or modification of
driving with resultant diminished independence, limited
social interactions, and poor quality of life. Bilateral loss
of vestibular function potentially has a more profound
effect on a persons ability to participate in the normal
activities of daily living than would a unilateral loss of
vestibular function, and patients with bilateral vestibular
loss (BVL) often restrict their activities and can become
isolated.
The main points this chapter addresses are as follows:
1. The assessment and physical therapy treatment
appropriate for people with bilateral vestibular
hypofunction (BVH) or loss (BVL).
2. The evidence that vestibular rehabilitation can
improve postural stability and decrease the
sense of disequilibrium in many patients,
enabling them to resume a more normal life.14
3. Preliminary evidence that visual acuity during
head movement also improves.
4. Expectations for the outcome of the rehabilitation process, including the observation that not
all patients experience improvement.
338
5. The necessity for patients with BVH to continue

with exercises or with activities that challenge
balance in order to sustain their improvement.
In addition, several case studies are used to illustrate
different points.
Primary Complaints
Balance
Patients with BVL are primarily concerned with their
balance and gait problems. During the acute stage of their
disease, they may feel off balance even when lying or sitting down. More typically, however, their balance problems are obvious only when they are standing or walking.
Patients in whom BVL develops after the use of an ototoxic medicationthe most common cause of BVL
often do not know they have a balance problem until they
get out of bed. Typically, these patients have been treated
with the ototoxic medication because of a serious infection. They are often debilitated, and their balance problems are initially attributed to weakness.
Even with full compensation, balance problems
persist. Although the other sensory and motor systems do
help compensate for the vestibular loss, these systems
cannot substitute completely for the loss of vestibular
function (see Chapter 20, Figs. 20.2 and 20.3). Normal
postural stability while walking requires the combined
use of at least two of three sensory cues: visual, vestibu-
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ASSESSMENT AND INTERVENTIONS FOR THE PATIENT WITH COMPLETE VESTIBULAR LOSS
lar, and somatosensory. Patients who have no vestibular

function, therefore, have difficulty when either visual
or somatosensory cues are also significantly decreased
(e.g., walking in the dark). Although balance may be
poor, it is not known what the actual frequency of falling
is for patients with BVL. Most patients are able to prevent falls even though they may sidestep or stagger occasionally.
Oscillopsia
Another problem for patients with BVL is the visual blurring that occurs during head movements. Initially, loss of
vestibular function results in a decrement in visual acuity
even when the patient is stationary, if the head is not supported.5 Even after the best compensation, patients say
that objects that are far away appear to be jumping or
bouncing. This visual blurring or oscillopsia increases
with irregular or unpredictable head movements such as
would occur while walking. As a result, patients may not
be able to read street signs or identify peoples faces as
they walk, or they may have difficulty seeing clearly
while in a moving car. Severe oscillopsia also affects postural stability because decreased visual acuity affects the
persons ability to use visual cues for stability.6
Sense of Disequilibrium or Dizziness

Patients often complain of dizziness, heaviness, or a
sense of being off-balance that is separate from their
actual postural instability. This feeling lessens or disappears when the person is lying down or sitting with the
head supported. It increases dramatically when the person
is moving. This dizziness or disequilibrium may diminish
as a result of compensation, but for many patients, it
remains a serious and debilitating problem that can lead
to decreased physical activity, social isolation, and
depression.
Poor physical condition can be a significant problem for
patients with BVL. It can be caused directly by a
decreased activity level because of either the patients
fear of falling or by the increased dizziness that occurs
with movement. It is especially a problem for patients
whose vestibular loss is secondary to ototoxic medications, who are already debilitated because of severe
infection. Many patients undergoing peritoneal dialysis,
for example, develop infections that are treated with gentamicin, a vestibulotoxic aminoglycoside.
339
Assessment
The assessment of patients with BVL is similar to that
for patients with unilateral vestibular deficits; therefore,
only certain aspects of the assessment are described here.
Physical therapy assessment of patients with BVL must
address the intensity of their subjective complaints, postural instability, and oscillopsia, overall physical condition, and their ability to perform activities of daily
living (ADLs). This assessment must also identify other
factors that might affect recovery, especially visual and
somatosensory deficits. A summary of the assessment
and the usual findings for patients with BVL is presented
in Box 21-1.
History
Etiology
Bilateral loss of vestibular function can occur for several
reasons (see Chapter 6). Most common is the effect of
an ototoxic medication such as gentamicin. Bilateral
vestibular loss was once considered to be an idiosyncratic response to gentamicin; initial studies indicated
that less than 3% of people who received gentamicin
have a vestibular deficit.7 Subsequent studies, however,
showed that the incidence of aminoglycoside ototoxicity
ranges from 9% to 15%.810 These are most likely conservative estimates based on relatively small studies
(fewer than 150 participants in each study) and the fact
that vestibular loss was assessed with electronystagmography. The prevalence is between 10% and 20%. In
patients who have renal impairment, are older than 65
years, are taking loop diuretics, or have previous vestibular loss, it rises to 20% if they undergo renal dialysis and
receive gentamicin.
The significance of knowing the underlying etiology of the BVL lies in the accompanying problems
that the patient may have. The patient who has a spontaneous or sequential BVL is less likely to have other
health problems that will affect recovery than the patient
who had a severe infection and was treated with an
ototoxic medication. Furthermore, the patient who has
a loss of vestibular function, with its resultant balance
and visual problems, secondary to ototoxic medication may also have to deal with significant anger and
depression.
Fall History
Patients with BVH are more likely to fall than normal
subjects in their age range and than patients with unilateral vestibular hypofunction.11 It is imperative that infor-
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Box 21-1
TEST RESULTS IN PATIENTS WITH BILATERAL VESTIBULAR LOSS (BVL)

Disability score: Continues to be abnormal with
symptoms typically interfering with both work and
leisure activities.
Activities of daily living (ADLs): Most people
with BVL will be independent in their basic ADLs,
such as dressing, bathing, getting on and off a toilet, preparing a simple meal, and light housekeeping. Bathing often is modified, however, because
of the difficulty getting into and out of a bathtub
and/or maintaining balance in a shower when the
person closes the eyes.
Balance confidence: Patient may or may not
achieve a criteria improvement to an average confidence in balance 80% across activities.
Abnormal findings in room light, including poor
vestibulo-ocular reflex (VOR) to slow and rapid
head thrusts; visual acuity with head stationary is
usually normal, but during gentle oscillation of the
head, acuity could change to 20/100 or worse.
With Frenzel lenses: No spontaneous, gaze-evoked,
head shakinginduced, tragal pressureinduced,
hyperventilation-induced, or positional nystagmus.
Dynamic visual acuity, as measured with the computerized system, remains abnormal during active
head movements in at least 25% of patients (see
Chapter 8).
Sensation
Somatosensory and visual information is critical to
functional recovery and must be carefully evaluated.
Coordination
Should be normal.
Range of Motion
Should be normal, but patients may voluntarily
restrict head movement because it makes them less
stable and also results in poor vision.
Strength (Gross)
Should be normal unless patient has become inactive.
Postural Deviations
Should be normal.
Positional and Movements Testing
Should not result in vertigo.
Sitting Balance
Patients may have difficulty maintaining their balance
during weight-shifting while sitting during the acute
stage but should not during the compensated stage.
Static Balance
Romberg test: Abnormal result during acute stage
in many patients.
Sharpened Romberg test: Patients with complete or
severe bilateral loss will not be able to perform this
with eyes closed.
Single-leg stance: Difficult to perform even during
compensated stage, with eyes open.
Standing on rail: Usually not tested.
Standing on foam surface: Difficult to perform
with decreasing base of support. Should not be
attempted in many patients.
Force platform: During compensated stage, anterior-posterior sway should be normal or close to normal with eyes open and closed on stable surface.
Increased sway when visual or somatosensory cues
are altered; loss of balance when both visual and
somatosensory cues are altered.
Dynamic Balance (Self-Initiated Movements)
Fukudas stepping test: Normal result with eyes
open during compensated stage; patient cannot perform with eyes closed (rapid loss of balance).
Functional Reach
May be decreased with eyes closed.
Ambulation
The patients gait is usually at least slightly widebased during compensated stage. There is a tendency to use visual fixation while walking and to turn
en bloc. Tandem walking cannot be performed
with eyes closed.
Gait speed: Preferred gait speed remains slower than
normal for age in at least 30% of patients with BVL
Walk while turning head: Gait slows and becomes
ataxic.
Singleton test: Loss of balance is expected. Uneven
surfaces or poor light will result in increased ataxia
and, possibly, loss of balance.
Fall risk: There can be clinically important
improvement in scores, but the majority of patients
(73%) remain at risk for falling on the basis of
Dynamic Gait Index scores.3
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mation about frequency of falls, when the most recent fall

occurred, conditions under which the fall occurred, and
whether or not an injury was sustained be obtained from
the patient. It is also important to identify whether or not
the patient has had any near falls, times when falling
to the ground was prevented because they grabbed onto
an object or a person or because someone caught them.
341
function. Typically, loss of vestibular function continues

even after the medication is stopped. Some improvement
in vestibular function may occur if some hair cells were
affected by the ototoxic drug but not killed. Potentially, an
increase in gain may also occur with the use of vestibular
adaptation exercises. This has been demonstrated in
patients with unilateral vestibular loss but not in patients
with BVL.16
Comorbidities
While taking the patients history, the clinician should
identify the presence of progressive disorders, especially
those affecting vision such as macular degeneration and
cataracts, and those affecting sensation in the feet, such
as diabetes. These disorders lead to a gradual decrease in
available sensory cues and will have an adverse effect on
balance in the future.
The patients complaints of disequilibrium and oscillopsia can be assessed using a visual analog scale (VAS).
The Dizziness Handicap Inventory12 and the Activities of
Daily Living Assessment for Vestibular Patients13 are
useful tools for assessing the patients perception of disability or handicap as well as the patients functional abilities and problems.
Vestibular Function
One important consideration in designing a treatment
program is the presence or absence of remaining vestibular function. Vestibular function can be documented with
tests such as the rotational chair and caloric tests. This
information is then used to determine which exercises to
give the patient. If no vestibular function remains, the
exercises must be directed at the substitution of visual
and somatosensory cues to improve gaze and postural
stability.
The presence of remaining vestibular function can
be used as a guide to predict the final level of recovery for
patients.2,3 Patients with incomplete BVL are often able
to return to activities such as driving at night and to some
sports. Patients with severe bilateral loss may not be able
to drive at night, and some patients cannot drive at all
because of the gaze instability. Activities such as sports
and dancing may be limited by the visual and the balance
problems.
Vestibular function tests can also be used to follow
the course of the vestibular loss and of any recovery of
vestibular function that might occur.14, 15 Certain aminoglycoside antibiotics are selectively taken up by vestibular hair cells, leading to a gradual loss of vestibular
Visual System
Assessment of visual function should include at least a
gross test of visual field and a measure of visual acuity,
because both can affect postural stability.6 Measuring
visual acuity during head movement is particularly important. The vestibulo-ocular system normally stabilizes the
eyes during head movements; when there is no vestibuloocular reflex (VOR) to stabilize the eyes during head
movement, small amounts of retinal slip (movement of
image across the retina) will degrade vision. For instance,
a retinal slip of 3 degrees per second (deg/sec) would
cause visual acuity to change from 20/20 to 20/200.17 As
such, in patients with no vestibular function, the head
movement that occurs in a moving car can cause a degradation of visual acuity that would make driving unsafe.
Dynamic Visual Acuity

Assessment of visual acuity during head movement
(dynamic visual acuity [DVA]) can be performed either
clinically or with a computerized system. The advantage
of the computerized system is that the test and result are
standardized and more reliable.18 Clear differences in
DVA scores occur among normal subjects, those with
dizziness from non-vestibular causes, and patients with
known vestibular loss (Table 21-1). The results of the
computerized DVA test are both sensitive (90% for those
older than 65 years and 97% for those younger than 65
years) and specific (94%) for vestibular loss. The clinical
DVA, however, is easy to perform and is sufficiently reliable to be useful as a guide to treatment and its efficacy
(Fig. 21.1).19
Somatosensory System
Particular attention should be paid to assessment of
vibration, proprioception, and kinesthesia in the feet.
Although mild deficits in sensation in the feet may
have no effect on postural stability in otherwise normal
individuals, but in patients with vestibular loss, somatosensory deficits may have profound effects on balance
and on the potential for functional recovery. As with visual system disorders, being aware of potentially progres-
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Table 21-1 DISTRIBUTION OF NORMAL AND ABNORMAL

DVA SCORES BASED ON A COMPUTERIZED SYSTEM
Type of Subject
DVA
(LogMAR)
Normal DVA
Score (%)
Abnormal DVA
Score (%)
Normal (n 51)
0.040 0.045
96.1
3.9
Dizzy, non-vestibular (n 16)
0.097 0.099
87.5
12.5
Unilateral vestibular loss (n 53)
0.282 0.140
11.3
88.7
Bilateral vestibular loss (n 34)
0.405 0.134
100
DVA Dynamic Visual Acuity; LogMAR logarithm of the mminimum angle of resolution.
sive disorders affecting somatosensory information is

important.
Balance and Gait

Patients with BVL must be given a detailed assessment of
balance and gait. Obviously, static balance should be
assessed first. In the acute stage, patients with bilateral
vestibular deficits may have positive Romberg test

results. In the compensated stage, the Romberg result is
usually normal. Although some patients are able to perform the Sharpened Romberg test with eyes open, they
cannot do so with eyes closed. Patients with bilateral
vestibular deficits also have difficulty performing tests in
which both visual and somatosensory cues are altered.
An example would be Fukudas stepping test, in which
cDVA Scores of Patients with Dizziness or Imbalance

1.20
cDVAL (LogMAR)
1.00
0.80
0.60
0.40
0.20
0.00
BVL
UVL
No Vestibular Loss
Figure 21.1 Distribution of dynamic visual acuity scores (shown as the logarithm of the minimum
angle of resolution [LogMAR]) obtained with the clinical test in patients with unilateral vestibular loss
(UVL) and bilateral vestibular loss (BVL) and in normal subjects. (From Venuto, et al, 1998.19)
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the eyes are closed and the patient is marching in place.

Patients may have normal responses with eyes open during this test but will fall with eyes closed.
Determining how well patients use different sensory
cues to maintain balance and whether they depend on
particular sensory cues is critical. It is important to recognize that these features may vary considerably from
patient to patient and can change over the course of
recovery. Bles and colleagues20 have shown that patients
with BVL are initially more dependent on visual cues
than on somatosensory cues for balance. With time, their
ability to use somatosensory cues improves. This
improvement varies from patient to patient, however, and
must be carefully assessed (Fig. 21.2).
The gait of patients with bilateral vestibular deficits
is often wide-based, slow, and ataxic. Patients decrease
their trunk and neck rotation in an effort to improve stability by avoiding head movements. Arm swing is simi-
343
larly decreased. Many patients use excessive visual fixation and therefore have increased difficulty if asked to
look up while walking. Patients typically turn en bloc
and may even stop before they turn. Asking patients to
turn their heads while walking results in increased ataxia
and, often, loss of balance.
The mechanisms used to stabilize gaze in the absence of
vestibular inputs have been well studied (Box 21-2). The
mechanisms involved in maintaining postural stability
are still somewhat less well understood, although
research is being done in this area.
Gaze Stability
Subjects without vestibular function must develop different mechanisms to keep the image of the target on the
Figure 21.2 Posturography test results from patients with bilateral vestibular loss demonstrating
the differences in ability to maintain postural stability when different sensory cues are altered or
removed. Patients are tested using the following six different conditions:
Available cues:
Unavailable or altered cues:
Test condition 1
Vision, vestibular, somatosensory
Test condition 2
Vestibular, somatosensory
Vision absent
Test condition 3
Vestibular, somatosensory
Vision altered
Test condition 4
Vision, vestibular
Somatosensory altered
Test condition 5
Vestibular
Vision absent, somatosensory altered
Test condition 6
Vestibular
Vision altered, somatosensory altered
Results show patients who have difficulty when both visual and somatosensory cues are altered (A),
when somatosensory cues only are altered (B), when visual cues only are altered (C), and when
either visual or somatosensory cues are altered (D).
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Box 21-2
MECHANISMS USED TO
STABILIZE GAZE
Change in amplitude of saccades

Use of corrective saccades
Modification of pursuit eye movements
Central preprogramming of eye movements
fovea during head movements (see Box 21-2). Central

preprogramming of movements is probably the primary
mechanism by which gaze stability is improved in
patients with BVL. The contribution of central preprogramming has been assessed by comparing the gain of
compensatory eye movements21,22 or by comparing visual acuity during predictable and unpredictable head
movements.23 The difficulty with central preprogramming as a substitute for the loss of vestibular function is
that it would not be effective in situations in which head
movements are unpredictable, such as walking.
Other mechanisms used to improve gaze stability
are modifications in saccadic and pursuit eye movements.21,24 Patients with complete BVL may make hypometric saccades toward a visual target. Then, as the head
moves toward the target, the eyes would be moved passively into alignment with the target. They may also
make accurate saccadic eye movements during combined
eye and head movements toward a target, and then make
corrective saccades back to the target as the head movement pulls the eyes off the target. These strategies enable
the patient to recapture a visual target after a head movement.21 Pursuit eye movements can be used during lowfrequency (and low-velocity) head movements to
stabilize the eyes. The limits of smooth-pursuit eye
movements depend on the nature of the stimulus (predictable vs. unpredictable; sinusoidal vs. constant-velocity). In general, for sinusoidal stimuli, smooth pursuit
works well at frequencies of up to 1 Hz. For constantvelocity stimuli, smooth pursuit can work well up to
target velocities of 100 deg/sec. Later evidence demonstrates that patients with bilateral vestibular deficits have
higher smoothpursuit gains than normal controls,
although the patients performance is still within the normal range.24
At one time, potentiation of the cervico-ocular reflex
(COR) was thought to contribute to the recovery of gaze
stability in patients with BVL.21,25,26 In the COR, sensory
inputs from neck muscles and facet joints act to produce
a slow-phase eye movement that is opposite to the direction of the head movement during low-frequency, brief
head movements. The COR, therefore, complements the
VOR, although in normal subjects it is often absent and,
when present, contributes at most 15% of the compensatory eye movement. In patients with complete BVL, the
COR operates at head movement frequencies up to 0.3
Hz, well below the frequency range of head movements
during normal activities. Therefore, although the COR is
increased in patients with BVL, it does not actually operate at frequencies that would contribute significantly to
gaze stability during the head movements that would
occur during most activities.
Kasai and Zee21 found that different patients with
complete BVL use different sets of strategies to compensate for the loss of VOR. Therefore, exercises to improve
gaze stability should not be designed to emphasize any
particular strategy but, instead, should provide situations
in which patients can develop their own strategies to
maintain gaze stability (see Box 21-2). No mechanism to
improve gaze stability fully compensates for the loss of
the VOR, however, and patients continue to have difficulty seeing during rapid head movements.
Postural Stability
A study on the course of recovery of patients with complete bilateral vestibular deficits over a 2-year period has
shown that patients switch the sensory cues upon which
they rely.20 Initially they rely on visual cues as a substitute for the loss of vestibular cues, but over time, they
become more reliant on somatosensory cues to maintain
balance. In this study, patients were required to maintain
balance when facing a moving visual surround. Over the
2-year study, the subjects recovered the ability to maintain balance to within normal limits in the testing paradigm except at high frequencies. The vestibular system
functions at higher frequencies than the visual or
somatosensory systems, a difference that would explain
why neither visual nor somatosensory cues can substitute
completely for loss of vestibular cues.
The contribution of somatosensory inputs from the
cervical region to postural stability in patients with complete BVL is not clearly understood. Bles and colleagues27 found that changes in neck position did not
affect postural stability in patients with complete BVL.
They concluded that somatosensory signals from the neck
do not contribute to postural stability. We do not know,
however, whether kinesthetic signals from the neck,
which would occur during head movement, affect postural stability. Certainly patients with bilateral vestibular
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dysfunction become less stable when asked to turn their

heads while walking. This observation may indicate that
kinesthetic cues do not contribute significantly to dynamic postural stability. Another interpretation is that such
patients rely more on visual cues to maintain postural stability, and thus, when the head moves and visual cues are
degraded, their balance becomes worse. The contribution
of somatosensory cues from the lower extremities to postural stability in patients with BVL is also not well understood. Certainly some patients depend on somatosensory
cues rather than on visual cues. Perhaps more importantly, we do not yet know how the degree of somatosensory
loss affects postural stability in these patients.
The loss of either visual or somatosensory cues
in addition to vestibular cues has a devastating effect
on postural control. Paulus and associates28 reported a
case in which the patient had a complete BVL plus a
loss of lower extremity proprioception. This patient
relied on visual cues to maintain his balance. When
the effectiveness of the visual cues was degraded (i.e., by
fixation on a visual target more than 1 m away), his
postural stability deteriorated significantly. Again, visual
and somatosensory cues do not substitute fully for the
lost vestibular contribution to postural stability (see
Chapter 20).2931
Patients can be taught, and often develop on their own,
strategies to use when in situations in which their balance
will be stressed. For example, they learn to turn on lights
at night if they have to get out of bed. They may also
wait, sitting at the edge of the bed, before getting up in
the dark to allow themselves to awaken more fully and
for their eyes to adjust to the darkened room. They should
be advised to use lights that come on automatically and
to have emergency lighting inside and outside the house
in case of a power failure. Patients may need to learn how
to plan to move around places with busy visual environments, such as shopping malls and grocery stores. For
some patients, moving in busy environments may require
the use of some type of assistive device, such as a shopping cart or a cane, but for many patients with BVL, no
assistive devices are needed after the patients become
comfortable walking in the environment.
Evidence that Exercise

Facilitates Recovery
There is some evidence that experience facilitates recovery after bilateral ablation of the labyrinth. Igarashi and
345
coworkers32 trained monkeys to run along a straight platform. Performance was scored by counting the number of
times the monkeys moved off the straight line. A twostage ablation of the labyrinth was then performed. After
the unilateral ablation, animals given specific exercises
recovered faster than nonexercised animals, but all animals eventually achieved preoperative functional levels.
After ablation of the second labyrinth, all monkeys had
difficulty with the platform run task. The control group
reached preoperative balance performance levels in
81 days, whereas the exercise group did so in 62 days.
This result was not significantly different owing to the
large variation in individual animals. These researchers
also measured how long the animals took to reach 8 consecutive trial days in which they could keep their balance
at preoperative levels. The exercise group achieved this
criterion in 118 days. The control group took longer. One
animal took 126 days, another took 168 days, and one
animal had not achieved that criterion at 300 days. The
conclusions from this study are that (1) recovery from
bilateral deficits occurs more slowly than recovery from
unilateral lesions, (2) exercise affects that rate of recovery in bilateral and unilateral lesions, and (3) the final
level of function may be improved if exercises are given
after bilateral lesions.
Several studies have studied the effectiveness of
vestibular exercises on postural stability during functional activities for patients with chronic bilateral vestibular
deficits. Krebs and colleagues,1 in a double-blinded,
placebo-controlled trial, found that the patients performing customized vestibular and balance exercises had better stability while walking and during stair climbing than
patients performing isometric and conditioning exercises,
such as using an exercise bicycle. Furthermore, the
patients who had vestibular rehabilitation were able to
walk faster. They used vestibular adaptation and eye-head
exercises as well as balance and gait training. In a continuation of this study, Krebs and colleagues4 again
demonstrated that as a group, those individuals performing the vestibular rehabilitation exercises had increased
gait velocity, improved stability while walking, and
decreased vertical excursion of the center of mass while
walking. They noted a moderate correlation between
improved gait measures at 1 year and the frequency of
performing the home exercise program over the preceding year. When results for the patients with BVL (n 51)
were combined with those for patients with UVL (n
33), 61% of the patients demonstrated significant
improvements in gait.
In a retrospective chart review of 13 patients with
BVL, Brown and associates3 noted that as a group, the
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patients had significant improvements in various measures (Dizziness Handicap Inventory, Activities-specific
Balance Confidence Scale, Dynamic Gait Index, Timed
Up and Go test, and Sensory Organization Test component of dynamic posturography). Again, not all
patients benefited to the same extent. These investigators
noted that 33% to 55% of the patients demonstrated what
were considered clinically significant changes on the different measures. In another retrospective study, Gillespie
and Minor2 found that 63% of the patients with BVL who
received vestibular rehabilitation demonstrated improvements (defined as reported increased activity levels,
reduced symptoms, and demonstrated normal gait velocity, normal Romberg test result, or normal DVA score).
Expectations of Level of Recovery

Several studies of patients with vestibular hypofunction
clearly state that some patients do not improve.3,4,3336 In
patients with UVH, depending on what outcome measure
is used, between 10% and 30% of subjects do not
improve.34,35 In patients with BVH, outcome is worse,
with between 25% and 66% failing to show improvement3 (Herdman preliminary data). These findings are
extremely important, because as clinicians, we deal with
individuals, not groups.
Treatment Approach
Not all exercise approaches are appropriate for patients
with BVL, however. Telian and coworkers37 studied the
effectiveness of a combination of balance exercises,
vestibular habituation exercises, and general conditioning
exercises for patients with bilateral vestibular deficits.
They were unable to demonstrate a significant change in
functional activity in these subjects after treatment. Thus,
vestibular habituation exercises do not appear to be
appropriate for these patients. This makes sense, because
habituation exercises are designed to decrease unwanted
responses to vestibular signals rather than to improve
gaze or postural stability.
Treatment
The treatment approach for patients with complete loss
of vestibular function involves the use of exercises that
foster (1) the substitution of visual and somatosensory
information to improve gaze and postural stability and
(2) the development of compensatory strategies that can
be used in situations in which balance is maximally
stressed (Boxes 21-3 and 21-4). Patients with some
remaining vestibular function may benefit from vestibular adaptation exercises to enhance remaining vestibular
function (Fig. 21.3, page 347). For both groups, postural
stability can be improved by fostering the use of visual
and somatosensory cues. This approach is also used in
the treatment of patients unilateral with vestibular hypofunction (see Box 21-4).
Once the patients specific problems have been
identified, the exercise program can be established.
During the initial sessions, particular attention should be
paid to the extent to which the exercises increase the
patients complaints of dizziness. The patients perception of dizziness can be the major deterrent (limiting factor) to his or her eventual return to normal activities.
Head movement, a component of all exercises, increases
that dizziness. Also, the home exercise program typically
requires that the patient perform exercises many times
daily. Patients may find that they become increasingly
dizzy with each performance of the exercises; the Head
Movement VAS can be used to quantify this problem.
Additionally, inability of the patient to sustain head
movement for 1 minute helps define the initial exercise
program.
It is important to explain to the patient that some
increase in dizziness is expected at the beginning of the
exercise program and with any increase in the intensity
of the exercises. Only one exercise involving head movement should be prescribed initially. Other exercises can
be added and the frequency and duration of the exercises
can be increased as the patient improves. The patient
should perform at least one set of all the exercises at the
time of the clinic visit. Patients should also be taught how
to modify the exercises if the dizziness becomes overwhelming (Box 21-5, page 347). They should be strongly encouraged to contact the therapist if they are having
difficulty. In patients for whom dizziness continues to be
a problem, we suggest meditation and relaxation techniques to try to reduce the effect of the dizziness on the
patients life.
Progression of Exercises
The reported number and frequency of patient visits to
the clinic varies tremendously from study to study.
Improvement in patients undergoing vestibular rehabilitation has been reported when patients were seen once a
day for 3 days38, two or three times a week for months,
once a week for 4 or 5 weeks,34,35,38, once a month,3,39-41
or even once in several months.42,43 It is difficult to determine appropriate practice patterns by comparing these
studies, however, because different exercise approaches,
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Box 21-3
PATIENT INSTRUCTIONS FOR EXERCISES TO IMPROVE GAZE STABILITY

1. To improve remaining vestibular function and
central preprogramming:
Tape a business card on the wall in front of you
so that you can read it.
Move your head back and forth sideways, keep
the words in focus.
Move your head faster but keep the words in
focus. Continue to do this for 1 to 2 minutes
without stopping.
Repeat the exercise moving your head up and
down.
Repeat the exercises using a large pattern such
as a checkerboard (full-field stimulus).
Note: When training the patient to perform this
exercise, the physical therapist should watch the
patients eyes closely. If the patient is making corrective saccades, he or she should slow the head
movement down.
2. Active eye-head movements between two horizontal targets to foster the use of saccadic or pursuit strategies and central preprogramming:
Look directly at one target, being sure that your
head is also lined up with the target.
Look at the other target with your eyes and then
turn your head to the target (saccade should
precede head movement). Be sure to keep the

target in focus during the head movement.
Repeat in the opposite direction.
Vary the speed of the head movement, but
always keep the targets in focus.
Note: Place the two targets close enough together
that when you are looking directly at one, you can
see the other with your peripheral vision. Practice
for 23 minutes, resting if necessary.
This exercise can also be performed with
two vertically placed targets.
3. Visualization of remembered targets to foster central preprogramming:
Look at a target directly in front of you.
Close your eyes and turn your head slightly,
imagining that you are still looking directly at
the target.
Open your eyes and check to see whether
you have been able to keep your eyes on the
target.
Repeat in the opposite direction. Be as accurate
as possible.
Vary the speed on the head movement.
Practice for up to 25 minutes, resting if necessary during the exercise.
different outcome measures, and different patient populations were used. However, two randomized clinical trials
demonstrated significant benefits in function in patients
with BVH who were supervised in the clinic only one
visit per week and performed an extensive home exercise
program for 8 weeks.1,4
Changing the duration of any given exercise, the
frequency of performance, and how many different exercises are given (Table 21-2 page 348) can modify the
intensity of the exercise program to improve gaze
stability. Patients find the exercises more challenging if
they have to perform them while standing as opposed
to sitting. Exactly which exercises are given initially
and the progression itself depend on the individual
patient. Concurrent with the exercises to improve gaze
stability, of course, the patient should be instructed in
exercises to improve postural stability. As with other
types of exercises, the initial program and the rate of
progression should be customized for each patient.
Guidelines to Treatment and Prognosis

The physical therapist should keep the following factors
in mind when working with the patient with a bilateral
vestibular deficit:
1. The patients perception of dizziness can be the
major deterrent to his or her return to normal
activities.
2. Recovery after bilateral deficits is slower than
after unilateral lesions and can continue for as
long as 2 years. This is not to suggest that the
patient should be actively engaged in rehabilitation for the entire 2 years but, rather, that
imparting this knowledge should help the
patient with BVH understand that improvement
will most likely be a slow process.
3. Recovery is easily upset by other medical
problems, such as having a cold or receiving
chemotherapy.
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Box 21-4
PATIENT INSTRUCTIONS FOR EXERCISES

TO IMPROVE POSTURAL STABILITY*
The purpose of these exercises is to force you to
develop strategies for performing daily activities
even when deprived of vision, proprioception, or normal vestibular inputs. The activities are supposed to
help you develop confidence and establish your functional limits. For all of these exercises, you should
take extra precautions so you do not fall.
1. Stand with your feet as close together as
possible with both hands helping you
maintain your balance by touching a
wall. Take your hand or hands off the
wall for longer and longer periods of
time while maintaining your balance.
Try moving your feet even closer together.
Repeat this for
minutes twice
each day.
Repeat exercise #1 with eyes
closed, at first intermittently and then continuously, all the while making a special
effort to mentally visualize your surroundings.
3.
4.
5.
2. Stand with your feet shoulder-width apart

with eyes open, looking straight ahead at a
target on the wall. Progressively narrow
your base of support from:
feet apart to
feet together to
a semiheel-to-toe position to
heel almost directly in front of the toes.
Note: Change your foot position 1 inch at
a time.
Do the exercise first:
with arms outstretched and then
with arms close to your body and
then
with arms folded across your chest.
6.
7.
Hold each position for 15 seconds and then

move on to the next most difficult exercise.
Repeat exercise #2 with eyes closed,
at first intermittently and then continuously,
all the while making a special effort to
mentally visualize your surroundings.
Repeat #
above but while standing
on a foam pillow.
(Note: Unusual for patients with bilateral
vestibular loss to do this exercise.)
Walk close to a wall with your hand braced
available for balancing.
Walk with a narrower base of support.
Finally, walk heel-to-toe.
Do this with eyes
(open/closed).
Practice for
minutes.
Walk close to a wall and turn your head to
the right and to the left as you walk.
Try to focus on different objects as you
walk.
Gradually turn your head more often and
faster.
Practice for
minutes.
Walk and turn your head to the right and to
the left as you walk while you count backwards out loud from 100 by 3s.
Try to focus on different objects as you
walk.
Gradually turn your head faster.
Practice for
minutes.
Practice turning around while you walk. At
first, turn in a large circle, but gradually
make smaller and smaller turns.
Be sure to turn in both directions.
*Therapist uses the blanks to mark which exercises the patient should perform as well as to specify durations and variations.
4. To maintain recovered function, patients may

always need to be doing some exercises, at
least intermittently.4
5. The patients postural stability will never be
completely normal. The patient may demonstrate a negative Romberg test result and may
be able to maintain the Sharpened Romberg

position with eyes open, but will not be able to
do so with eyes closed.
6. Initially, the patient may need to use a cane or a
walker while ambulating. Some patients, especially older patients, need to use a cane at least
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349
Figure 21.3 Exercises that enhance

the adaptation of the vestibular system
should be used for any patient who has
remaining vestibular function. These exercises should be performed many times a
day and can be done while the patient is
sitting and, eventually, standing. (Modified
from Tusa and Herdman, 1993.46)
Box 21-5
ADJUSTMENTS MADE
TO EXERCISES BECAUSE
OF SEVERE DIZZINESS
Perform the exercises fewer times each
day.
Move the head more slowly.
Perform each exercise for a shorter period.
Rest longer after each exercise.
some of the time. Most patients, however, are

eventually able to walk without any assistive
devices. Ambulation during the acute stage is
wide-based and ataxic with shortened stride
length and sidestepping to the right and left.
The patient will turn en bloc and turning the
head will increase instability. Ambulation will
improve, but it, too, will not be normal.
7. Patients will be at increased risk for falls.11
Patients will need to be careful when walking in
low-vision situations, over uneven surfaces, or
when they are fatigued.
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Table 21-2 SUGGESTED PROGRESSION FOR GAZE STABILITY EXERCISES

Exercise
Duration
Frequency
Position
X1 viewing paradigm against plain stationary

background; horizontal or horizontal-andvertical head movement
Maybe for 1
minute each time
2 or 3 times daily
Sitting until can perform the head

movements easily
and then standing
X1 viewing paradigm against plain stationary

background; horizontal or horizontal-andvertical head movement
Increase to 1 minute
each exercise
Increase to 5
times daily
Standing*
X1 viewing paradigm with target held in hand

against a plain background; horizontal and
then vertical head movements
1 minute each
exercise
Up to 5 times
daily
Standing*
Add eye-head exercises, horizontal and vertical
No specific duration
2 or 3 times daily
Sitting at first and

then standing
X1 viewing paradigm with target held in hand

and also with target at distance
1 minute each
exercise
2 or 3 times daily
Standing*
Eye-head exercises, horizontal and vertical
2 or 3 times daily
Standing* if possible
X1 viewing paradigm with target held

in hand and also with target at distance
1 minute each
exercise
4 times daily
Standing*
4 times daily
Standing*
Add remembered target exercise
4 times daily
Sitting at first and

then standing
X1 viewing paradigm with target held

in hand and also with target at distance
1 minute each
exercise
4 times daily
Standing*
4 times daily
Standing*
Remembered target exercise
4 times daily
Standing*
Some patients may be able to progress to X2

viewing paradigm with target held in hand
and also with target at distance
1 minute each
exercise
4 times daily
Standing*
4 times daily
Standing*
4 times daily
Standing*
X1 with target held in hand and also with

target at distance
1 minute each
exercise
4 times daily
Standing*
4 times daily
Standing*
4 times daily
Standing*
Add finding numbers written randomly on large

(6 ft 5 ft) checkerboard pattern placed on wall
2 times daily
Stand and step to

touch number
The exercise can be made more difficult by changing the base of support (e.g., from feet apart to feet together).
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Future Directions
Currently research is being conducted to determine
whether individuals with BVL may benefit from some
form of sensory stimulation to replace the absent vestibular signals. Although this work is in its infancy, the preliminary results are promising. Kentala and colleagues44
have used a rate gyroscope and linear accelerometer to
encode an individuals anterior-posterior sway. This
information is then fed back to the individual via a vibrotactile array. The amount of vibration and the location of
the vibration is related to the degree and direction of
sway. These investigators found that individuals with
UVL and BVL demonstrated a marked reduction of anterior-posterior sway on the Sensory Organization Test
component of the computerized dynamic posturography
test when they were using the vibrotactile array.
351
Rather than a vibrotactile cue, Hegeman and

colleagues45 used auditory feedback to indicate either
the amount of sway or the sway velocity of patients
with BVL. Anterior-posterior and side-to-side sway was
measured and encoded in four different stance conditions: eyes openfirm surface, eyes closedfirm surface,
eyes opencompliant surface, and eyes closedcompliant surface. These researchers reported improvements, to normal levels, in single-limb stance with
eyes open on a firm surface when patients used the
auditory feedback. They noted no improvements, however, when tests were conducted with eyes closed on a
compliant surface. Although these initial results are
encouraging, it remains to be seen how useful these
devices will be and how the devices will affect the
approach to rehabilitation.
CASE STUDY 1
A 64-year-old woman with a history of acute
unsteadiness is referred for treatment. Six weeks
prior to this clinic visit, she had a chronic bladder
infection that had not responded to other antibiotics
and was started on IV gentamicin at home q8hr for
10 days. She had no history of renal failure, nor was
she taking other antibiotics or a loop diuretic at that
time. She began to complain of imbalance 2 days
after the last dose of gentamicin. She had no complaints of hearing loss, tinnitus, or vertigo. Her imbalance was severe, and she was using a walker. She was
unable to walk independently. Standing, walking or
moving her head exacerbated the balance problem.
Comment
This patients history suggests an ototoxic reaction to
gentamicin. Fewer than 15% of all individuals treated with gentamicin experience BVL, and she had no
known risk factors that would increase the likelihood
of an ototoxic reaction, such as renal failure and taking a loop diuretic.
Pertinent History
The patient had been treated for depression and anxiety. Current medications were Zoloft, Valium, and
Premarin.
Neurological findings were normal except for visual
acuity of 20/20 3 OU with head stationary, which
decreased to 20/80 4 during 2-Hz head oscillations (clinical DVA test). Patient made corrective
saccades with slow and rapid head thrusts, worse to
the right. She had a positive Romberg response. Gait
was extremely slow and cautious without the walker.
She stopped frequently and could not turn around
without stopping. Patient also had a significant scoliosis.
Comment. The large decrease in visual acuity during
head movement (4 lines) is consistent with a severe

vestibular deficit. The presence of corrective saccades
with slow head rotations as well as with rapid head
thrusts also suggests a profound deficit. Although
gentamicin was given systemically, her vestibular loss
appears to be asymmetrical. The loss does not apper
to have been compensated at this time, on the basis of
the positive Romberg result as well as the poor VOR
during slow head rotations. Her gait pattern may
reflect fear as well as the vestibular deficit. Her history of depression may be a factor in the final level of
recovery.
Caloric Test
No response to either cool or warm irrigation of
either ear. Iced-water irrigation of both the right and
left ears resulted in nystagmus with peak slow-phase
eye velocities of 8 deg/sec. The direction of the nystagmus reversed when the patient was moved from
supine to prone position.
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Comment. Iced water is a stronger stimulus than either
cool or warm water. The nystagmus generated by iced
water irrigation may represent either a response of the
peripheral vestibular system or an alerting response to
the extreme cold. If the nystagmus were due to excitation of the hair cells in the inner ear, the direction of
the nystagmus would reverse when the patient was
moved from supine to prone because the direction of
endolymph flow would reverse. If the nystagmus
were due to an alerting response, it would not reverse
when the patient was moved from supine to prone
position. The test results for this patient suggest some
residual function in each ear.
The patient was seen 1 week later to institute a
vestibular rehabilitation program. At that time she was
still using a walker. She reported that her imbalance
was induced by movement, occurred only while walking, and was worse in the dark. She denied having any
falls but reported that she did stagger and sidestep
while walking, and tended to drift to both the right
and the left if she tried to walk without her walker.
Social History
The patient lived with her husband. Her home had no
stairs. She did not smoke or use alcohol.
Current Functional Level
She was independent in self-care activities but was no
longer driving. She had been inactive since the onset
of this problem.
She stated that her symptoms disrupted her performance of both her usual work and outside activities
(rated a 3 on the Disability Scale). She scored a 56 on
Jacobsons Dizziness Handicap Inventory, indicating
that she would not go for a walk by herself, could not
walk in the dark, and was limited in her ability to
travel or participate in social activities. She also
reported feeling frustrated, embarrassed in front of
others, and handicapped. She rated her disequilibrium while walking as a 9.3 on an analog scale of 0 to
10 (10 worst). She rated her oscillopsia as a 5.7 on a
similar scale.
Quantitative Dynamic Visual Acuity

The patients visual acuity during 120-deg/sec horizontal head movements was LogMAR .450
(approximately 20/50-3; normal LogMAR 0.000).
Gait
When asked to walk without the walker, her cadence
was slow and she had a widened base of support.
Her step length was decreased but symmetrical.
Arm swing and head and trunk rotation were markedly decreased, especially when she turned. She could
not walk a straight path but had no sidestepping
or foot crossover. Her gait pattern was affected by
her scoliosis (arm swing asymmetry). She was able
to walk more rapidly without a significant change
in base of support or gait pattern. When asked to try
to turn her head horizontally while walking, her
cadence slowed significantly and she sidestepped
occasionally.
Comment
The patients Disability Scale and Dizziness
Handicap Inventory scores both indicate a moderate perception of disability/handicap. Shepard and
colleagues have demonstrated that patients who score
a 5 on the Disability Scale are less likely to experience improvement with vestibular rehabilitation than
those who score 3 or lower, as this patient did (see
Chapter 19). Although she has been using
a walker, she was able to ambulate safely without
it. Head movements (turning her head or turning herself around) increased her instability. Her dynamic
visual acuity was consistent with that of other
patients with BVL.
Goals
The short-term goals for this patient were (1) to perform the vestibular adaptation exercises without a
significant increase in symptoms, (2) to walk daily,
and (3) to no longer use her walker at home. The
long-term goals were (1) to return to all normal activities except possibly driving, (2) to improve visual
acuity during head movements by two lines on the
quantitative DVA test and to 20/50 on the clinical
DVA test, and (3) to decrease symptoms by 50% during head movements.
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Plan
The patient was started on a home exercise program,
which included the X1 viewing paradigm to be performed with both horizontal and vertical head movements for 1 minute each four times a day. The target
was to be placed against a plain wall. Initially, she
was to perform this exercise seated and then was to
perform the exercise standing with her feet apart. She
was also instructed to practice walking in a hallway
twice daily for 5 minutes each time, with rests, without touching the walls. Finally, she was told to walk
for 20 minutes daily outside with her husband. She
was given a calendar to fill in to ensure compliance.
The total daily duration of her exercises at this point
was 36 minutes. The program was limited until the
patients response could be determined. The patient
was seen at 1-week intervals.
On the first follow-up, the patient was doing well
with the exercises and was no longer using her walker at all. The exercise program was changed to
include the eye-head exercises both vertically and
horizontally, and the X1 paradigm using a near target
held in the hand was added. She was to practice walking and turning her head horizontally for 5 minutes
twice daily. She was also instructed in a static balance
exercise, in which she would stand while gradually
decreasing her base of support. This was to be performed with eyes open and then eyes closed. She was
to continue walking for 20 minutes daily. Total exercise time was increased to 45 minutes.
On next follow-up visit, the patient reported that
she initially had difficulty with the exercises involving head movements, all of which increased her
dizziness. However, she reported that after 2 days of
performing the exercises, she was able to perform
them without a significant increase in dizziness.
Review of the exercises showed that she was performing them all correctly and was maintaining fixation on the X1 viewing paradigms, although her head
movements were slow. The exercise program was
modified to include performing the X1 paradigm
using a target on a checkerboard, and the imaginary
target exercise was added. For these exercises, she
was instructed to attempt to move her head more rapidly while maintaining focus on the target. She was
also instructed to add walking and moving her head
vertically. The X1 viewing paradigm using a target
placed against the wall was discontinued. Eventually,

the patient was instructed in the X2 viewing paradigm.
One month after the initiation of her exercise program, the patient was walking with improved
cadence and a narrower base of support. She still had
difficulty walking a straight line, but she was able to
turn her head while walking and turn around without
stopping. She no longer used a walker at any time.
Her rating of subjective complaints of disequilibrium
was a 0.6 (down from 9.3) and of oscillopsia was a
1.5 (down from 5.7). Her quantitative DVA score was
LogMAR 0.143 (initial DVA was LogMAR 0.450), a
three-line improvement. The plan at that time was for
the patient to continue with the rehabilitation process
to further improve her gait and to enable her to return
to more of her normal activities.
On her next visit, 1 week later, the patient came in
complaining of increased difficulty with her balance
and greater dizziness. She reported that the exercises
were okay but she was dizzy while walking and even
when she rolled over in bed.
Comment
The patient was making good progress, and both her
balance and dynamic visual acuity had improved considerably when she suddenly had greater difficulty
walking and more complaints of dizziness. Her complaint that she has increased dizziness when she rolls
over in bed sounds like benign paroxysmal positional vertigo (BPPV).
Re-examination
Eye movements were recorded while the patient
was moved into the right and left Dix-Hallpike positions. She developed an upbeating nystagmus, concurrent with complaints of vertigo, when moved into
the left Dix-Hallpike position. The latency and duration of the nystagmus and vertigo were consistent
with posterior canal canalithiasis. These results indicated that although the patient had a bilateral vestibular deficit, there was remaining function in the left
posterior canal. The caloric test had previously shown
remaining function in the left horizontal canal. The
patient was treated for left posterior canal BPPV using
the canalith repositioning maneuver. After successful
remission of her positional vertigo, she resumed her
exercises for the bilateral vestibular deficit.
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CASE STUDY 2
A 34-year-old woman with a history of diabetes and
renal failure had been undergoing peritoneal dialysis for 11/2 years. She had been treated with gentamicin 9 months and 6 months previously for peritonitis.
She had no complaints of disequilibrium after either
of those drug courses. Two months after her previous treatment with gentamicin, she again developed
peritonitis and again received IV gentamicin. After a
few days, she complained of vertigo and tinnitus,
experienced disequilibrium, and could not walk unassisted. She also complained that she was not able to
see clearly when her head was moving. She was
admitted to the hospital for a work-up of the vertigo
and disequilibrium.
Significant findings on clinical examination included
a spontaneous nystagmus with fast component to the
left, poor VOR to slow head movements, and large
corrective saccades with rapid head movements bilaterally, worse with head movements to the right than
to the left. The test for head-shaking nystagmus was
not performed because the patient complained of
severe nausea after even gentle head movements and
vomited. She also had a positive Romberg test result.
The Sharpened Romberg and Fukudas stepping tests
were not performed. The patient could not ambulate
without the assistance of two people.
Comment
This patients signs and symptoms (vertigo, disequilibrium, oscillopsia, spontaneous nystagmus, and
poor VOR) certainly were suggestive of a vestibular
disorder. Furthermore, her history included multiple

treatments with gentamicin, an ototoxic medication.
In bilateral dysfunction due to treatment with an ototoxic drug, the symptoms of oscillopsia and disequilibrium develop over time and may not appear until
after the drug treatment is finished. Once the symptoms appear, they may continue to worsen for several weeks. Some patients have a partial reversal of
symptoms with time. Often the vestibular symptoms
are accompanied by hearing loss. Typically, however,
the vestibular loss is symmetrical and patients do not
have vertigo or spontaneous nystagmus, both of
which are associated with either unilateral vestibular
loss or asymmetrical bilateral vestibular deficits.
Although gentamicin usually results in BVL, symptoms of asymmetrical effects on the vestibular and
auditory systems have been reported.6
This patients poor VOR to slow head movements
and the presence of corrective saccades during rapid
head thrusts bilaterally suggested a bilateral vestibular deficit, which was confirmed by the rotational test
results. This patients gait disturbance appeared to be
unusually severe, and further testing showed a moderate loss of proprioceptive and kinesthetic perception
in the feet, which would contribute significantly to
the vestibular problem. This sensory loss was probably due to diabetes. This finding was particularly
important in developing her exercise program and in
predicting her final level of recovery.
Both computed tomography and magnetic
resonance imaging were normal. Audiogram showed
an asymmetric sensorineural hearing loss, right worse
than left (Fig. 21.4). Caloric tests showed a poor
Figure 21.4 Hearing test results from a patient with gentamicin ototoxicity. Circles and triangles indicate right ear, and Xs and squares indicate left ear. Note the asymmetry in hearing loss for this patient.
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response bilaterally to warm or cool water, although

iced water in the left ear did result in a weak but
appropriate response. There was a directional preponderance to the right. Rotational chair test showed a
severe bilateral vestibular deficit (Fig. 21.5). There
was little optokinetic after-nystagmus, and the VOR
time constant (Tc) was 2.4 sec to 60-deg/sec step rotations. At 240-deg/sec step rotations, some vestibular
response was evidentthe gain of the response was
0.15, and the Tc was 2.4 sec.
Treatment
At this point, the patient was started on a vestibular
rehabilitation program. She performed the X1 viewing paradigm exercise (see Fig. 21.3) first with
horizontal head movements for 1 minute, and then
with vertical head movements for 1 minute. Because
head movement exacerbated her nausea, she rested
for 10 minutes or more after each of these exercises. Initially she performed these exercises while
sitting, up to 5 times a day. She also practiced
standing unsupported, first with her feet apart
and her eyes open and then gradually moving her feet
Eye velocity
240.0
0.0
VOR 240
10
20
30
Time, sec
Figure 21.5 Plot of the decay in slow-phase eye velocity
with time during VOR-after nystagmus. Patient is first rotated
in a chair in complete darkness for 2 minutes, and then the
chair is stopped. The slow-phase eye movements that occur
are due to the discharge of the velocity storage system and
represent the function of the vestibular system. The results
here show the poor peak slow-phase eye velocity (35
deg/sec) and the short time constant (2 sec) in a patient
with bilateral vestibular loss. A step rotation at 240 deg/sec
was used. Eye movements were recorded with electro-oculography.
355
together and briefly closing her eyes. She was

instructed on how to use a walker, and emphasis was
placed on increasing her endurance. Initially, she
needed contact guarding while using the walker
and would occasionally lose her balance, especially
when trying to turn or if she moved her head too
quickly. After 4 days, she was able to walk independently with the walker and was discharged from the
hospital. At that time, she no longer had nausea with
gentle head movements.
Comments
Although this patient had a bilateral vestibular deficit,
the caloric and rotary chair tests showed that she
had remaining vestibular function (response to
iced water caloric test on the left and the responses to
60- and 240-deg/sec step rotations). Her initial exercise program, therefore, consisted of vestibular
adaptation exercises, because she had remaining
vestibular function, and ambulation training. Her balance exercises were designed to gradually increase
the difficulty of maintaining balance by slowly reducing her base of support, changing her arm positions (arms out, arms at sides, arms across the chest),
and then altering her use of visual cues. Although
she had decreased sensation in her feet, subtracting
visual cues was used as a treatment approach in order
to facilitate her ability to use the remaining
somatosensory and vestibular cues.
Follow-Up
The patient continued to be followed up as an outpatient. Exercises designed to facilitate the substitution
of alterative strategies to maintain gaze stability as
well to improve her static and dynamic balance were
added to her program. The patient no longer needed
to use a walker but she had a wide-based gait and had
to stop walking before turning around. Her Romberg
test result was negative but she could not perform the
Sharpened Romberg test. Although her vision
improved and she could read if she was sitting quietly, she could not see clearly while in a car and had not
resumed driving.
Approximately 2 months later, the patient had
a retinal hemorrhage in her left eye. She already had
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retinal damage in the right eye from her diabetes,
which essentially meant that she now had only partial
visual, vestibular, and somatosensory cues for balance. As a result, she could no longer keep her balance even in well-lighted conditions. For 1 week she
used either a wheelchair or, at home, a walker.
Fortunately, her vision recovered and she was again
able to walk independently.
On her last visit she reported that she had returned

to most activities except driving. Her base of support
while walking was more narrow, and her stability
while turning had improved. Her Romberg test result
was clinically normal but she could not perform a
Sharpened Romberg test with eyes open. She was
seeking part-time employment and was waiting for a
kidney transplant.
CASE STUDY 3
A 61-year-old man was referred by a neurologist for
treatment of disequilibrium secondary to BVL. The
patient had been hospitalized for a subarachnoid
hemorrhage 18 months previously. During his hospitalization, he had several systemic complications,
including renal failure, pulmonary infiltrates, and
ventriculitis, and was treated with two courses of vancomycin, gentamicin, and ceftazidime.
The neurologist saw him 7 months after this hospitalization because of the patients persistent disequilibrium. At that time, the patient complained that he
stumbled occasionally and that he had increased difficulty walking on uneven surfaces, in the dark, or
when he moved his head quickly. He denied having
nausea, vertigo, or a rocking sensation, although he
did state that he had a feeling of being tilted when
he walked. He stated that the disequilibrium began
after the hospitalization. He also had bilateral hearing loss but had no complaints of tinnitus, pressure,
or fullness in the ears. The remainder of his history
was noncontributory.
The neurological findings were normal except for
the following: (1) visual acuity, as assessed using a
wall chart, decreased from 20/20 with the head stationary to 20/100 during 2-Hz oscillations of the head,
(2) right Horners syndrome, (3) staircase saccades
downward from the midposition, (4) decreased VOR
gain based on visualization of the optic nerve head
and on the presence of compensatory saccades during
rapid head thrusts, (5) mild decrease in vibration sensation in his feet, right more than left, (6) inability to
perform tandem walking, Sharpened Romberg test, or
Fukudas stepping test, and (7) bilateral hearing loss.
The caloric test showed a severe reduction in function bilaterally (Fig. 21.6). Quantitative rotary chair
testing of the oculomotor system using step rotations
showed low VOR gain (0.2 and 0.13 to the right and
left, respectively) and short Tcs (2.2 sec bilaterally)
to a 60-deg/sec step rotation and low gain (0.19 and
0.34) and Tcs (1.9 sec and 1.2 sec) to 240-deg/sec
rotations. It was concluded that the patient had BVL,
probably from the gentamicin, and he was referred
for vestibular rehabilitation.
Treatment
Prior to establishment of an exercise program, additional testing was performed. Dynamic posturography showed inability to maintain balance when both
visual and somatosensory cues were altered and a
decreased ability to maintain balance when visual
cues were inappropriate (Fig. 21.7). Quantitative
DVA testing showed a change in acuity from 20/20
(static) to 20/40 during head movements. Quantitative vibration threshold confirmed the moderate loss
of vibration perception in the patients feet. His gait
was wide-based, and he frequently sidestepped while
walking. He appeared to use excessive visual fixation
to maintain balance during ambulation.
The patient was started on a program of exercises designed to (1) enhance remaining vestibular function, (2) develop alternative mechanisms to improve
gaze stability, (3) improve static balance in the
absence of visual cues, and (4) improve balance
while ambulating.
Follow-Up
Six weeks later, the patients Romberg test result was
normal but he still could not perform a Sharpened
Romberg test with eyes open, nor could he perform
Fukudas stepping test with eyes closed. He continued
to walk with a widened base of support. Quantitative
testing of the oculomotor system showed no change
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Figure 21.6 Results from bithermal caloric irrigation of the external auditory canals in a
patient with profound bilateral vestibular hypofunction. SCV Slow component velocity.
from the previous test. Quantitative DVA testing

showed an acuity of 20/30, a marked improvement over the previous value. The patient wished
to return to driving, and the physical therapist suggested that should he decide to drive, he should
start first in local traffic and even in an empty parking lot on a weekend. He was advised that driving at
night and high-speed driving would still be hazardous.
Figure 21.7 Results from posturography test in a patient with bilateral

vestibular loss. Test conditions were
those shown in Figure 21.2.
One month later the patient reported that he had

returned to driving during the day and that he was
working part-time. He still could not walk in the dark
or with his eyes closed without assistance. Several
suggestions were made to the patient concerning
modifications in his home to ensure safety, including
emergency lighting that would come on automatically if there were a power failure, railings for all stairways, and safety bars in the bathroom.
357
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Summary
Patients with bilateral vestibular problems can be expected to return to many activities but will continue to have
difficulties with balance in situations in which visual
cues are absent or diminished. The level of disability
partly depends on the degree of the vestibular loss but
also reflects involvement of the visual and somatosensory systems. Treatment approaches include increasing the
function of the remaining vestibular system, inducing the
substitution of alternative mechanisms to maintain gaze
stability and postural stability during head movements,
and modifications of the home and working environment
for safety. Patients should be able to return to work, and
most of them will be able to ambulate without the use of
a cane or walker, at least when they are in well-lighted
environments.
Acknowledgment
The work described here was supported by NIH grant DC
03196 (SJH).
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22
Management of the
Pediatric Patient with
The vestibular system develops relatively early in gestation.15 Investigations of the development and appropriate
testing of this system have demonstrated that it is a
dual-functioning system. The vestibular system is composed of vestibulo-ocular and vestibulo-spinal subsystems, each represented by distinct tasks and testing
methods. Labyrinthine reflexes, which are mediated by
the vestibulo-spinal system, provide postural tone necessary for the emergence of early motor milestones (e.g.,
rolling, sitting, standing).68 The role of the vestibuloocular system in visual stabilization, acuity, and the
development of visual spatial and perception abilities has
been well documented.912 It is therefore logical to
deduce that individuals with deficits of the vestibular system since birth or very early in life will present with difficulties in either motor or visuospatial abilities or both.
The incidence of peripheral vestibular disorders in
children (e.g., Mnires disease, perilymphatic fistula,
benign paroxysmal positional vertigo [BPPV]) similar to
that in adults has been reported.1324 Furthermore, like
adults with central nervous system impairment, children
with traumatic brain injury or other central nervous system insult may be expected to have central vestibular
deficits. However, investigations of vestibular dysfunction in children with these diagnoses are scarce.20, 2529
The functional integrity of the vestibular system is rarely
tested in young children, and thus, any impairment is
undetected and untreated. This situation may be in part
due to childrens inability to describe symptoms or even
360
know that what they are experiencing is not normal. 6,

30, 31 One of the major difficulties in the identification of
vestibular dysfunction in children has been the unavailability, or the omission of the use of, traditional and more
recently developed tests of vestibular function in this
population. This chapter reviews the incidence of
vestibular deficits in young children, the development of
postural control abilities, and appropriate testing and
intervention for this population.
Incidence of Vestibular
Deficits in Children
There are numerous reports in the literature regarding
vestibular dysfunction of various etiologies in young children and the consequent functional impairments.13, 15, 17, 19,
21, 32, 33
Tsuzuku and Kaga33 and others17, 26, 27, 31, 34 have
reported learning disabilities and delayed development of
walking and balance abilities in children with vestibular
system anomalies. Others have reported motor and balance deficits in young children with sensorineural hearing
impairment (SNHI) and evidence of vestibular hypofunction (Figs. 22.1 and 22.2).18, 3538 In spite of these reports,
children with SNHI or complaints of dizziness are rarely
tested for vestibular function. Casselbrant 21 reported
anomalies of postural control in children with otitis
media, which was reversed after insertion of tympanostomy tubes. However, vestibular function tests were not
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MANAGEMENT OF THE PEDIATRIC PATIENT WITH VESTIBULAR HYPOFUNCTION
361
Figure 22.1 Plot of mean single-leg

stance times of children with and without
sensorineural hearing impairment (SNHI).
Children with SNHI and abnormal postrotary nystagmus test (PRNT) results
score lower than those with SNHI and
normal PRNT results. (From Rine et al,
1996.18)
reported. Schaaf39 reported that the incidence of vestibular disorders was high in developmentally delayed
preschoolers with a history of otitis media.
Furthermore, Eviatar and Eviatar35 used per-rotary
and cold caloric stimulation to examine vestibular function in full-term and premature infants. They reported
that in premature, low-birth-weight infants, there is a
maturational delay in vestibular system function, as evidenced by a reduced percentage of positive nystagmus
response until 12 months of age. These investigators concluded that deviation of responses from the mean and
standard deviation of the normative sample can be considered abnormal after the age of 12 months. In addition,
although the incidence is lower than adults, there are
Figure 22.2 Plot demonstrating the difference of the mean deviation of age-equivalent
scores achieved on the Learning Accomplishment Profile (LAP) from chronological age
between children with sensorineural hearing
impairment (SNHI) and normal post-rotary
nystagmus test (PRNT) results and those with
SNHI and abnormal PRNT results. Those with
abnormal PRNT results achieved scores
below age level. (From Rine et al, 1996.18)
recent reports of BPPV13, 15, 40 in young children, as well

as Mnires disease19 and vestibular neuritis16 with consequent vertigo or impairments of balance abilities. Also,
in spite of the documented functional relationship of the
visual and vestibular systems and the effect that vestibular deficiency may have on gaze stability and oculomotor
control,12 children found to have visuomotor deficits on
educational or developmental testing are rarely tested for
concurrent vestibular function or gaze stabilization
deficits. However, interpretation of test results may be
compounded by changes due to adaptation or plasticity.
Investigations of plasticity and recovery of function
support the idea that age at the time of injury as well as
age at the time of testing does affect results obtained on
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tests of function.41, 41 Recovery of function is well documented and evidenced on vestibular tests of adults with
unilateral lesions of the peripheral vestibular apparatus,
in spite of the fact that the peripheral apparatus does not
regenerate or recover. On the basis of evidence that similar as well as different neural changes occur in individuals with nervous system damage at birth or during
childhood in comparison with those who sustain damage
later in life, it is logical to assume that different neural
substrate changes occur in young children with vestibular
deficits. Furthermore, these changes may mask the
deficits typically noted with traditional testing methods.
Rine et al42 reported that the vestibular-related impairments evident on functional and post-rotary nystagmus
test results were not identified by rotary chair testing in
children diagnosed with SNHI since birth. The children
with SNHI presented with delayed maturation of vestibular and vision ratios on posturography testing, hypoactive
responses on post-rotary nystagmus testing, and balance
abilities below age level (see Fig. 22.2). However, results
of per-rotary nystagmus (rotary chair testing) were within normal limits for the majority of the children tested. In
a separate study, Rine et al 17 reported evidence of a progressive delay in gross motor development in children
with SNHI and concurrent vestibular hypofunction.
Horak et al43 found that adults with bilateral vestibular deficits since birth did not demonstrate the lack of leg
muscle responses to perturbations evident in adults who
had adult-onset bilateral vestibular loss. However, activation of trunk muscles was delayed and smaller in amplitude in the early-onset group as than in either subjects
without a deficit or those with adult-onset deficit. These
results suggest that somatosensory inputs from the cervical and upper trunk areas compensated for the vestibular
loss in the early-onset group but not the adult-onset group.
In contrast, Rine and colleagues38 noted delayed recovery
responses on dynamic balance testing as well as deficient
reweighting of sensory cues during posturography testing
in young children with bilateral vestibular hypofunction
since birth (Fig. 22.3). Mira and coworkers,44 who examined children with benign paroxysmal vertigo, reported a
high incidence of autonomic and neurologic signs (e.g.,
pallor, nausea, hyperhidrosis, phonophotophobia, blurred
vision, migraine) accompanying the typical vertiginous
attacks. Computed tomography (CT), electroencephalography (EEG), and audiometric test results were normal, as
were nystagmus responses to rotational and caloric testing. The variation of clinical symptoms seen with a
peripheral vestibular deficit sustained early in life, versus
in adulthood, may also be evident in children with central
vestibular deficits.
1
0.8
0.6
SNHI-hypo
0.4
SNHI-n
Norm
0.2
0
S-Ratio
Vision
Ratio
Figure 22.3 Children with sensorineural hearing impairment

(SNHI) and concurrent vestibular hypofunction (SNHI-hypo)
achieved significantly lower somatosensory (S) and vision effectiveness ratios than those with SNHI without vestibular deficit
(SNHI-n) and as well as those without deficit (Norm). This finding indicates deficient sensory organization for postural control.
Although vestibular and postural control deficits

have been documented in adults with central nervous system involvement, similar investigations of children are
scarce.20, 25, 26, 28 It is logical to assume that like adults,
children with traumatic brain injury or other central nervous system conditions present with similar vestibular
deficits. In addition, owing to maturation issues involved
in the development of postural control and, particularly,
the effectiveness of vestibular function in postural control, the consequences to motor recovery may differ, and
varied mechanisms of compensation and adaptation may
mask vestibular deficits. Liao et al 28 reported poor static
postural control under various sensory environments in
children with spastic cerebral palsy. Although it is
expected that the muscle tone impairment involved is to
a great deal responsible, postural sway results were significantly different between children with and children
without impairment only on the swayed surface (SS),
eyes closedswayed surface (ECSS), and swayed
visionswayed surface conditions (SVSS), and thus were
similar in all other conditions. This finding suggests central vestibular system and sensory organization impairment. Nashner et al 45 and others 25, 29 reported similar
results, as well as a reversal of muscle activation patterns.
However, in none of these studies was vestibular function
formally tested. The identification of a vestibular deficit
is important to the development of appropriate intervention as well as for prognostic purposes. Weiner-Vacher
and colleagues5 have reported that the acquisition of
walking ability is related to measures of otolith, not
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Chapter 22
canal, vestibular function. Until recently, with the emergence of the use of vestibular-evoked myogenic potential
tests, clinical testing of otolith function has not been possible. Further research is needed in this area, particularly
because early identification and intervention during critical periods may affect recovery.
In summary, children, like adults, can and do have
central and peripheral vestibular deficits. Reportedly, a
delay in acquisition of motor skills and learning disabilities is evident in children with vestibular dysfunction. For
an understanding the implication of vestibular deficits
early in life, as well as to enable the selection and interpretation of testing and the development of appropriate
interventions for children, a review of the development of
postural control and oculomotor control as they relate to
vestibular function is warranted.
Development of Postural and

Oculomotor Control as Related
to Vestibular System Function
Numerous reports on the development of postural control
support the idea that although postural response synergies
and the ability to use each of the sensory components for
postural control are evident in young children learning to
sit and walk, the muscle responses, weighting of different
sensory information, and integrative abilities of postural
control are not like those of adults until adolescence.3, 4650
Forssberg and Nashner51 and others3, 46, 47 reported that
although the automatic responses to perturbation seen in
adults were present and functional in young children,
response latencies (e.g., short, medium, and long) were
significantly longer and matured at different rates. Haas
and colleagues46 claimed that the change in short-latency
responses to adult-like levels by 5 years of age reflected
improved nerve conduction velocity. The long-latency
response, which is reportedly an indicator of vestibulospinal function,52, 53 was not reduced to adult-like levels
until 15 years of age. These investigators attributed this
finding to acceleration of central polysynaptic transmission and myelinization. In addition, Shumway-Cook and
Woollacott54 reported that the attenuation of response
seen in 7-year-old children and adults was not observed in
younger children, with greater variability of responses in
4- to 6-year-old children. Additional studies demonstrated
that the development of sensory integrative capacity and
experience within a posture affect maturation of these
muscle responses.50, 55
Woollacott and coworkers55 reported that children
without experience in sitting or standing did not demon-
363
strate postural responses. Although muscle responses

occurred in reaction to perturbation in all experienced
subjects (either sitting or standing), the temporal organization of postural responses of the youngest experienced
sitters (8 to 10 months old) and standers (14 months old)
differed from those of adults and older children. Instead
of the typical distal-to-proximal sequence of muscle activation, proximal muscles (neck) initiated the response.
Investigations by Forssberg and Nashner51 showed
that although children 3 through 10 years of age could
maintain balance on all posturography test conditions,
children younger than 7.5 years performed like vestibulardeficient adults in the posturography test conditions that
required dependence on vestibular function (eyes closed
and sway surface, and sway-referencing of both the visual surround and support surface). Furthermore, Foudriat
and colleagues50 reported that children 3 through 6 years
of age had better stability in the swayed vision (SV) posturography condition than in the swayed surface (SS) test
condition. Rine et al 49 reported increased variability of
responses on posturography testing in children 4 to 6
years of age. These investigators 49 and others 48 also noted
that somatosensory effectiveness was adult-like by 4
years of age (Fig. 22.4).
The following conclusions may be gleaned from
these reports:
Experience within a posture is critical for the
development of postural control abilities;
By 3 years of age, somatosensory effectiveness
in postural control emerges, but in children
younger than 7.5 years, visual and vestibular system effectiveness in postural control is immature;
Maturation of postural responses occurs in a
stagelike pattern. The period between ages 4
years and 6 years is a transition period in which
mature patterns are emerging.
Investigators have suggested that these changes are
due to maturation of the effectiveness of individual sensory systems and the sensory integrative mechanisms
involved in postural control.48, 49, 56, 57
Reportedly, although vision is dominant in the early
stages of learning to balance in a posture, shorter-latency
proprioceptive responses are intact and more effectively
used if visual information is removed.5557 Riach and
Hayes56 found that Romberg Quotients (RQs), the
amount of sway with eyes closed expressed as a percentage of sway with eyes open, were less than 100 in young
children because sway was greater with eyes open than
with eyes closed. In adults, RQ is greater than 100. These
results suggest that, although visual information domi-
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Figure 22.4 Median of ratio scores attained by individuals of varying age without deficits.
(From Rine et al, 1998.49)
nates postural responses in young children, it also destabilizes.

Riach and Starkes57 reported that like adults, children are able to reduce sway with visual fixation, but
younger children (3 to 5 years old) had an increased number of saccades during attempted visual fixation than
older children and adults. These investigators proposed
that the increased saccades may be due either to an inability to visually fixate as well as adults or to an attempt to
improve stability by increasing saccades. However, this
conclusion is refuted by reports that the basic ability to
stabilize visual flow with head and eye movements is
acquired by 3 months of age.12 Von Hofsten and
Rosander12 noted that although a substantial lag was evident in 1-month-old infants, the lag was diminished by
age 3 months. This ability was attributed to maturity of
both the visual and vestibular systems. It is possible that
although infants can stabilize the visual environment,
they are not able to coordinate and integrate this information with other sensory system information about vertical
orientation.
Hirabayashi and Iwasaki48 and Rine and colleagues49
found immaturity of visual and vestibular system effectiveness in postural control through the age of 15 years.
Because children younger than 7 years attain signifi-
cantly different stability scores from those of adults in the

eyes open and eyes closed conditions of posturography
testing, scores in the other conditions cannot be used
to depict sensory system function in postural control. To
eliminate this problem, ratio scores were calculated
to provide a measure of sensory system effectiveness in
postural control.48, 49 The investigators reported that
somatosensory function was similar to that in adults by 3
to 4 years of age.48, 49 Although adult values in visual
function ratios were achieved by 15 years of age, this was
not true of vestibular function ratios.48 However, functional effectiveness of the vestibular system for gaze stabilization is reportedly adult-like by 3 years of age. Rine
and Braswell 31 developed a clinical test of dynamic visual acuity (DVA) for use with young children and reported
normative data. Test score is the difference between
acuity with the head stable and acuity with the head
moving at 2 Hz. Children as young as 3 years achieved
scores similar to those in adults. Furthermore, it has been
demonstrated that deficits in peripheral dysfunction not
only affect DVA in young children, but results in reading
acuity deficits 58, 59
In summary, functional maturation of the vestibular
and visual systems for postural control continues through
15 years of age, with the following observations:
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Although visual system effectiveness in postural

control is less mature than that of the somatosensory system prior to age 7.5 years, it is the dominant source of information for postural control in
standing.
Vestibulo-ocular mechanisms are intact and
mature by 1 year of age.
Vestibular system effectiveness for gaze stabilization is mature by 3 years of age.
The vestibulospinal mechanism, or the effectiveness of the vestibular system in postural control,
continues to develop after 15 years of age.
The sensory integrative capacity required for
postural control evolves between 7 and 15 years
of age.
The finding that development of postural control is
affected by the integrity of all systems involved as well as
by practice and experience in a posture suggests that
deficits in any one system, in central processing capabilities, or in the ability to experience various upright postures will impede development. Furthermore, the finding
that vestibular system effectiveness in oculomotor is
adult-like on tests of DVA by 3 years of age, but that its
effectiveness in postural control is not adult-like until
adolescence, indicates that the two vestibular systems
mature at different rates and function separately.
Therefore, a comprehensive assessment of vestibular
function in children should include tests of both vestibulo-ocular (VO) and vestibulospinal (Vsp) function, which
have been normed for this age group. This assessment is
important for both (1) the identification of deficits and
(2) the development of appropriate early interventions for
children with motor, oculomotor, or postural control
deficits secondary to vestibular dysfunction.
Evaluation of Children with

Vestibular System Dysfunction
A comprehensive examination of vestibular function
includes functional and diagnostic tests of VO and Vsp
function. 7 Because diagnostic procedures are costly and
may be uncomfortable, particularly for young children,
screening for appropriate referrals for in-depth testing is
warranted. On the basis of the literature, the following
children should be tested with regard to motor and balance development and oculomotor control: those with
SNHI, those with identified learning disability with evidence of Vsp or VO dysfunction, those with recurrent and
chronic inner ear infections who also present with difficulties of coordination, reading, or developmental delay,
and those with complaints of dizziness or visual stabi-
365
lization difficulties (Table 22-1). Therapists can complete

developmental functional testing of motor and postural
control abilities, perceptual and oculomotor abilities, and
screening of VO and Vsp function.7, 31, 60 The purpose of
these tests is threefold: (1) to establish that a functional
balance deficit exists, (2) to isolate the contributions of
the various components of the postural control system,
and thus determine which component(s) is (are) problematic, and (3) to provide a basis for referral for further
diagnostic testing and the development of remedial
programs. Children who attain scores below age-appropriate levels and those in whom screening identifies Vsp
or VO dysfunction should be referred for more comprehensive testing.
Functionally, balance represents postural control or
vestibulospinal abilities, as does the aberrant persistence
of labyrinthine reflexes. Clinical functional measures of
balance that have been normed and standardized for
use with children include the Functional Reach Test ,61
the balance subtests of the Peabody Developmental
Motor Scales (PDMS),62 the locomotor subtest of the
second edition PDMS (PDMS-II),63 and the BruininksOseretsky Test of Motor Proficiency (BOTMP).64 Care
should be taken in the selection of tests, because not all
are appropriate for all ages (Table 22-2). In addition to
testing balance, the PDMS and BOTMP include visuomotor, perceptual-motor and eye-hand coordination subtests, which enable age-appropriate functional testing of
the VO system. Tasks include target skills, tracing, bilateral coordination, and pencil-and-paper tasks. The
BOTMP, PDMS, and the PDMS-II are valuable in documenting general gross and fine motor developmental status as well as providing more specific measures of
balance and visuomotor development. The prone extension test component of the Sensory Integration and Praxis
Tests (SIPT)65 also provides a test of Vsp function. Other
test components of the SIPT are used primarily to assess
children with learning disabilities, focusing on form and
space perception, praxis, and tactile discrimination.
For younger children, the Test of Sensory Functions
in Infants66 and the DeGangi-Berk Test of Sensory
Integration 67 can be used to test ocular motor control and
developmental reflex integration (e.g., symmetrical and
asymmetrical tonic neck reflexes; Figs. 22.5 and 22.6).
These tests of sensory integration dysfunction, which is
reportedly correlated to vestibular dysfunction,6 are
appropriate for children with only mild motor delays. The
use of these tests and interventions for motor planning,
dyspraxia, and sensory integrative dysfunction are more
appropriately and completely reviewed elsewhere6 and
are not further addressed here. Children who present with
deficits on any of the complete tests noted previously or,
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Table 22-1 SYMPTOMS OF VESTIBULAR DYSFUNCTION IN CHILDREN

Peripheral disorders
Central disorders
1. Nystagmus on head movement.

2. Visual instability on head movement; complaints of blurring or double vision; positive
dynamic visual acuity test result.
3. Belowage level balance abilities (e.g., tandem, single-leg stance).
4. Complaints of spinning sensation or dizziness.
5. Belowage level vestibular ratios (also vision and somatosensory ratios, if since birth)
on SOT; step or loss of balance on test conditions 5 & 6.
6. May or may not show increased latency on DPT.
7. Hypoactive or hyperactive responses on PRNT.
8. May or may not have hearing loss or tinnitus.
9. May be fearful of movement activities, or crave them; asymmetrical posturing in sitting or
standing.
10. Complaint of incoordination.
1. Delay or belowage level performance on gross motor tasks.
2. Delay or belowage level performance on visuomotor, visual perception tests; positive or
negative dynamic visual acuity test result.
3. Persistence of tonic reflexes.
4. May manifest increased latency and amplitude of responses on posturography DPT.
5. Visual instability, particularly with head movement; failure on tests of dynamic visual
acuity.
6. Normal, hypoactive, or hyperactive responses on PRNT, although majority either hypoactive or hyperactive.
7. Belowage level performance on dynamic posturography SOT with stepping or loss of
balance on test conditions 46.
8. Belowage level vision and vestibular ratios on posturography SOT.
9. Possible sensory integrative dysfunction.
DPT dynamic perturbation test component of posturography test; PRNT post-rotary nystagmus test; SOT sensory organization test.
Table 22-2 ASSESSMENT OF VESTIBULAR DYSFUNCTION IN CHILDREN

Vestibular
System Tested
Assessment Tool
Test Type
Peabody Developmental Motor

Scales62, 63
Motor development
Vsp
Balance ability/development
Visual perception
Balance, locomotor, nonlo- VO
comotor, visuomotor, and
reflex subtests
Bruininks-Oseretsky Balance and gross motor

ability
Test of Motor
Balance, visuomotor, eyeProficiency64
hand, and bilateral coordination subtests
Vsp
Vsp, VO
Age Group
Items/Behaviors
Tested
Birth80 mo
Developmental reflexes
Balance beam, EO & EC
Single-leg stance EO & EC
Hopping
Tandem stand and walk
Visual track, perception, tracing
Target activities
414 yr
Balance on beam in tandem and

single-leg stance
Single-leg EO & EC
Target and tracing tasks
Romberg test, finger to nose,
bilateral coordination tasks
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Table 22-2 ASSESSMENT OF VESTIBULAR DYSFUNCTION IN CHILDREN (continued)

Vestibular
System Tested
Age Group
Items/Behaviors Tested
Sensory integration and

motor planning
Postural control, bilateral motor, and reflex
integration subtests
Vsp, VO
35 yr
Pivot prone and supine flexion

Postural tone
Dysdiadochokinesis
Tapping, jumping, and bilateral
tasks
ATNR and STNR testing
Test of Sensory
Function in
Infants66
Sensory processing and

reactivity in infants
VO, Vsp
418 mo
Responses to tactile, vestibular,

and visual ocular motor control
The Sensory
Integration and
Praxis Tests65
Sensory integration and

motor planning abilities
Visual perception
Vsp, VO
48 yr
Form and space perception

Praxis
Tactile discrimination
Vestibular integration
Southern California
Post Rotary
Nystagmus Test70
Vestibular ocular
system test
VO
511 yr
Nystagmus duration after

rotation
Functional Reach61
Balance ability in
standing
Vsp
515 yr
Forward reaching, standing
Pediatric Clinical
Test of Sensory
Interaction for
Balance76
Balance under varying

sensory conditions
Vsp
49 yr
Measures of sway in double-leg

stance with EO & EC, while
standing on foam or floor, or
with conflict dome
Dynamic Posturography Testing 49, 73
Functional test of
balance
Effectiveness of vestibular, visual, and
somatosensory systems
Vsp
Normative data
3 yradult on
SOT
SOT: computerized measures of

sway
DPT: measures EMG responses
to perturbation, standing
Timed Up and Go
test
Functional stand-andwalk test
Vsp
DPT component: 1.5

yradult
Time to rise from chair, walk

3 m, and return to sitting
Vestibular AutoRotation Test69
Visual stability (visuovestibular function)
VO
3 yradult
Maintain eyes stable with head

movement at various frequencies
Dynamic Visual
Acuity Test31
Gaze stabilization
VO
3 yradult
Visual acuity with head stable

and moving at 2 Hz.
Assessment Tool
Test Type
DeGangi-Berk Test
of Sensory
Integration67
ATNR asymmetrical tonic neck reflexes; DPT dynamic perturbation test; EC eyes closed; EMG electromyography; EO eyes open;
SOT sensory organization test; STNR symmetrical tonic neck reflexes; VO vestibulo-ocular system; Vsp vestibulo-spinal system.
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Figure 22.5 The prone extension test examines

the childs ability to assume and maintain a pivot
prone position. Inability to do so is indicative of
persistence of the tonic labyrinthine reflex.
Figure 22.6 One method of testing whether the asymmetrical tonic neck reflex is interfering with function is to request that
the child maintain a quadruped position with elbows extended
as he/she looks to the left or right. (A) The child without deficit
is able to do so without difficulty. (B) In the child with a deficit,
the arms collapse as the child attempts to look to his right.
more specifically, on the balance, reflexive, or visuomotor subtests, should be further examined for sensory
(vision, somatosensory, and vestibular) and postural control system effectiveness, to include screening of the neurological and musculoskeletal systems.
The musculoskeletal system must be examined to
determine whether restrictions in range of motion, pain,
reduced strength, or limited endurance is present, as any
of these may affect postural alignment or the availability
of movement strategies to maintain equilibrium. Furthermore, these measures may assist in differential diagnosis
of normal central nervous system response to an abnormal musculoskeletal system or an abnormal central nervous system response to a normal musculoskeletal system.
Subtests of the PDMS, BOTMP, and the sensory integration tests can provide screening of neurological status
(e.g., Romberg testing with eyes open and closed, fingerto-nose test with eyes open and closed, test of developmental tonic reflex integration). Further neurological
screening should include testing of deep tendon responses, cranial nerves and status of equilibrium reactions as
well as screening of the sensory systems involved in postural control.60
Sensory screening should include an examination
of the visual, somatosensory, and vestibular systems.
Somatosensory screening involves testing the integrity of
the tactile and proprioceptive senses, to include testing of
touch sensitivity, localization and discrimination (graphesthesia), and proprioception or position sense in the
lower extremities. Visual screening should include tests
of visual tracking and visual field capabilities as well
as an examination of the integrity of VO responses
(see Table 22-2). VO mechanisms can be examined by
noting the presence of abnormal responses such as gazeevoked or positional nystagmus, corrective saccades on
the head-thrust test,68 and visual stabilization during head
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369
Figure 22.7 For children who do not know letters, vision charts with symbols can be used.
(Obtained from Lighthouse Low Vision Products, 36-02 Northern Blvd., Long Island City, NY 11101.)
rotation (DVA testing)31 or vestibular autorotation testing

(VAT).69 For children, visual acuity charts are available
with symbols (Fig. 22.7) to complete DVA testing, which
has excellent sensitivity and specificity for the identification of vestibular hypofunction in children.31 Additional
screening tests of the VO system include the head-shake
or post-rotary nystagmus tests.69 The Southern California Post-Rotary Nystagmus Test (PRNT)69, 70 has been
normed for children through 9 years of age and is reportedly a reliable measure, having good correlation with
rotary chair testing for the identification of hypofunction.
If a balance or a visuomotor deficit is found concomitant
with evidence of VO or Vsp deficit on tests previously
described, further diagnostic testing of vestibular function
is warranted.
To isolate and test canal vestibular function, caloric
and rotary chair testing are used. Normative values are
available for children as young as 1 year.10, 35, 71 Otolith
vestibular testing for children, to include vestibularevoked myogenic potentials, off-vertical axis rotation, and
subjective visual vertical, has also been reported.5, 16, 32, 40

To test Vsp function, dynamic posturography testing is
used.38, 52, 72 Dynamic posturography testing involves
both a sensory organization test (SOT) and dynamic perturbation test (DPT), which complement and expand upon
the information provided by traditional clinical testing,
and yield an objective, functional measure of postural
control.49, 73, 74 Although the sensory and motor tests noted
previously enable the clinician to isolate the integrity of
the different components of postural control, they do not
measure the functional use and effectiveness of the sensory modalities, the integrative capabilities necessary for
postural control, which the SOT provides. In addition,
sensory system ratios calculated from results obtained
from the SOT may be used to monitor dominance or
maturation of sensory system effectiveness in postural
control. Recently, normative values of SOT measures, to
include ratio scores, have been reported for children 3
through 15 years of age.48, 49 A clinical, less sophisticated
form of the sensory organization test, which requires
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inexpensive materials and is portable, has also been developed.34, 75, 76 Westcott and colleagues76 developed a pediatric version of this test, the Pediatric Clinical Test of
Sensory Interaction for Balance (P-CTSIB), and reported
fair to good reliability when combined sensory conditions
scores were used. With the P-CTSIB, the examiner documents duration of balance (up to 30 seconds) and body
sway under the six SOT conditions using a dome and
medium-density foam.
The DPT component of posturography may be used
to determine whether neurological dysfunction is evident,
and at what level, and provides an indirect measure of Vsp
function.52, 77 Furthermore, maturation changes in the
neuromotor component of postural control can be measured and monitored. Although Muller and colleagues 3
and Dichigans and associates 52 have reported that
responses are evident with minimal maturation changes in
the very early stages of learning to stand and walk, normative data for children have not yet been published.
Harcourt78 reported that although posturography testing
may not be as sensitive as caloric testing in the identification of individuals with peripheral vestibulopathy, it does
provide additional information and is most valuable for
identifying patients with central abnormalities.
Treatment of Vestibular
Dysfunction
Peripheral Disorders
As in adults with peripheral dysfunction, once a diagnosis
is complete, medical management and rehabilitation of
the child with peripheral dysfunction should begin. This
may include medication, surgery, or visual habituation
and balance training activities (see previous chapters
in this volume). Rine and colleagues79 completed a waitlisted, controlled study to determine the efficacy of
exercise intervention for the improvement of motor development and postural control in children with bilateral
vestibular hypofunction. Children participated in exercise
intervention focused on substitution and habituation, three
times weekly, under the direction of a physical therapist.
The previously noted progressive motor development
delay was halted, and visual and somatosensory effectiveness ratios that were previously deficient improved to
within normative ranges. Braswell 59 reported improve-
ments of scores on DVA tests and subjective reports of

gaze stability after exercise intervention in children with
vestibular hypofunction. DAgostino and coworkers15
described a case of horizontal canal BPPV in a 10-yearold child, with spontaneous recovery after short-term
hospitalization and repeated mobilization (e.g., roll sideto-side) in the supine position.
The balance and habituation training activities must
be modified to the childs level of cognitive maturation
and interest level, with particular consideration of the
caregiver. Unlike the adult, who will be responsible for
his or her own exercise regime, the child depends on parents and therapists to carry out the program and ensure
compliance. To maximize the childs participation and
cooperation, the use of toys, games, and other items to
facilitate visual tracking, or the use of swings to provide
the movement during visual stabilization activities, is
important. Instead of letters, which are not motivating or
fun, line pictures, moving ball or animal with symbols or
letters, or even simple computer or video games may be
used. If the child can interact with, attempt to grasp, or
point to specific letters or symbols while sitting, swinging, and so on, the exercise becomes a game, is fun, and
may minimize resistance and maximize effort and cooperation. This cooperation and effort are critical to the
effectiveness of the exercise regimen.
Typically, when acute symptoms have subsided and
appropriate medical treatment is rendered (e.g., surgery
to repair fistula), children are eager to resume play and
other age-appropriate activities. It is critical to monitor
progress and provide short-term training to be carried out
at home with caregivers (e.g., visual tracking exercises,
visual stabilization regimen, balance and movement exercises to enable resumption of age-appropriate levels of
activity).
Central Vestibular and

Postural Control Deficits
As noted previously, few studies have been conducted to
examine vestibular function in children with central nervous system disorders. However, reports in the literature
do note the following: Children with learning disabilities
present with sensory organization and balance deficits,28,
29 postural control deficits are evident in children with
cerebral palsy, and vestibular stimulation does improve
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Chapter 22
motor and visual abilities in children with central nervous

system deficit or autism as well as in low-birth-weight,
premature infants.11, 27, 8082 Specific clinical signs and
symptoms of central deficits have been delineated elsewhere in this volume.
Reportedly, postural control deficits are the most
consistent finding. Therefore, children with deficits of
balance, postural control ability, and visuomotor function
should be evaluated for VO and Vsp function as well as
differential diagnosis of the multiple factors involved.
Treatment can then be developed to facilitate either the

use and integration of systems intact but not used or compensatory mechanisms. For example, a child with hypertonicity and developmental delay as well as evidence of
VO and Vsp dysfunction should participate in programs
that include facilitation and improvement of visual stabilization ability, movement tolerance and balancing during visual stabilization, and balance training in varying
sensory environments to encourage the use of intact systems and facilitate integration of information.
CASE STUDY 1
A 7.5-year-old girl was admitted to the hospital with
complaints of dizziness, nystagmus, spinning sensation, and inability to sit or stand. After being diagnosed with vestibular neuritis, she was hospitalized
and treated for 3 days. Upon discharge, she was
referred to physical therapy for evaluation and treatment of symptoms. Evaluation revealed the following:
Equilibrium reactions: Intact; single-leg stance
with eyes open (EO) 2 seconds, eyes closed (EC)
1 second either leg; unable to walk on 3.5-inch
balance beam in forward or sideways directions;
able to stand in tandem 3 seconds, but not to walk
without sidestepping.
Neurological screening: Deep tendon reflexes
intact; finger-to-nose test result negative; rapid
alternating upper and lower extremity movements
intact.
Vision and VO testing: Upon testing, optokinetic and gaze-evoked nystagmus noted; tendency
to keep head tilted to the right; favors left
eye by semiclosure of the right during DVA
test, which had normal result except for this
squint.
Posturography testing: Loss of balance noted
on conditions 5 and 6; vision ratio within
normal limits; vestibular ratio well below
normative values for age ( 2 standard deviations below mean).
371
Parent was trained in visual stabilization training using flash cards the child enjoyed and was familiar with for single words:
1. Child to read card as it is moved to right and left
at 1 Hz; with card stabilized at midline, child to
read card as head is turned to the left and right at
1 Hz. Once child is able to do this without difficulties, speed to be increased to 2 Hz. Practice
2 minutes each, daily.
2. With 4 word cards taped on wall centered in
front of child, child sitting 6 feet away, she practices reading cards as head is rotated right and
left (binocularly and monocularly).
3. Encourage play as before and practice on balancing: walking between tape lines 4 inches apart on
floor, gradually reducing to 3 inches; progress to
walking heel to toe on line or foot prints.
Practice 2 minutes daily.
4. Hopping games: hopscotch; jump rope swung
slowly back and forth by Mom, and child to
jump over it.
Due to difficulties in transportation, weekly monitoring of progress and adjustment of exercises were
done via phone contact. In 2 months, all symptoms
were relieved. The child was able to tandem stand and
walk 5 feet. No difficulties were noted with reading or
visual fixation with either card or head movement.
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CASE STUDY 2
Seven-year-old boy was referred for assessment
because of recent complaints of dizziness, vertigo,
and vision difficulties. Child was the product of premature birth, with low birth weight (1.5 lb).
Sensorineural hearing impairment was diagnosed at
18 months. However, with use of hearing aids, audiological results were within normal limits, and the
child did comprehend spoken language and spoke
clearly. He also had a history of frequent ear infections, for which drainage tubes were inserted twice
(bilaterally). Owing to vision and reading difficulties,
this child had been recently put in a special education
program for learning disability. He was referred for
testing to establish vestibular functional status and to
determine whether further testing or treatment was
warranted. Parent reported the boy having typical
activity levels until recently, including playing T-ball
and basketball with peers (intramural sports). Review
of records indicated treatment with gentamicin and
amoxicillin during the past few years.
Vision and VO testing: Subjective reports of dizziness with moving visual stimuli (e.g., looking up
at sky and watching clouds, watching television,
changing visual direction in classroom). Child and
parent reported that his eyes do funny things;
when asked to demonstrate this, child replicated
nystagmus. Difficulties with smooth pursuit evident, using corrective saccades and attempted
head turns to maintain fixation on moving target.
DVA score is normal. Although nystagmus was
not exaggerated on head-shake test, child reported
dizziness. Hyperactive response to PRNT with

35 seconds duration of nystagmus and severe
vertigo after rotation in either direction.
Motor and balance ability: Able to maintain
single-leg stance for 6 seconds EO, 3 seconds EC.
Able to walk 3.5-inch balance beam but not to
balance standing across beam in double- or
single-leg stance. On balance subtest of BOTMP,
achieved age-equivalent score of 4 years 11
months; on visual-motor coordination subtest,
age-equivalent score of 7 years 8 months.
Neurological screening: Deep tendon reflexes
within normal limits, as were rapid alternating
movements, integration of labyrinthine reflexes,
and finger-to nose test result.
Posturography (SOT) results: Patient relied on
stepping strategy to maintain upright on conditions 5 and 6; posturing noted on condition 4;
vision ratio of .29 ( 2 standard deviations below
norm for age) and vestibular ratio of .45 (2 standard deviations below norm for age).
Patient was referred for further medical diagnostic
testing for possible fistula, which was substantiated.
Surgical correction was performed. Physical therapy
after surgery focused on visual stabilization and balance retraining. Within 2 months, all vertigo and
dizziness were eliminated. Reading ability improved
such that the child was removed from the learning
disability program and placed in a gifted program.
Within 6 months, the child resumed all activities,
including playing basketball with peers.
CASE STUDY 3
Nine-year-old girl with a diagnosis of spastic hemiplegia since birth presented with gait and balance
deviations and delayed gross motor functioning. IQ
score was within normal limits, so she was placed in
a fully integrated classroom with physical and occupational therapy provided 1:1 twice weekly each.
Neurodevelopmental status: Hypertonicity was
evident in the right upper and lower extremities.
Gait deviations included toe-heel contact on the
right, knee flexion during midstance on right, lack
of arm swing, and wide base of support. Child was
unable to run or balance in single-leg stance on
right with EO or EC. Equilibrium reactions were
372
intact but delayed: reliance on tilting reactions in

quadruped and kneeling, and reliance on protective extension (stepping) in upright. Balance in
all positions was challenged by head rotations.
Gross motor functional level was 30 months. Tonic
neck reflexes were easily elicited and affected
alignment: ATNR and STNR were evidenced in
quadruped position with increased arm flexion in
the direction of head turning, and inability to lean
forward with less than 120 degrees flexion at the
hips if head was extended to look forward; tonic
labyrinthine evident with inability to assume pivotprone extension. A 1-inch leg-length discrepancy
was noted, with the right leg being shorter.
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Chapter 22
Vision and vestibular testing: Intolerance to movement in net swingfearful with complaints of
dizziness. Hyperactive nystagmus response on
PRNT (duration of 90 seconds either direction).
Subjectively, patient reported that she felt upside
down for the duration of the nystagmus following
PRNT. Child was able to balance in double-leg
stance with eyes open or closed with minimal
sway but could not balance with dome on head
and staggered if asked to stand on foam with eyes
open or closed or when also using dome (indicative of failure on posturography conditions 4
through 6). Visual tracking intact in all directions
with difference of two lines on DVA testing (head
stationary versus rotating side-to-side).
Owing to the lack of dizziness or complaints of
vertigo, a central vestibular deficit was identified, and
no further diagnostic testing was performed. Physical
therapy treatment continued as before, with the addition of facilitation of integration of tonic reflexes
through the use of vestibular stimulation on scooter
board as well as in net swing with and without visual
fixation, with gradual increase in velocity and direc-
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23
Management of the
Elderly Person with
The complaint of dizziness is one of the most common

reasons that older adults visit the doctors office.1 The
incidence of dizziness increases with age and accounts for
1.3% of all visits to internists in people 45 to 64 years old,
2.9% in people older than 65, and 3.8% in people older
than 75. Although dizziness can be caused by many different medical conditions, it is estimated that as many as
45% of cases are due to vestibular disorders.2 Aktas and
colleagues3 have reported that in 31% of their subjects
with hip fracture, vestibular disease was a comorbidity. In
80% of their patients with falls of unknown cause,
Pothula and associates4 found symptoms of vestibular
dysfunction. The vestibular insult or injury may be the
same as in a younger individual, but the functional sequelae may be very different because of the persons comorbid health status. Older adults with vestibular disorders,
therefore, often present with very different problems from
those of their younger counterparts. This chapter provides
information about the normal changes in the vestibular,
visual, and somatosensory systems with aging as well as
the pathological changes that can occur in each system.
Practical suggestions are made as to how older adults may
be treated differently because of their age.
Normal Changes of Aging

Vestibular Function
To appreciate the effect of aging on the mechanisms and
potential for recovery in vestibular disease, one must
376
understand the normal anatomy and physiology of the

vestibular system (see Chapters 14). Several concepts
are particularly important and will be emphasized here.
Semicircular Canal Function

The input from the receptors in the semicircular canals
produces compensatory oculomotor responses (vestibuloocular reflex [VOR]) and compensatory postural responses (vestibulospinal reflex [VSR]). In the ideal situation,
the eye movement produced by the head movement is
equal (but opposite) to the head movement, and the VOR
is said to have a gain (eye velocity head velocity) equal
to 1. With aging, there is a decrease in the numbers of
both hair cells and vestibular neurons.57 Functionally,
VOR gain decreases, resulting in reduced visual compensation in response to head movement. These changes,
however, appear to be frequency- and velocity-dependent.8,9 Baloh and coworkers10 found that older subjects
had lower visual-VOR gain as velocity increased than
younger subjects. Although these researchers examined
this issue only at low-frequency rotation, there appears to
be 35% less in visual-VOR gain in subjects younger than
75 years old than subjects aged 19 to 39 years. If the visual-VOR gain decreases with age, especially at higher
velocities, it would lead to greater retinal slip and therefore poorer visual acuity during head movement. The
changes in vestibular function have been compared to a
progressive bilateral vestibular deficit911 and may contri-
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MANAGEMENT OF THE ELDERLY PERSON WITH VESTIBULAR HYPOFUNCTION
bute to the complaints of disequilibrium (an off-balance

sensation) and to the gait ataxia, without any true vertigo, of many older people who are have nonsyncopal
dizziness. Paige12 suggests that this gradual, mild bilateral vestibular loss results in a mismatch in the visual
and vestibular mechanisms. Interestingly, Nadol and
Schuknecht11 reported that degenerative changes can
occur in only one labyrinth, producing sudden, severe vertigo or leading to chronic vertigo and disequilibrium.
Another change related to aging is a decreased ability to adapt the gain of the vestibular system.9 This would
affect the ability of the system to adjust to loss of function or other stresses of the system.
Preexisting vestibular disorders can cause balance
problems that manifest slightly differently in older individuals. Subclinical vestibular dysfunction may have
developed in an older adult when he or she was younger.
Then, with the decrease in the number of hair cells and
vestibular neurons with rising age, along with the drop in
the vestibular and other systems ability to compensate,
the patient experiences symptoms of vestibular dysfunction. Thus, the problems are due to decompensation
rather than to a new vestibular disorder.
Bilateral vestibular disorders are more common in
older than in younger adults. The most common cause of
bilateral vestibular loss is antibiotic therapy after a major
infection (see Chapters 6 and 21). The presence of visual
and somatosensory changes with aging complicates the
functional recovery for patient with a bilateral vestibular
loss. Patients who present with instability of gait and
functional mobility are more likely to require the use of a
walker or cane and will always have difficulty walking in
the dark.13,14 These functional deficits may require environmental and behavioral adaptations to prevent falls and
injuries in the older person. One practical suggestion is
that the older person increase the lighting in the house,
especially nightlights, and that he or she carry a flashlight
at night so as never to have to walk in total darkness.13
Installation of grab bars in the bathroom, especially in the
tub or shower, has been shown to be helpful in decreasing falls in older persons.
Utricular and Saccular Function

The presence of calcium carbonate crystals (otoconia) on
the maculae of the utricle and saccule make these structures sensitive to the pull of gravity and to linear acceleration. These crystals are held in place by a gluelike
substance, and in all people there is a normal degeneration
and regeneration of the crystals.15 In addition, degenerative changes in the otoconia of the utricle and saccule
increase with aging.15 This process may contribute to the
377
relatively high incidence of benign paroxysmal positional

vertigo (BPPV) in the elderly. The incidence of idiopathic BPPV has been reported as peaking in the sixth and
seventh decades of life.16 Baloh and coworkers10 reported
that of 116 patients aged 70 or older that they saw for
complaints of dizziness, 25% had BPPV. Whitney and
colleagues17 found that 23% of patients referred to a
vestibular clinic had the diagnosis of BPPV and a mean
age of 61 years.
Oghalai and associates18 suggest that older persons
with undiagnosed BPPV have more reports of falls, are
more likely to have had past depression, and have impairments of activities of daily living (ADLs). In their sample
of older persons seen in a general medical clinic, 9% had
a positive Dix-Hallpike test result, although none was
being seen for a balance or vestibular disorder. Gamiz and
Lopez-Escamez19 reported that older adults with BPPV
showed significant changes in the Medical Outcomes
Short-Form Medical Survey (SF-36) and short-form
Dizziness Handicap Inventory (DHI) values 30 days after
undergoing the canalith repositioning maneuver. Eightytwo percent of the adults in their survey older than 60
years also had a negative Dix-Hallpike test result at 30day checkup, suggesting that older persons are successfully treated with canalith repositioning.
Several theories have been suggested in relation to
why older persons appear to have a higher incidence of
BPPV than younger persons. BPPV has now been associated with osteoporosis and osteopenia,20 giant cell
arteritis,21 and higher rates of mild head trauma and diabetes.22 All of these conditions are more common in older
adults. Gizzi and colleagues23 have even suggested that
the presence of BPPV is five times more common in persons for whom a blood relative also had reported BPPV
in the past, suggesting that BPPV may be associated with
a genetic link.
A newly developed BPPV subscale of the DHI may
be helpful in identifying BPPV in older persons who
present to a balance clinic.17 Determining whether the
older patient becomes dizzy or experiences vertigo when
moving from supine to sitting position or while rolling
over are two of the key questions included in the new
subscale; a yes answer significantly increases the likelihood that the person has BPPV.
Even if a patient does not present with a diagnosis
of BPPV or with complaints consistent with BPPV, it is
recommended that the older adult always be assessed for
BPPV during the clinical examination, because of its
prevalence.18 Because the Dix-Hallpike test result may be
false-negative in some patients, Viirre and coworkers24
have suggested that clinicians perform the Dix-Hallpike
test, then the roll test, and then repeat the Dix-Hallpike
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test if results of the first two tests are negative. Whitney

and associates17 also suggest repeating the Dix-Hallpike
maneuver as well as performing the test at different
speeds with older adults in order to dislodge the otoconia.
Also, the examiner is more likely to find evidence of
BPPV earlier in the day.17
When performing assessment or treatment for
BPPV in older persons, however, it is important to consider the possibility that the patient may have cervical
spine and cardiopulmonary disorders as well. Cervical
spine range of motion should be assessed before position
testing. Great care should be exercised in extending and
rotating the older adults head because of possible structural changes due to arthritis or other cervical disorders.
Also, the patient should be screened carefully for vertebral basilar compromise. If the patient presents with a
long history of cervical disease (e.g., rheumatoid arthritis
or Pagets disease), a tilt table is useful during the testing
and repositioning maneuvers. For a patient with normalpressure hydrocephalus, the neurosurgeon should be consulted about possible problems with placing the patient in
the head-down position.
It is important to move more slowly with the repositioning maneuvers in adults older than 80 years and with
the adult who has multiple medical problems.25 The ultimate success rate of repositioning in older adults is similar to that in younger persons but may require more than
one visit. We think that the reason for the difference is
that it is difficult to obtain sufficient neck extension
and/or rotation for an effective treatment in older
patients. Care should also be taken with individuals who
have metastatic cancer or who have had a cerebrovascular accident. We often perform the repositioning maneuver with two clinicians present to help the patient with
position changes if they are severely impaired.
Another special group is adults with mental and/or
physical disabilities. Having a family member present is
helpful to ensure the older adult that he or she will not be
harmed by the maneuvers. It is very frightening for older
persons with mental challenges to undergo the canalith
repositioning maneuver. As a precaution, we also routinely monitor blood pressure in people older than 75
years who have abnormally high or low blood pressure.

It is difficult to determine whether dizziness is truly due
to a vestibular deficit without sophisticated testing (see
Chapter 8). The results of these tests in older persons
must be interpreted carefully and should be based on agerelated normal values.26 For example, in people in their
90s, caloric testing may document bilateral vestibular

loss, but such people do not actually have a bilateral
vestibular loss.
Visual Deficits
Visual acuity, the ability to accommodate, and smooth
pursuit normally decline with age.27,28 These normal
changes associated with aging can make adaptation after
a vestibular insult more difficult.
An inability to adapt to the dark has been shown in
the literature to be one of the reasons why older adults
may fall.29 Combining the dark adaptation disorder with
vestibular dysfunction can make it dangerous for older
adults with vestibular disorders to move from areas with
ample light to darkened areas. This change in light has
been shown to cause temporary blindness in older adults
for more than a minute.29
In addition to dark adaptation, visual acuity and contrast sensitivity have been related to falls in older
adults3034 and may contribute to imbalance after a
vestibular disorder. Older adults may have other eye disorders, including cataracts, glaucoma, and macular
degeneration, that impair vision.35 Cataracts typically
cloud the lens and may cause blurred vision. In patients
who have macular degeneration, near and distant vision
are affected without adversely affecting peripheral
vision.35 Individuals with glaucoma also have difficulty
with peripheral vision.35 Depth perception disorders, such
as cataracts in one eye, and double vision make maintaining upright stance more difficult. Multifocal lenses have
also been implicated in falls in older persons. Lord and
associates34 reported that wearers of progressive, bifocal,
or trifocal lenses were more likely to have described a
fall, especially descending stairs, as well as more trips
and falls outside their homes.
A home inspection would be very helpful for the
person with glaucoma or other visual disorder to ensure
that the home is free of hazards. The Home Safety
Checklist developed by the U.S. National Safety Council
is an excellent tool for identifying fall hazards in the
home (Box 23-1).36 Any of the visual disorders described
can potentially raise the risk of falls and complicate the
patients rehabilitation course. A home visit by the physical or occupational therapist to reduce hazards may be a
very helpful intervention for people who have visual
impairments.35
Somatosensory Changes
Older adults appear to have a greater chance of reduced
somatosensory function. Age-related electrophysiologi-
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379
Box 23-1
HOME SAFETY CHECKLIST FOR DETECTION OF FALL HAZARDS

Housekeeping
1. Do you clean up spills as soon as they occur?
2. Do you keep floors and stairways clean and free of clutter?
3. Do you put away books, magazines, sewing supplies,
and other objects as soon as youre through with them
and never leave them on floors or stairways?
4. Do you store frequently used items on shelves that are within easy reach?
yes
yes
no
no
yes
yes
no
no
Floors
5. Do you keep everyone from walking on freshly washed floors before theyre dry?
6. If you wax floors, do you apply 2 thin coats and buff each thoroughly or else use
self-polishing, nonskid wax?
7. Do all small rugs have nonskid backings?
8. Have you eliminated small rugs at the tops and bottoms of stairways?
9. Are all carpet edges tacked down?
10. Are rugs and carpets free of curled edges, worn spots, and rips?
11. Have you chosen rugs and carpets with short, dense pile?
12. Are rugs and carpets installed over good-quality, medium-thick pads?
yes
no
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
Bathroom
13. Do you use rubber mat or nonslip decals in the tub or shower?
14. Do you have a grab bar securely anchored over the tub or on the shower wall?
15. Do you have a nonskid rug on the bathroom floor?
16. Do you keep soap in an easy-to-reach receptacle?
yes
yes
yes
yes
no
no
no
no
Traffic Lanes
17. Can you walk across every room in your home, and from one room to another,
without detouring around furniture?
18. Is the traffic lane from your bedroom to the bathroom free of obstacles?
19. Are telephone and appliance cords kept away from areas where people walk?
yes
yes
yes
no
no
no
yes
yes
yes
no
no
no
yes
yes
yes
no
no
no
Lighting
20. Do you have light switches near every doorway?
21. Do you have enough good lighting to eliminate shadowy areas?
22. Do you have a lamp or light switch within easy reach from your bed?
23. Do you have nightlights in your bathroom and in the hallway leading from your
bedroom to the bathroom?
24. Are all stairways well lighted?
25. Do you have light switches at both the tops and bottoms of stairways?
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Stairways
26. Do securely fastened handrails extend the full length of the stairs on each side of
stairways?
27. Do rails stand out from the walls so you can get a good grip?
28. Are rails distinctly shaped so youre alerted when you reach the end of a stairway?
29. Are all stairways in good condition, with no broken, sagging, or sloping steps?
30. Are all stairway carpeting and metal edges securely fastened and in good condition?
31. Have you replaced any single-level steps with gradually rising ramps or made sure
such steps are well lighted?
Ladders and Stepstools
32. Do you have a sturdy step-stool that you use to reach high cupboard and closet
shelves?
33. Are ladders and step-stools in good condition?
34. Do you always use a step-stool or ladder thats tall enough for the job?
35. Do you always set up your ladder or stepstool on a firm, level base thats free
of clutter?
36. Before you climb a ladder or stepstool, do you always make sure its fully open
and that the stepladder spreaders are locked?
37. When you use a ladder or stepstool, do you face the steps and keep your body
between the side rails?
38. Do you avoid standing on top of a stepstool or climbing beyond the second step
from the top on a stepladder?
Outdoor Areas
39. Are walks and driveways in your yard and other areas free of breaks?
40. Are lawns and gardens free of holes?
41. Do you put away garden tools and hoses when theyre not in use?
42. Are outdoor areas kept free of rocks, loose boards, and other tripping hazards?
43. Do you keep outdoor walk-ways, steps, and porches free of wet leaves and snow?
44. Do you sprinkle icy out-door areas with de-icers as soon as possible after a
snowfall or freeze?
45. Do you have mats at door-ways for people to wipe their feet on?
46. Do you know the safest way of walking when you cant avoid walking on a
slippery surface?
47. Do your shoes have soles and heels that provide good traction?
48. Do you wear house slippers that fit well and dont fall off?
49. Do you avoid walking in stocking feet?
50. Do you wear low-heeled oxfords, loafers, or good-quality sneakers when you work
in your house or yard?
51. Do you replace boots or galoshes when their soles or heels are worn too smooth to
keep you from slipping on wet or icy surfaces?
yes
yes
yes
yes
yes
no
no
no
no
no
yes
no
yes
yes
yes
no
no
no
yes
no
yes
no
yes
no
yes
no
yes
yes
yes
yes
yes
no
no
no
no
no
yes
yes
no
no
yes
yes
yes
yes
no
no
no
no
yes
no
yes
no
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Personal Precautions
52. Are you always alert for unexpected hazards, such as out-of-place furniture?
yes
no
53. If young grandchildren visit, are you alert for children playing on the floor and toys
left in your path?
yes
no
54. If you have pets, are you alert for sudden movements across your path and pets
getting underfoot?
yes
no
55. When you carry bulky packages, do you make sure they dont obstruct your vision?
yes
no
56. Do you divide large loads into smaller loads whenever possible?
yes
no
57. When you reach or bend, do you hold onto a firm support and avoid throwing
your head back or turning it too far?
yes
no
58. Do you always use a ladder or stepstool to reach high places and never stand on
a chair?
yes
no
59. Do you always move deliberately and avoid rushing to answer thephone or doorbell?
yes
no
60. Do you take time to get your balance when you change position from lying
down to sitting and from sitting to standing?
yes
no
61. Do you hold onto grab bars when you change position in the tub or shower?
yes
no
62. Do you keep yourself in good condition with moderate exercise, good diet,
adequate rest, and regular medical checkups?
yes
no
63. If you wear glasses, is your prescription up to date?
yes
no
64. Do you know how to reduce injury in a fall?
yes
no
65. If you live alone, do you have daily contact with a friend or neighbor?
yes
no
After identifying a fall hazard, the hazard should be eliminated or reduced. One point is allowed for each No
answer. Score 1 to 7, excellent; 8 to 14, good; 15 and higher, hazardous.
This checklist was developed by the U.S. National Safety Council in cooperation with AARP, Itasca, IL, 1982.
(Used with permission.)
cal and functional declines in the peripheral nervous

system have been described in groups of healthy subjects
and patients with neuropathological disorders. These
age-related somatosensory changes can result in diminished vibratory and passive motion sense and an increase
in lower extremity reaction times.37,38 Pathological
changes such as axonal degeneration due to neuropathy
result in abnormalities in distal somatosensation.39,40
These somatosensory changes have functional implications. Ducic and colleagues41 and Reid and associates42
have reported that there are changes in balance as one has
less sensation distally.
Older adults have more difficulty sensing vibration
in the distal extremities as well as less sensitivity for
detecting smaller monofilaments. Diabetes is one of the
most common conditions in older adults that causes

changes in distal somatosensation and vision.43
Musculoskeletal Deficits
Another potential difficulty in rehabilitating the older
population with a vestibular disorder involves the musculoskeletal system. An assessment of grip strength is one
of the most effective ways to obtain an overall idea of
strength in older adults.44 Older adults may have weakness or even muscle paralysis of various etiologies. Older
adults who have preexisting conditions, such as polio and
cerebral palsy, and in whom late-onset vestibular disease
develops are more difficult to treat.
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Weakness is very common in the lower extremities,

especially the ankles, in older adults. Careful attention to
ankle strength is very important in the patients rehabilitation. The inverted pendulum model of postural control
shows that the ankles play a critical role in the maintenance of postural control.45 Foot and ankle muscles
appear to be very weak in many older patients, and
strength training may be indicated. Waddington and
coworkers46 found that training with a wobble board
enhanced older adults ability to discriminate movement
at the ankle.
Postural Hypotension
Patients who show vestibular symptoms often complain
of dizziness and/or imbalance. The dizziness needs to
be differentiated from lightheadedness due to postural hypotension associated with changes in position.
Postural hypotension and vestibular-induced dizziness
can be easily confused if one does not make a careful
examination. Typically, patients with postural hypotension become lightheaded or dizzy when standing up,
and the symptoms last for seconds. There is also a 20mm
Hg drop in systolic pressure from supine to standing
if blood pressure is measured immediately after rising.
The patient is asked to lie in supine for up to 5 minutes,
then is asked to stand with the blood pressure cuff secured
to an extremity. A drop of 20 mm Hg or more indicates
postural hypotension. Many drugs commonly taken
by older adults can produce postural hypotension, including diuretics. Postural hypotension alone can put a person at risk for falling because of the significant dizziness
that the patient experiences when changing positions
quickly.
raises the possibility that white matter disease may be a

factor in falls in older persons.
Fear of Falling
Another common problem experienced by older individuals who have vestibular disorders is fear of falling.51
Balance performance and confidence are related in
community-living older people.52 Older adults with
vestibular loss often experience fear of falling53 and, as a
result, may reduce their activity level.5456 This fear of
falling is extremely disabling to older adults and may
actually prevent optimal functioning. Tinetti and associates54 suggest that therapists work with patients to reduce
their fear of falling, thus also enhancing their function.
When asking a patient about a fall, the therapist
must make sure to be using the same definition of a fall
as the patient. The therapist should determine whether
the patient has many near fallscoming close to, but
not actually, hitting the ground. Falls with no known
cause are of concern to the therapist and must be investigated further to determine their cause. Noting whether
the patient was injured during a fall and required medical
attention is also very important to a better understanding
of the seriousness of the fall reports.
Attention
Older adults may have disturbances in coordination and

tend to move slowly. Patients with cerebellar disease
appear to improve with balance therapy.47 It is not uncommon for cerebellar atrophy to be a sign of abnormal aging
in the older adult. Patients with cerebellar atrophy often
do not complain of dizziness, vertigo, or hearing loss.
Their chief complaint is often that their balance has been
getting worse over a period of years. Working on the
rhythm of gait is very helpful for such patients, because
their step lengths can be variable, making them unstable
while ambulating.
The role of attention in postural control in the elderly is

important.5762 Shumway-Cook and associates,57 studying
postural control in older adults while standing, have
found that older adults allocate their resources differently
from younger adults. These investigators found that the
older adults balance was more affected than the young
adults when they were concurrently performing a balance task and a simple cognitive task. Those older people
who had a history of falling had significant changes in
balance, as measured by center of pressure. Ludin-Olssen
and collegaues58 determined, in the nursing home setting,
that older adults who talked as they walked with assistive
devices were more likely to fall than those who did not
talk as they walked.58,62
The concept of attentional resources is interesting,
and one that can be incorporated into practice. We now
instruct older patients who have great difficulty walking
in the clinic to try not to walk and talk at the same time.
They are instructed to stop walking while talking, to
paraphrase the title of the Ludin-Olssen article.58
White Matter Disease
Depression
Studies have now suggested that older adults who have

significant white matter disease are at greater risk of
falling.4850 This is a relatively new area of research that
Older adults who have vestibular disorders may be experiencing clinical depression. A simple screening examination can be performed with the Geriatric Depression
Cerebellar Atrophy
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383
Screening Scale.63 This scale consists of 30 yes-or-no

questions asking the patient to answer how he or she has
felt over the past week. The test is simple to use and can
help the therapist decide whether to make a mental health
referral.
Both cognition and depression affect the ability of
the patient to follow through with an exercise program.
The older adult who is depressed or who has little support at home may have to be seen more frequently in the
clinic and will need closer monitoring by the therapist.
The patient who displays an indifferent or negative
attitude toward therapeutic intervention should not be
merely dismissed as lacking motivation. Coexisting
depression may be the cause of the indifference. Anxiety
has been reported to be more common than depression in
persons with vestibular disorders.64 Jacob65 and Clark
and associates66 have suggested that anxiety is strongly
related to vestibular dysfunction.
as far as they can without touching the wall or the yardstick. They are permitted to use any strategy they choose
to complete the trial. Duncan and associates79 have determined that scores of 6 inches or less on the functional
reach test show a significant increase in the risk of falling
in older adults. Individuals who reach between 6 and 10
inches are at moderate risk for falling.79 This test has some
drawbacks. Functional reach is related to height; taller
patients have longer functional reach scores than those
who are shorter in stature. Functional reach scores have
also been shown to change over the course of rehabilitation.83 Functional reach is sometimes administered
to the patient who has dizziness,80 although WernickRobinson and colleagues have suggested the test may
have little value in persons with vestibular dysfunction.84
The functional reach test appears to be helpful in older
adults who complain of balance problems, but it may
have less discriminative value in persons with vestibular
disorders.
Risk of Falling in Older Adults

with Vestibular Disorders
Questionnaires for
Balance Assessment
The actual risk of falling in older adults who present to a

vestibular clinic is unknown. In a sample of 247 persons
who presented to a vestibular clinic with a mean age of
62 years, 36.8% reported having one or more falls in the
last 6 months.67 Various studies have reported a reduction
in falls rates after physical therapy intervention.13,68,69
There are standardized tools that one can use to
determine risk of falling in older adults. Specific tools
that can be used to assess balance are the Berg Balance
Scale (BBS)7077 and the functional reach test.7883 The
BBS has been used extensively to assess balance in older
adults who have Parkinsons disease or stroke or who are
frail (Box 23-2). It has been validated for use in persons
with vestibular dysfunction.77 This 14-item examination
assesses the patients balance in increasingly difficult
positions and has a maximum score of 56. As the scores
decrease from 56 to 36, the risk of falling increases.76
Shumway-Cook and associates76 determined that scores
of 36 and lower on the BBS relate to 100% risk of falls
in community living older adults.
Another tool that is helpful for assessing risk of falls
is the functional reach test.78 The test was developed in
older male veterans. It yields a difference score in the
patients willingness to reach forward without taking a
step. In order to be able to perform the test, the patient
must be able to stand for 30 seconds without support in
flat or no shoes and must have at least 90 degrees of shoulder flexion. Patients are typically instructed to raise the
arm, make a fist, and then reach forward along a yardstick
The Activities-Specific Balance Confidence (ABC) Scale

is a 16-item questionnaire that can be completed by the
patient or administered by the caregiver (Box 23-3).85,86
The patients perceived confidence in performing 16
activities that are performed in and outside the house are
rated by the patient from a range of 0 (no confidence) to
100 (100% confident). Scores that are closer to 100 are a
better score on this scale. The ABC scale and the DHI
have been shown to have a moderately negative correlation (r 2.64), indicating that the ABC scale is a valid
tool for use in persons with vestibular dysfunction.87 The
ABC scale has shown to be sensitive to change over the
course of rehabilitation.69,88,89
The ABC scale has been compared to the Modified Falls Efficacy Scale.56 Both scales are sensitive tools
that can be used in community-based older adults, and
both discriminate individuals who are high-functioning
from those who are low-functioning. Lajoie and
Gallagher90 have reported that older adults who score
66% or less on the ABC are at high risk for falling. Myers
and coworkers85 previously reported that persons who
scored less than 80% on the ABC scale were somewhat
impaired and that those who scored less than 50% were
often home-bound individuals. Older adults should be
able to perform most of the 16 ABC activities with great
confidence.
The Vestibular Activities of Daily Living (VADL)
Scale is another questionnaire that is helpful in determining the functional capabilities of people living with vestib(text continued on page 387)
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Box 23-2
BERG BALANCE SCALE

1. Sitting to Standing
Instruction: Please stand up. Try not to use your hands for support.
Grading: Please mark the lowest category that applies.
(4)
(3)
(2)
(1)
(0)
able to stand no
hands and stabilize
independently
needs minimal
assist to stand or
to stabilize
needs moderate or
maximal assist to
stabilize
(1)
(0)
needs several tries

to stand 30 sec
unable to stand 30
sec unassisted
able to stand independently using

hands
able to stand using

hands after several
tries
2. Standing Unsupported
Instruction: Stand for 2 minutes without holding.
(4)
(3)
(2)
able to stand safely 2 min.
able to stand 2
min with
supervision
able to stand
unsupported
If Subject Able to Stand 2 Min Safely, Score Full Marks for Sitting Unsupported. Proceed to Position
Change Standing to Sitting.
3. Sitting Unsupported Feet on Floor
Instruction: Sit with arms folded for 2 minutes.
Grading: please mark the lowest category that applies.
(4)
(3)
(2)
(1)
(0)
able to sit safely
and securely 2 min
able to sit 2 min

under supervision
able to sit 10 sec
unable to sit without support 10 sec
4. Standing to Sitting
Instruction: Please sit down.
Grading: Please mark to lowest category that applies.
(4)
(3)
(2)
(1)
(0)
sits safely with

minimal use of
hands
sits independently
using uncontrolled
descent
needs assistance to
sit
controls descent
by using hands
able to sit 30
seconds
uses back of legs

against chair to
control descent
5. Transfers
Instruction: Please move from chair to bed and back again. One way toward a seat with armrests and one way
toward a seat without armrests.
Grading: Please mark the lowest category that applies:
(4)
(3)
(2)
(1)
(0)
able to transfer
safely with minor
use of hands
able to transfer
safely; definite
need of hands
able to transfer
with verbal cuing
and/or definite
need of hands
needs one person

to assist
needs two people

to assist or supervise to be safe
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BERG BALANCE SCALE

6. Standing Unsupported with Eyes Closed
Instruction: Close your eyes and stand still for 10 seconds.
(4)
(3)
(2)
able to stand 10
sec safely
able to stand
10 sec with
supervision
able to stand 3 sec.
7. Standing Unsupported with Feet Together

Instruction: Place your feet together and stand without holding.
(4)
(3)
(2)
able to place feet
able to place feet
able to place feet
together independ- together independ- together independently but unable to
ently and stand 1
ently & stand for
hold for 30 sec
min safely
1 min with
supervision
(1)
(0)
unable to keep
eyes closed 3 sec
but stays steady
needs help to keep

from falling
(1)
needs help to
attain position but
able to stand 15
sec feet together
(0)
needs help to
attain position and
unable to hold for
15 sec
The Following Items are to be Performed While Standing Unsupported.

8. Reaching Forward with Outstretched Arm
Instructions: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner
places a ruler at end of finger tips when arm is at 90 degrees. Fingers should not touch the ruler while reaching
forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position.)
(4)
(3)
(2)
(1)
(0)
can reach forward
needs help to keep
can reach forward
can reach forward
reaches forward
confidently 10
from falling
2 inches safely
5 inches safely
but needs
inches
supervision
9. Pick up Object From the Floor
Instructions: Pick up the shoe/slipper that is placed in front of your feet.
(4)
(3)
(2)
(1)
unable to pick up
able to pick up
able to pick up
unable to pick up
but reaches 12
slipper but needs
slipper safely and
and needs superviinches from slipper sion while trying
supervision
easily
& keeps balance
independently
(0)
unable to try/needs
assist to keep from
falling
10. Turning to Look Behind Over Left and Right Shoulders

Instruction: Turn to look behind you over or toward left shoulder. Repeat to the right.
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BERG BALANCE SCALE

(4)
(3)
(2)
turns sideways only
looks behind one side
looks behind from
but maintains balance
only; other side shows
both sides and
less weight shift
weight-shifts well
(1)
needs supervision
when turning
(0)
needs assist to keep
from falling
11. Turn 360 Degrees

Instruction: Turn completely around in a full circle. Pause, then turn a full circle in the other direction.
(4)
(3)
(2)
(1)
(0)
needs close supervi- needs assistance
able to turn 360 safely able to turn 360 safely able to turn 360
sion or verbal cuing while turning
one side only in 4 sec safely but slowly
in 4 sec each side
Dynamic Weight Shifting While Standing Unsupported.
12. Count Number of Times Step Touch Measured Stool
Instruction: Place each foot alternately on the stool. Continue until each foot has touched the stool four times.
(4)
(3)
(2)
(1)
(0)
able to stand indeable to stand indeable to complete
able to complete
needs assistance to
pendently and safependently and com4 steps without
2 steps; needs
keep from falling/
ly and complete 8
plete 8 steps 20 sec
aid/with superviminimal assist
unable to try
steps in 20 sec
sion
13. Stand Unsupported One Foot in Front of the Other Foot
Instruction: Place one foot as close as possible in front of the other foot.
(4)
(3)
(2)
(1)
(0)
takes small step
able to place feet
loses balance while
able to place one foot
needs help to step
independently;
tandem and holds
stepping or standahead and holds
in place; holds
holds 30 sec
30 sec
ing
30 sec
15 sec
14. Stand on One Leg
Instruction: Please stand on one leg as long as you can without holding onto anything (knee does not have to
be bent).
(4)
(3)
(2)
(1)
(0)
tries to lift leg; unable
able to lift leg indeable to lift leg indeable to lift leg
unable to; tries or
to hold 3 sec; remains
pendently; able to
independently;
pendently; or needs
needs assist to prestanding independently
hold for 10 sec
assist holds 510 sec holds 3 sec
vent falling
Total Score
Maximum Score
Reprinted with permission of the Gerontological Society of America,1030 15th Street, NW, Suite 250,
Washington, DC 20005. The Activities-Specific Balance Confidence (ABC) Scale (Figure), L.E. Powell &
A.M. Myers Journal of Gerontological Med Sci 1995, Vol. 50 No. 1. Reproduced by permission of the publisher via Copyright Clearance Center, Inc.
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387
Box 23-3
THE ACTIVITIES-SPECIFIC BALANCE CONFIDENCE (ABC) SCALE

For each of the following activities, please indicate
your level of self-confidence by choosing a corresponding number from the following rating scale:
0% 10 20 30 40 50 60 70 80 90 100%
no confidence
completely confident
How confident are you that you will not lose your
balance or become unsteady when you. . .
1. walk around the house? ______%
2. walk up or down stairs? ______%
3. bend over and pick up a slipper from the
front of a closet floor? ______%
4. reach for a small can off a shelf at eye level?
______%
5. stand on your tip toes and reach for something above your head? ______%
6. stand on a chair and reach for something?
______%
7. sweep the floor? ______%
8. walk outside the house to a car parked in the
driveway? ______%
9. get into or out of a car? ______%
10. walk across a parking lot to the mall?
______%
11. walk up or down a ramp? ______%
12. walk in a crowded mall where people rapidly
walk past you? ______%
13. are bumped into by people as you walk
through the mall? ______%
14. step onto or off of an escalator while you are

holding onto a railing? ______%
15. step onto or off an escalator while holding
onto parcels such that you cannot hold onto the
railing? ______%
16. walk outside on icy sidewalks? ______%
Instructions to Participants
For each of the following, please indicate your level
of confidence in doing the activity without losing
your balance or becoming unsteady by choosing one
of the percentage points on the scale from 0% to
100%. If you do not currently do the activity in
question, try and imagine how confident you would
be if you had to do the activity. If you normally
use a walking aid to do the activity or hold onto
someone, rate your confidence as if you were
using these supports. If you have any questions
about answering any of these items, please ask the
administrator.
Instructions for Scoring
The ABC is a 16-point scale, and ratings should consist of whole numbers (0 to 100) for each item. Total
the ratings (possible range 0 to 1600) and divide
by 16 to obtain each subjects ABC score.
If a subject qualifies his/her response to items #2, #9,
#11, #14 or #15 (different ratings for up vs down
or onto vs off), solicit separate ratings and use
the lowest confidence of the two (as this will limit
the entire activityfor instance, likelihood of using
the stairs).
From Powell and Myers, 1995.86 Reprinted with permission of the Gerontological Society of America, 1030
15th Street, NW, Suite 250, Washington, DC 20005, via Copyright Clearance Center, Inc.
ular disorders.91,92 The VADL scale is further discussed in

the chapter by Cohen on disability (see Chapter 24).
The modified Fast Evaluation of Mobility, Balance,
and Fear Baseline (FEMBAF) questionnaire is extremely
helpful in determining risk factors for falling (Box 234).93,94 The therapist fills out yes or no answers to the
risk factor questions either as he or she interviews the
patient or after having obtained information from the
patients medical chart. This questionnaire has a compre-
hensive list of fall risk questions, answers to which help

guide intervention.
Dizziness Assessment
The DHI is extremely helpful in determining what
type of intervention will most benefit the patient with
vestibular dysfunction.53 This tool helps determine the
self-perceived handicap of the individual completing the
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Box 23-4
MODIFIED FAST EVALUATION OF MOBILITY, BALANCE,

AND FEAR BASELINE QUESTIONNAIRE
Name
Weight
Lives with Somebody
Age
/
/
Blood Pressure
Gender
Height
Lives at Home, Alone
Lives in an Institution
Risk Factors
YES
NO
1. Needs aid for two (or more) basic activities of daily living (washing, cooking,
dressing, walking, continence, feeding)
2. Needs aid for two (or more) instrumental activities of daily living (money
management, shopping, telephone, medications)
3. Has had a fracture or articular problems at hips, knees, ankles, feet
4. Has visible articular sequela in the mentioned joints
5. Uses a walking device (e.g., cane, walker)
6. Limits physical activity to basic activities of daily living at home
7. Self-defines as anxious
8. Complains of vertigo
9. Complains of imbalance
10. Makes complaints suggesting an existing postural hypotension
11. Fell one or two times in the current year
12. Fell more than twice in the current year
13. Required nursing after the fall
14. Had a fracture after the fall
15. Is afraid of falling in general
16. Is afraid of falling indoors (e.g., bathtub, kitchen)
17. Is afraid of falling outdoors (e.g., bus, stairs, street)
18. Avoids going outside for fear of falling
19. Presents three or more somatic pathologies that require regular medical supervision
20. The pathologies require home-based medical-social supervision
21. Shows a specific pathology likely to induce falls:
neurological (e.g., cancer, peripheral neuropathy, multiple sclerosis, lupus)
cardiovascular (e.g., postural hypotension)
musculoskeletal (e.g., total joint replacements, arthritis)
sensory (e.g., visual impairment)
other (amputation, Parkinsons disease, Alzheimers disease)
22. Takes medications that are potentially dangerous in regard to falls:
hypotensives
neuroleptics
hypnotics/anxiolytics
antiarrhythmics
antiparkinsonians
analgesics/anti-inflammatory drugs
various vasoregulators
Risk Factors ( total of yes answers):
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MODIFIED FAST EVALUATION OF MOBILITY, BALANCE,

AND FEAR BASELINE QUESTIONNAIRE
Task Completion
Scores are determined for fear, pain, mobility difficulties, and lack of strength for each of the following:
TASK
SCORE
(3, 2, 1)
1. Sitting on a chair, with folded arms, raises both legs horizontally
2. Sitting on a chair with armrests, stands up without aid, without using banister
3. Sitting on a chair, stands up without aid, walks five steps, turns around, goes back
and sits down
4. One-footed standing (left foot): stands on left foot without aid during 5 seconds
minimum
5. Repeat with one-footed standing (right foot)
6. Romberg Test: stands with heels together, eyes closed, remains steady for 10 seconds
7. Squatting down: without aid, squats down until buttocks reach knee level, then stands up
8. Picking up a pencil from the ground without aid or support
9. Standing jumping without losing balance, over a distance equal to ones own foot
10. Stepping over an obstacle (foam or cardboard, 10-cm wide x 15-cm high) without
touching it; the foot to arrive past the obstacle at a distance equal to its own size (left)
11. Repeat with overstepping to the right
12. Shoving forward to trunk; subject to remain steady following a nudge between
shoulder blades (examiners arms stretched out, nudge realized by a sudden bending
of hand on trunk)
13. Repeat with shoving backward (nudge on the sternum)
14. Climbing stairs without losing balance, without aid or using banister
(five steps minimum)
15. Repeat with descending stairs (five steps minimum)
16. Transfer from standing-kneeling (both knees on the ground); stable, no
assistance for rising
17. Managing the eyes-closed forward fall; the subject lets himself/herself fall,
eyes closed, onto the examiner standing 50 cm from him/her
18. Repeat with eyes-closed backward fall
Fembaf Total Task Completion Score:
Fembaf Total Subjective Complaint Scores:
fear
pain
mobility difficulties
3 successfully completed without imbalance
2 task initiated but unsteady or partially completed
1 unable to perform or initiate task
lack of strength
From DiFabio and Seavy, 1997.94 With permission of the American Physical Therapy Association.
389
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form. The patient answers 25 questions related to dizziness and/or handicap. There are three subdivisions of the
test, and subscores can be calculated. The test has been
divided into emotional, physical, and functional subsets.
Information from this tool can significantly direct the
treatment of the patient. If the patient checks only the
physical symptoms, one needs to look at assessing positions and specific movements that predispose or increase
the patients dizziness and/or falls.
Older adults who have lost mobility as a result of
dizziness often check a significant number of the emotional questions on the DHI. One then must determine the
actual activity level of the person. Scores on the DHI
have also been related to falls in persons with vestibular
disorders.89 Scores of 60 or higher were associated with
increased reports of falls in persons with vestibular disorders. Use of the SF-36 form can be helpful in assessing
the activity level of the patient; the DHI, however, is
more responsive to changes after a 6- to 8-week course of
vestibular rehabilitation.95,96
Typical Balance Tests

If the patient is complaining of balance problems, the
single-leg stance (SLS), Romberg, and tandem Romberg
tests are also performed. Bohannon and associates97 have
found that SLS times significantly decrease as people get
older.97 SLS, Romberg, and tandem Romberg tests help
the therapist determine what kind of functional movements might be difficult for the patient.97101 Generally,
the patient who is unable to stand in SLS usually has great
difficulty going up and down stairs without holding onto
the railing. Such a patient may also have strength deficits
if unable to stay in SLS. The strength deficits can be
determined through further testing. The patient who has
difficulty with the Romberg and tandem Romberg test is
often challenged while walking through tight spaces.
Standing with the feet close together may be very destabilizing for such a patient. Some older adults may live in
homes with narrow hallways or small rooms with little
clearance, and the therapist must consider the patients
environment in designing the treatment program.
or descend is critical. Some extrinsic environmental

hazards that have been identified are items such as poor
lighting, uneven or slippery surfaces, loose rugs, steep
stairs, objects in the pathway, long bathrobes, inappropriate furniture, and lack of handrails, especially in the bathroom.102
Modification of the home environment so that the
patient does not have to reach excessively either up or
down to perform ADLs is helpful. The investigators at the
Center for Studies in Aging in Toronto developed a device
to assist persons in the bathroom or kitchen who are very
unsteady. The device, made of a material that makes it
easy to grip, is secured easily without damaging walls.
Persons who have difficulty reaching without holding on
may significantly benefit from this type of appliance in
the home. Primary care physicians, especially in managed
care situations, should be made aware that such services
are available to their patients.
Many of the older adults seen in our clinic with
complaints of dizziness and balance dysfunction do not
have a specific diagnosis. A total vestibular workup and a
neurology assessment of such patients are helpful and
should be performed so that the physical therapist knows
what to treat.
Duration of Treatment
Older adults frequently need to be treated for a longer
time than a younger patient. The longer duration of treatment is related to the number of risk factors present in
such patients as well as to their fear. They may be seen on
a more traditional schedule of one to three times per
week because of their multiple medical problems and the
risk of falling when unsupervised at home. Many older
patients have difficulty being transported to physical
therapy. This fact can complicate rehabilitation; the older
adults cancellation rate is often higher. If their transportation system breaks down or if the weather is bad,
many older adults will be forced to cancel their appointments; referral to a local agency for the aging may be
indicated to help the patient obtain dependable transportation. Evidence now suggests that treatment outcomes in older adults are similar to those in younger
persons with the same vestibular disorder.88
Home Assessment
Preparing the patient to function independently in his or
her own home is very important. Occasionally, a home
visit is necessary for older persons with vestibular dysfunction, if the therapist is concerned about their safety.
Determining how many stairs the patient must ascend
What to Do Once the Risk

Factor Has Been Identified
After the older person with vestibular dysfunction has
been assessed, it is important to determine what problems
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Chapter 23
identified in the evaluation must be addressed, referral

being one alternative. Patients who have visual problems
should be referred to an appropriate physician for further
eye testing. People with undiagnosed vestibular disorders
should be referred to a neurologist or otolaryngologist. If
a neuropathy is suspected, a referral to a neurologist, a
physical therapist specializing in electromyography, or a
physiatrist is recommended.
The physical or occupational therapist can also provide an environmental assessment with specific recommendations, determine whether the patient needs an
assistive device, and teach the patient about safety and
clothes to wear to reduce the risk of falling. In addition,
shoe type and wear can be determined, and recommendations can be made to the patient. The older adult who
may have chosen to wear inappropriate shoes can sometimes be counseled to change.
During the environmental assessment, lighting in the
patients home may be identified as a major risk factor.
Many older adults use low-wattage light bulbs or keep the
lights off most of the day in order to save money. Use of
nightlights is strongly suggested, especially in the bathroom. Motion detector lights, which are automatically
391
activated when one passes through the plane of the sensor, may also have some value. Additionally, the layout of
some patients homes may cause significant changes in
contrast of light levels, which has been identified as a
contributer to falls.32,33 Proper lighting must be addressed
with the patient and family.
Motor weakness is most often assessed by performance of a manual muscle test or through the use of a
dynamometer. Strength deficits can be addressed because
older patients have the potential to improve their
strength, although it may take up to 6 weeks for improvement to be evident.103105 Range of motion is a major factor that can be improved through rehabilitation. Patients
can be significantly at risk for falls if they lack adequate
distal range of motion in their feet.106 Having normal
plantar-flexion and dorsiflexion is extremely helpful in
preventing falls and achieving normal gait, because the
feet are the only part of the body touching the ground
when one is walking. Assessing flexibility of the toes and
foot musculature may be of added benefit; having strong
dynamic stabilizers distally may make the patient more
stable. If the patient has an extremely immobile foot, performing normal balance reactions will be difficult.
CASE STUDY 1
Mrs. H is a 91-year-old woman referred to physical
therapy with a diagnosis of bilateral BPPV. She has
been seen by a neurotologist who wants to schedule
Mrs. H to for a joint visit with himself and the physical therapist for repositioning.
The patient is a well-oriented and extremely
pleasant older woman. Her chief complaint is that she
became very dizzy 3 weeks ago when she looked up
at her clock at home and also when she sat up or went
from sitting to lying down. Her daughter is very concerned and worried about her mother, stating several
times during the examination that she believes Mrs. H
should move in with her. Mrs. H lives alone in a small
one-bedroom apartment. She normally takes the van
that leaves daily from her apartment complex to the
grocery store, and she loves to shop! Mrs. H cleans
her own apartment but has someone come in once a
month to do the heavy cleaning. She arrives at the
outpatient clinic carrying a straight cane while seated
in a wheelchair. Patient reports that she does not use
a cane in her apartment and that she has used a cane
elsewhere for the past 4 years. She holds onto furniture as she ambulates around the apartment, and
rarely uses a wheelchair except for long distances
when a wheelchair is available. She reports that when
she shops, she uses the shopping cart like a wheeled
walker.
Mrs. H is taking no medications except vitamins
but does have a 39-year history of Pagets disease.
Her laboratory findings were as follows:
Caloric testing: severely reduced responses
bilaterally with absence of iced water responses.
Oculomotor screening, normal. Rotational chair
response, abnormal with moderately decreased gain
and a mild directional preponderance. Positional
testing, normal. She is not ataxic and does not have
oscillopsia.
Patients Timed Up & Go score is 30 seconds.
She moves slowly while carrying her straight cane.
Patient has a very kyphotic posture. She has decreased
neck and shoulder range of motion, and her overall
strength is F to G.
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The patient has already been diagnosed with bilateral BPPV. She is more symptomatic in the left
Hallpike-Dix position than in the right, so the left ear
is treated first. Four people are present for the repositioning, including the physician, because of the
patients age and Pagets disease. Pagets disease produces excess bone, which can result in narrowing of
the vertebral foramen. It is decided to use a high-low
table with two movable parts. Her trunk and head are
lowered as a unit and at the same time her feet are elevated to put her in the Trendelenburg position. The
patient is initially brought down to the left and then is
log-rolled from her left side to her right side.
Movements are coordinated among the persons helping to perform the maneuver. Her head is slowly
brought up as her feet are returned to the horizontal
position. This positioning avoids excessive neck
extension and excessive torque to her back during the
modified canalith repositioning maneuver. Infrared
goggles are in place throughout the procedure. The
patient has classic torsional and upbeat nystagmus
that fatigues within 20 seconds. The second time she
is repositioned during the same session she has no

symptoms. She is told to stay upright and to not move
her head up or down for 1 hour.
Patient is scheduled to return in 1 week for repositioning of the other ear; she could not make it back in
any sooner because of her daughters schedule. When
the patient returns, there is no evidence of BPPV in
either ear. She can look up to her clock at home and
lie down without symptoms. She has returned to her
normal shopping excursions and says that she feels
great.
Her daughter is very concerned about how active
her mother is and wants her to stop many of her activities. The daughter is strongly encouraged to allow
her mother to stay active and to enjoy her trips out of
her apartment.
During her last visit, Mrs. H is instructed in lower
extremity strengthening exercises so that she can
maintain her strength distally. Patient is discharged
after being seen for two physical therapy visits. She
no longer has any dizziness and she is satisfied with
her gait.
CASE STUDY 2
Mrs. M was a 68-year-old woman seen in physical
therapy with a presenting diagnosis of multisensory
deficit. Mrs. M was well oriented and very cooperative. She stated that she had been having difficulty
walking and that she had fallen twice within the last
few weeks. Patient was seen by an otolaryngologist
because of her falling. Quick head movements and
bending made her unstable.
Her past medical history included a silent heart
attack, hypertension, cirrhosis of the liver without a
history of alcoholism, mastoiditis, obesity, claustrophobia, uterine cancer, tinnitus, and stomach ulcers.
In addition, the patient took medication for her knee
arthritis. Past surgical history included a hysterectomy
and two operations for cancer.
Mrs. M was taking the following medications:
potassium chloride, famotidine, aspirin, a multivitamin (Centrum Silver), and furosemide.
Vestibular testing results showed that she had a
normal oculomotor battery, normal static positional
testing, severely reduced vestibular responses bilaterally with present iced water caloric responses,
and reduced gain on rotational chair testing. Patient
had had two previous infectious events necessitating IV antibiotics. She had osteomyelitis of a toe 10
years ago and again 2 years ago, which were treated
with IV antibiotics. Furosemide can be ototoxic, so
the patient was counseled to consult with her physician about whether another medication could control
her lower extremity swelling without the same side
effects.
The patient stated that she occasionally got dizzy
with changing positions. Her DHI score was 12/100.
She stated that the onset of her gait instability was
gradual and that it was getting worse.
Patient lived alone in a condominium on one floor
with an elevator in the building. She formerly worked
as a superintendent of schools in her area. Mrs. M
was widowed at an early age and raised two children
alone.
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Walking with head turns and quick head movements increased her symptoms. Her ABC score was
51%. She did not use an assistive device.
She had fallen twice in the last few weeks. She
tripped over a box the first time, and the second time
she got tangled in a chair cover and lost her balance.
Patient stated that she also has had many near falls.
She stated that she almost fell the morning of the
evaluation while sitting down on the commode. Mrs.
M reported difficulty getting up from the floor.
Patients strength and range of motion were generally within normal limits for her age. She had diminished vibration sense but had intact proprioception
distally at her ankles. She became short of breath
with exertion during functional activities and gait.
Mrs. Ms timed Up & Go score was 12.5 seconds.
Her repeated 5 times sit-to-stand test score was 16.2
seconds. Her Sensory Organization Test composite
score on the EquiTest (Neurocom International, Inc.)
was 77. Her Berg Balance Score was 55/56, and her
Dynamic Gait Index score was 19/24. The patient was
able to stand in SLS for 15 seconds on the right and
10 seconds on the left.
Overall it appeared that the patients balance was
fairly good during testing except for during dynamic
gait activities. She also reported falling two times
in the last 4 weeks, which put her at high risk for
another fall.
Goals for Mrs. M included improving the DGI from
19/24 to 22/24 and the EquiTest composite score
from 77 to 85, decreasing the DHI score from 12/100
to 5/100, and raising the ABC score from 51% to
70%.
The plan was to see the patient for 3 or 4 visits over
the next 2 to 3 months to improve her dynamic balance, increase her stamina, and decrease her fear
of falling. She agreed to the stated goals. The plan
was to discuss a pool exercise program with her to
attempt to have her increase her strength and mobility in a nonweight-bearing exercise program that she
might enjoy, to avoid any worsening of knee pain
associated with the more intense activity level.
Mrs. M had been prescribed the following exercises: walking with head turns to the right and left, stepping up to a stool but not onto it and down, bending
down toward the floor from the sitting position, a
walking program, and walking with 180-degree
turns. She was instructed to do the exercises two
times a day.
393
The patient was seen four times in physical therapy.

During her second visit, she reported that her physician had changed her diuretic. She had not fallen
since her last visit to physical therapy. During her
second physical therapy visit, it took her 20 seconds
to rise from the chair 5 times, which was worse than
on the first visit. Her ABC score had increased by
11% to 65%, and her DHI score increased from 12 to
22. Her DGI score had increased from 19 to 21/24.
Her composite sensory organization test value on the
EquiTest was 82, an increase of 5. Patient was prescribed standing plantar-flexion next to the kitchen
sink, the trace-the-alphabet exercise with her foot,
walking and turning 180 degrees, walking with head
turns, and walking and making 360-degree turns. She
was told to try to do the exercises two times a day.
During her third physical therapy visit, Mrs. M stated that she had been having difficulty finding time to
do the exercises. She could do the alphabet exercise
without holding onto the kitchen sink. Walking and
looking up was a problem for her, but walking backwards was easier. Mrs. M complained of swelling in
her feet. She was instructed to keep them elevated but
was also shown how to perform ankle pumps and
ankle isometrics. SLS times had improved to 21 seconds on the left and 20 seconds on the right. Her 5
times sit-to-stand test time was 17.3 seconds, and her
composite sensory organization test score was
77/100. Her DHI score remained at 22/100, and her
ABC score was 64%.
Mrs. M was given written ankle exercises, a SLS
exercise, a seated exercise in which she rolled a
rolling pin under her foot, standing weight-shift exercises, and walking with head movements.
During the patients fourth and final visit, she stated that she had difficulty with the standing weight
shifts and that moving back onto her heels while balancing was difficult. The alphabet exercise and walking backward were not a problem for her. SLS
continued to be a challenge for her balance. Patient
reported that she had not been walking as the therapist had requested. Her DGI score had increased to
23/24. Her DHI score had remained at 22/100. Her
sensory organization test score remained at 76, and
her ABC score was 61%. Her 5 times sit-to-stand test
time had improved to 12 seconds, and her Timed Up
& Go test time was now 11 seconds. SLS times had
improved to 28 seconds on the left and 30 seconds on
the right.
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Her home exercises for the fourth physical therapy
visit consisted of standing in SLS and moving her
head slightly to the right and left, walking on her toes
in plantar-flexion, and standing in SLS on a pillow.
Mrs. M was discharged at the end of her fourth
clinic visit. She had made great strides with her walking and was no longer falling. The four visits were
spaced out at 3-week intervals over a 3-month period.
She had met one of her goals and had partially met
three of the other four goals that were initially developed in her plan of care. She was satisfied with her
progress and was instructed to rejoin the cardiac exercise group that she had belonged to after she had her
Summary
Older adults with vestibular disorders have some unique
differences from younger adults. The normal physiological changes associated with aging in the vestibular apparatus, the eye, and somatosensation can complicate the
rehabilitation of the older adult with a vestibular disorder.
Older adults can improve with vestibular rehabilitation
but may need special care. Comorbid medical problems
that may be seen in older adults with vestibular disorders
require the physical therapist to think carefully before
initiating an intervention program. Patient safety and
encouraging compliance with the intervention are essential. Careful identification of the patients functional limitations enables a therapeutic program to be devised to
restore the older adults function safely.
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24
Disability in
In the first published paper on vestibular rehabilitation,

Cawthorne1 wrote that any disorder of the labyrinth will
be accompanied by balance disturbances that may be
severe enough in extreme cases to render the sufferer
helpless and immobile. He also said that three weeks
after an acute episode of vestibular failure, presumably
acute vestibular labyrinthitis or neuronitis, the patient
begins to creep about cautiously. When the patient has
recurrent, momentary attacks of vestibular failure or with
the head in certain positionshere he must have anticipated the diagnosis of benign paroxysmal positional
vertigo (BPPV)the result will be less devastating.
Nevertheless, these recurrent attacks may engender such
a feeling of insecurity that the sufferer feel impelled to
limit his activities, and such people will frequently not
venture out of doors unaccompanied.1 Modern research
has supported and extended his observations, but no other
writers have summarized the problem so well.
Evaluating Disablement
Knowing someones symptoms may not help to understand that patients functional limitations because symptoms and disablement are not necessarily related.26
Disablement is sometimes more heavily influenced by the
individuals life needs than by physiology. For example,
the need to care for an elderly, disabled spouse may make
someone with clinically significant vestibular weakness
more functionally independent than someone with more
social support, fewer life stresses, and more normal test
398
results.6 Furthermore, determining level of disablement is

tricky. Self-ratings by patients may differ from ratings by
their physicians and therapists, and from ratings by their
significant others.2 Rigby et al4 pointed out that the
patient is often more critical than the clinician.
A good assessment of disablement directly addresses the functional limitations caused by the disorder rather
than the signs and symptoms of that disorder.7 A variety
of measures have been used to evaluate quality of life,
disability, and outcomes of intervention, including subjective self-ratings of performance and objective ratings
by health professionals. Some measures are specific to
vestibular or balance disorders; others are more general.
Assessments that are specific to vestibular disorders are
sensitive to the subtle problems experienced by this population but do not allow comparison with other health
conditions. General assessments allow comparison across
health conditions but are insensitive to subtle but functionally significant problems experienced by people with
vestibular disorders. The vast body of literature on evaluations for disability is beyond the scope of this chapter.
For an excellent review of many general measures, as
well as a discussion of the relative merits of general versus specific assessments, see the text by Dittmar and
Gresham8 as well as Reeds Quick Reference series.9,10
Three self-administered surveys of function have
been developed specifically for vestibular disorders. The
Dizziness Handicap Inventory (DHI)3 is easy to use but
omits some essential personal care skills and lacks sensitivity. It was developed and normed for patients with
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Chapter 24
Mnires disease but has been used in other vestibular

disorders. The Vestibular Disorders Activities of Daily
Living Scale (VADL)2,6 was developed for a wide range
of vestibular disorders, is more specific to details of activities of daily living (ADLs), and is more sensitive than the
DHI. A promising new self-assessment specifically for
patients with Mnires disease is the Mnires Disease
Outcomes Questionnaire, which addresses symptoms,
some motor skills, and some social activities.11 It could be
improved with the addition of questions about problematic personal care activities, home management skills, and
driving or other community mobility skills.
Self-ratings do not yield an unbiased assessment of
performance skills but represent the patients personal
point of view. A widely used general self-rating is the
Medical Outcomes Study Short-Form Health Survey
Questionnaire (MOS SF-36).12 The poor to moderate correlation of the DHI and MOS SF-36 suggests that they
measure different domains.13,14 The World Health Organizations International Classification of Functioning,
Disability and Health (ICF)the revised International
Classification of Impairments, Disabilities and Handicapshas the benefit of being an objective classification
system but is cumbersome for even simple descriptions15
and is not an assessment per se. Nevertheless, anyone
interested in the topic of disablement should be familiar
with the concepts embodied in the ICF.
Standardized tests allow for comparisons among
subjects with similar diagnoses and among diagnostic
groups. Investigators who use them, however, sometimes
see the forest and forget the trees. The literature is replete
with papers that report significant differences between
average test scores but omit the important details as to
what those test scores actually mean. Although many
reports indicate that people with vestibular disorders have
reduced functional independence and quality of life, few
papers describe the tasks that are particularly problematic. That type of detailed information is essential for program development and treatment planning.
Several studies have used subjects with more than
one diagnosis. In general, patients with vestibular disorders rate themselves as impaired in functional skills or
having decreased quality of life.1620 Individuals with
benign paroxysmal positional vertigo (BPPV) seem to be
less impaired than others; patients with Mnires disease
and head trauma are relatively more impaired.2,21,22 A
study of a heterogeneous group of patients with vestibular disorders showed that, in general, inability to walk
easily, restrictions in social life, and concerns about work
are especially common.23 Of particular concern is driving
ability, because driving a car is potentially hazardous to
the driver with a vestibular disorder as well as to other
DISABILITY IN VESTIBULAR DISORDERS
399
people. In industrialized countries, driving a motor vehicle is often essential for independent community mobility in the absence of adequate public transportation
systems, which are lacking in much of the United States.
Two studies have surveyed patients using instruments
specific to the problem of driving.24,25 Cohen et al.26 used
the Driving Habits Questionnaire, a well-normed instrument for doing a self-assessment by structured interview,
and modified it by adding questions on some topics likely to be specifically problematic for patients with
vestibular disorders.24 These investigators found that
56% of patients with postoperative vertigo, 22% of
patients with chronic vestibulopathy, and 15% of patients
with Mnires disease continued to drive despite their
physicians advice against it. Similarly, when Sindwani et
al.25 asked subjects whether they would continue to drive
if their physician said it would be dangerous, 52% said
they would. McKiernan and Jonathan27 are rightly concerned about this problem.
Benign Paroxysmal
Positional Vertigo
Only a few papers mention disability and functional limitations in BPPV. Epley28 noted that BPPV is at least
mildly disabling for many patients. Some patients, he
commented, must sleep sitting up. Some people with the
disorder are nauseated much of the time and, if their jobs
require upward pitch rotations of the head such as looking up (e.g., car mechanic), they may be unable to work.
Epley28 also noted that some patients may have
reduced ability to participate in active recreational activities. These observations were later supported by Cohen et
al.2 Herdman and Tusa29 described complications that can
occur after use of Epleys canalith repositioning maneuver. They noted that the patient in their Case 3 had such
severe disequilibrium that she had difficulty walking.
Disequilibrium so severe is unusual, but many patients
feel that they must walk more slowly and carefully than
usual. After treatment with repositioning maneuvers,
most patients report that they can walk more normally,
even though to the objective observer they may not have
appeared to be ataxic before treatment. This discrepancy
is easily explained. Many people are quite sensitive to
subtle changes in their movement skills and may be aware
of subtle differences that cannot be observed. Asking the
patient to walk for several steps and report how he or she
feels after treatment is an easy way to assess treatment
success immediately. If the patient has some ataxia, then
another trial of the maneuver may be indicated.
Cohen et al. have studied changes in ADLs in
patients with BPPV in more detail. Using a five-point,
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self-rated scale of ADL independence, Cohen and

Jerabek30 found that most patients with BPPV rated
themselves as having to use safety guarding for many
tasks before treatment, but rated themselves as independent after treatment. Similarly, using the VADL, Cohen et
al.2 reported that many patients with BPPV rated themselves as having mild discomfort or not performing tasks
as well as usual, and these ratings improved after intervention. For tasks that involved pitch (up/down) rotations
of the head, subjects rated themselves as having to be
more careful.
This finding is consistent with the clinical descriptions given by patients. Some patients complain of difficulty making the bed, putting away grocery items on
cupboard shelves, or changing a light bulb. Patients often
report having discomfort when they look up or when they
bend down to tie their shoes or reach for an object on the
floor. Parents and grandparents of young children complain of being unable to bend down to pick up a child.
More than one patient has complained of having vertigo
when reclined in the dentists chair. Occasionally, a
female patient complains of having had vertigo while her
hair was washed at the beauty salon. Although not usually handicapping, vertigo elicited by BPPV can be serious
enough to affect job performance, especially when the
occupational role involves significant vertical or pitch
rotations of the headthat is looking up or down. A
range of jobs can be affected, including car mechanic,
truck driver, nurse, dentist, and any scientist who uses a
light microscope.
Driving skills are of at least slight concern. In the
driving study by Cohen et al,24 many people with BPPV
reported having to be cautious; 23% reported having difficulty under conditions of degraded visibility, spatial
challenges, and busy traffic. By comparison, 14% of normals in the same survey reported having some difficulty.
Some subjects with BPPV limited their driving to local
roads and avoided highways, and some said they had
stopped driving altogether. This decreased community
mobility may influence the ability to go to work, run
errands, care for dependent children and disabled adults,
and otherwise participate in community life (Table 24-1).
Chronic Vestibulopathy
The term chronic vestibulopathy is used at Baylor College
of Medicine to refer to patients with chronic, recurrent,
brief episodes of vertigo elicited by head movement.
These patients have uncompensated labyrinthitis or
vestibular neuronitis, and unilateral weakness on bithermal caloric testing or reduced vestibulo-ocular reflex
(VOR) gains during low-frequency sinusoidal rotations in
darkness.31,32 They do not have Mnires disease. They

do have decreased independence in ADLs, as indicated by
scores on both the VADL and DHI.31 Decrements have
been found in all subscores of the VADL: functional,
ambulation, and instrumental or higher-level skills.
Problematic skills span the range of ADLs, including
bathing and dressing, ambulation on level and uneven surfaces, home management, and community mobility.16,33
These patients often decrease their activities outside the
home, forgoing participation in social activities such as
church groups, daily walking programs outside the home,
essential shopping trips, and other activities.34 After 4 to
6 weeks of vestibular rehabilitation, these scores improve.
The psychological construct of locus of control
that is, ones sense of ability to influence ones own
recoverywas weakly associated with improvements on
the VADL and more strongly associated with improvements on the DHI. This finding indicates the important
influence of psychological factors on functional recovery.
This idea is supported by a retrospective report from a
heterogeneous group of patients that showed a relationship between performance on tests of balance skills and
self-perceived handicap35 and by another report of the
relationship between symptoms and handicap.36
Driving skills are a concern in patients with chronic
vestibulopathy. They are often aware that they do not
drive well.2,16,33 In the driving study by Cohen et al,24
23% of subjects reported having difficulty driving under
conditions of degraded visibility, spatial challenges, and
busy traffic. Driving in the rain, at night, in freeway traffic, and in a ramped parking garage (where repeated turns
may elicit vertigo) were the most problematic. This group
reported having more driving problems than other patient
groups.
Bilateral Vestibular Impairment

Bilateral vestibular weakness causes disequilibrium and
oscillopsia. In his autobiographical case report, JC37 discussed the disabling effects of his own symptoms. In the
initial stage he had to stabilize his head against the bed
frame to reduce oscillopsia so he could read. Later, he
was still unable to read street signs or see faces clearly
while moving. Therefore, to avoid rudeness to his
acquaintances, he used the strategyconsidered socially
inappropriate in taciturn New Englandof greeting
everyone he passed on the street. Patients with bilateral
vestibular loss (BVL) are at significant risk of falling,
and their scores on the DHI total score and subscores
indicate perceived significant functional.38
No patients seen for vestibular rehabilitation at
Baylor College of Medicine have been unable to perform
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Chapter 24
401
Table 24-1 PERCENTAGE OF SUBJECTS HAVING DIFFICULTY WITH PARTICULAR

DRIVING CHALLENGES, BY DIAGNOSTIC GROUPS
Percent of Subjects Having Difficulty
Driving
Challenge
Normal
(n 51)
Postoperative
(n 9)
BPPV
(n 34)
CV
(n 27)
Mnires
Disease
(n 47)
Patients
vs.
Normal
Subjects
(P value)
Diagnostic
Groups
Differ
(P value)
Rain
35
50
36
67
40
0.024
0.019
Alone
67
26
67
29
0.001
0.001
Parallel parking
33
50
41
62
45
0.101
0.594
Left turns across

traffic
57
15
46
30
0.001
0.086
Freeway driving
12
62
15
67
26
0.011
0.001
High-traffic local
roads
13
43
13
58
33
0.022
0.028
Rush hour driving
21
57
19
59
31
0.004
0.063
Night
22
43
37
73
57
0.002
0.108
Parking spaces
10
56
15
44
21
0.037
0.015
Changing lanes
12
50
18
59
30
0.007
0.006
Staying in lane
56
12
44
17
0.001
0.005
Traffic checks
56
26
52
33
0.001
0.105
Ramped garages
10
43
29
61
35
0.003
0.333
BPPV benign paroxysmal positional vertigo; CV chronic vestibulopathy.

From Cohen et al, 2003,24 with permission of Elsevier.
personal care skills, but many of them have commented

on having to use safety guarding while taking a shower as
well as while doing household chores. Several people
have said they had to modify the way they performed
sports or have reduced their participation in athletics and
other leisure activities outside the home. Shortly after
developing bilateral vestibular weakness most people
have difficulty walking over uneven surfaces and must be
careful when walking on uneven sidewalks or across open
ground. No data, however, are available on these points.
No studies have evaluated the driving performance
of subjects with BVL per se, but these patients comment
consistently that they do not see details clearly while
driving. Of 34 patients with total or near-total BVL seen
at Baylor College of Medicine for vestibular rehabilitation over a 10-year period, 4 were unable to drive for reasons unrelated to their vestibular impairment; 10 had
stopped driving; and 20 could drive but complained of
having to drive more slowly and carefully than usual,
avoiding the highways whenever possible. All of the drivers complained of having difficulty reading the dashboard indicators and reading signs. This observation
suggests that patients with BVL have significant oscillopsia. This idea is supported by two studies. In the first
study, 7 of 10 patients with significant bilateral vestibular
weakness had decreased ability to select information
from an alphanumeric sign while being driven than while
sitting still.39 In the second study, patients with BVL had
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decreased dynamic visual acuity (DVA) compared to normals both while walking and while standing still.40
Although some of the patients in the second study were
aware of decreased DVA while walking, none were aware
of decreased DVA during quiet standing.
studied as inpatients for up to 6 days and as outpatients

for up to 3 months. Compared to results in a sham treatment group, vestibular rehabilitation given during the
inpatient, postoperative week did not influence recovery
during the inpatient period or during outpatient followup. As a whole, however, the sample showed clinically
and statistically significant improvements in ADL independence over time. As indicated in Figure 24.1 showing
previously unpublished data, Friedman repeated measures analysis of variance showed significant changes in
personal care activities (p 0.01) during the first postoperative week, which largely leveled off by Week 3. In
higher level skills not performed as in-patients, Wilcoxon
matched pairs signed rank tests indicated that skills
improved from Week 3 to Week 7 (p 0.03), but did not
change significantly from Week 7 to Week 13. Thus, in
the acute phase of recovery from acoustic neuroma resection patients have significant functional limitations in
their ability to care for themselves independently.
Return to work is related to the length of time after
surgery, the preoperative health status and motivation of
the patient, and the nature of the patients job. In two
reports, some subjects were unable to return to work or
had to change their jobs, but 70% to 79% of subjects
could return to their usual work.43,45 Another paper reported that 49% of patients who had undergone acoustic neu-
Acoustic Neuroma
In one of the first studies of the effect of acoustic neuroma resection on functional skills, Weigand and Fickel41
surveyed 541 members of the Acoustic Neuroma
Association who had undergone surgery in the decade
from the mid-1970s to the mid-1980s. Two percent to 5%
of respondents had difficulty returning to self-care activities, housework, and shopping, and 10% to 15% reported some sexual dysfunction. In a later, more detailed
examination of challenging tasks, routine self-care tasks
were affected minimally but climbing a ladder was difficult for more than 60% of subjects who had undergone
acoustic neuroma section.42 Bateman et al.43 subsequently reported that 6% of patients surveyed 1 to 3 years after
acoustic neuroma surgery had some difficulty climbing
stairs but that only 1% of respondents had difficulty gardening or doing household chores.
Cohen et al.44 studied a group of subjects after they
underwent acoustic neuroma resections. Subjects were
Mean Score
Lower Extremity Dressing
Ambulation
Toilet Transfers
4
3
2
1
3
Mean Score
21
49
91
Retreiving Objects
from the Floor
21
49
91
21
49
Occupational Role
Stair Climbing
4
3
2
1
21
49
Post-operative Day
91
21
49
Post-operative Day
91
21
49
Post-operative Day
Figure 24.1 Mean independence ratings for representative activities of daily living (1 independent; 5 dependent). Individual postoperative days are indicated in the first week; days 21, 49, and 91
are approximations. Occupational role refers to jobs or work. Error bars are 95% confidence intervals.
91
91
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Chapter 24
roma resection were able to return to work within 4

months and that 99% had returned to work within 1
year,46 a finding that was confirmed by two other studies
(see Fig. 24.1).42,44
These return-to-work data may be somewhat deceptive. Many patients complain that they need at least minor
adaptations to their jobs, often because of hearing loss but
sometimes due to blurred vision or disequilibrium. The
job responsibilities of some people change.42 Andersson
et al.47 pointed out that although only 12% of their 141
subjects were on sick leave or medical retirement after
acoustic neuroma resection, at least some of the 38%
of subjects who said they had retired for other reasons
may have been influenced to retire by their postoperative
status.
As with changes in measures of balance and
vestibulo-ocular reflex,44 changes in self-assessment of
disability or handicap usually stabilize by 3 months after
surgery.48 A retrospective study of military personnel and
civilians in high-risk jobs showed that of young to middle-aged adults who had cerebellopontine angle tumor
surgery and who voluntarily worked in high-risk occupations, 86% returned to their previous level of work performance.49 The investigators suggested that motivation
to return to their chosen careers was an important factor
for their subjects.
Driving a motor vehicle is essential for community
mobility in many places. Therefore, despite their surgeons instructions not to drive within the first postoperative month, many patients drive anyway.24 As with the
other diagnostic groups, driving is a challenging task for
these patients, more challenging under conditions of
degraded visual information. Not surprisingly, after
acoustic neuroma resection, many people say they have
difficulty driving at night; they do not have difficulty in
daylight.42 In a study conducted in Great Britain, 6% of
patients reported being unable to drive 1 to 3 years after
acoustic neuroma surgery.43 In the driving study by
Cohen et al.24 53% of postoperative acoustic neuroma
subjects reported having difficulty driving under a variety
of challenges, including conditions of degraded visibility,
spatial orientation problems, and busy traffic.
Social activities are also sometimes affected.
Weigand and Fickel41 reported that 8% of people had difficulty returning to social activities after acoustic neuroma
excision. Bateman et al.43 reported that 15% of their
patients had difficulty attending large social gatherings.
The specific social context affects participation. People
who had difficulty attending large gatherings may have
been disturbed by their hearing loss or difficulty localizing sounds. Indeed, Bateman et al.43 reported that 9.5% of
403
their subjects had difficulty localizing sound sources, and

6% had difficulty following a conversation in a crowd.
Postoperatively, patients have a small but significant
reduction in the rate of seeing friends weekly, but more
than 80% of subjects did see friends at least once a week
before and after surgery.42 Participation in sports was also
decreased postoperatively although that change was not
statistically significant.42 That finding is supported by
more recent work showing that 3% to 4% of respondents
to a survey reported having decreased their participation
in athletic activities.43 Although these numbers are small,
such changes may have had serious social ramifications
for the individuals affected.
The effect of tumor size on overall quality of life is
unclear. In one study patients with tumors smaller than
1.5 cm had a better postoperative quality of life than
patients with larger tumors,50 but other groups have
found that tumor size is not significantly related.42,48
Quality of life is not affected by age at time of surgery42,44,51,52 or by participation in vestibular rehabilitation in the acute phase of recovery.44,5052 One group has
reported that patients given vertigo habituation exercises
took longer to resume independent ambulation than
patients who did not have vestibular rehabilitation.51
The effect of facial nerve weakness after surgery
is also unclear. One report indicated that for many
patients, the effect on facial expressions and thus on
socialization is a significant factor in disablement,41 but
another report indicated that facial nerve weakness is
rarely disabling.4 Postoperative facial nerve weakness
is most likely to be an significant factor when eye closure
is affected, because difficulty blinking or closing the eyelid can lead to serious eye deformities and decreased
vision.
These data are interesting but do not tell the entire
story. Descriptions of research findings are necessarily
dry reading. Disablement, however, is anything but dry.
The difficult work involved in coping with the consequences of surgery is often emotionally charged and frustrating. Several patients with facial nerve damage have
commented that they no longer go out to restaurants with
friends or relatives because they are embarrassed about
drooling on the involved side. Some patients have said
that difficulty localizing sound with just one ear in a
noisy environment prevents them from going out to
social events and other community activities.
An extreme example illustrates the problem and the
multiple roles for therapists who do vestibular rehabilitation. A patient who lived alone complained of severe disequilibrium and falls 2 months after acoustic neuroma
surgery. She also complained that her eye was sore. She
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had not washed her clothes because she was unable to

negotiate the stairs in her apartment building leading to
the laundry facilities while carrying laundry. She was
unable to clean up the piles of laundry and papers on the
floors and work surfaces in her apartment and had fallen
on some of the piles. She was too embarrassed to ask for
help or to mention these problems to her physician.
Instead, she purchased more clothing and put all the dirty
laundry in bags. As well as doing balance therapy, the
occupational therapist who saw her for vestibular rehabilitation 2 months after surgery informed her ophthalmologist about the patients visual problems, and helped this
patient develop strategies for hand-washing lingerie, carrying other laundry items, and keeping her home better
organized and clutter-free.
The following paragraphs contributed by a patient
who is also a staff member make the experience of recovery from acoustic neuroma resection more vivid. Emily
K. Murphy, R.E.E.G.T., is a senior research technician in
the Center for Balance Disorders, Bobby R. Alford
Department of OtolaryngologyHead and Neck Surgery, Baylor College of Medicine. She runs the VIIth
nerve intraoperative monitoring service and often staffs
the kind of procedure she underwent. A creative and
enthusiastic individual, she took responsibility for her
own rehabilitation. Two years after her surgery, she
drives her car in heavy traffic, wears high heels occasionally, goes biking and canoeing, does award-winning
photography, and generally enjoys life. The following
two paragraphs are her words:
A couple of years ago, I was shocked to find out
that I had an acoustic neuroma, a tumor whose
removal I regularly monitor during surgery as
part of my work. I remember thinking prior to
this that it was, No big deal. . . . Youve got the
tumor, you just get it out. Its a different ball
game when its in your field. Prior to surgery, I
had bilaterally equal vestibular function. When I
awoke from surgery, I felt as if I were in a centrifuge. By the second day, I had slowed down to
2 rpm, which was tolerable. The first month, with
my head and eye movements relatively uncoordinated, I tired easily. I can remember sitting in the
doctors office, looking at a nebulous pattern on
the carpet, and the whole floor seeming to shimmerwithout my moving at all! Recovery was
gradual (partly, I believe, because my good ear
isnt that good). Doing things like jigsaw puzzles
was good brain training, and safe because I was
sitting. It was hard work, and after 15 minutes I
would break out in a sweat from the effort and
have to take a break. After a rest, I would go at it

again, gradually lengthening my tolerance. The
ultimate challenge, though, was walking. Turning
my head from side to side as I walked threw me
off balance. If I were walking down the street and
heard a car, I had to stop to turn and look.
Even today, the hardest situation for maintaining my balance is leaving a movie theater near
us. It has the unfortunate design of having small
rows of lights at the edge of each step. In the
dark, the bright lights are disorienting. With this
decreased visual reference, I have almost fallen
but was saved by my faithful husband. We have
learned to let him go down first, and I keep my
hand on his shoulder to steady myself. Even after
over two years, I still have some problems with
balance at night, walking with a flashlight, etc.
However, the good news is there is nothing I
dont do or try. I climb ladders (daytime!), use
power tools, sail our catamaran, use a treadmillanything I want to do. I just must be cautious when suddenly turning. I think attitude is
extremely important. Instead of moaning about
why me? one must look at each gain as a goal.
The choice is being depressed about it for the rest
of your life, or looking at it as a bump in the road
of life. At some point you reach the top of the
hill, and things start coming more easily.
Mnires Disease
A peculiarity of Mnires disease is that the symptoms
come and go. The intermittent nature of symptoms means
that patients may feel normal or have a constant low level
of discomfort and disability in between attacks or
episodes but they feel significantly worse during exacerbations, with consequent greater disability. Patients with
Mnires disease have a significantly reduced quality of
life on days when they have increased symptoms; on days
when they have significant Mnires attacks, they are
the most debilitated (Fig. 24.2).53,54 Haye and QuistHanssen,55 surveyed 111 patients with Mnires disease
seen between 1960 and 1970. They reported that
Mnires symptoms and fear of a Mnires attack are
incapacitating. They found that 23% to 46% of subjects
had difficulty walking at dusk, were unfit for work or
took early retirement, and had problems at work, at
home, and among friends. Fifty-five percent of their subjects complained of nervousness.
Pharmacological and surgical interventions have
improved considerably since the 1960s, so differences in
reported percentages of disability from the mid-20th cen-
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Chapter 24
Mean Independence
5
4
3
Legend:
Out of Bed
LE Dressing
Walking
2
1
Usually
Meniere's Attack
Figure 24.2 Mean independence ratings for representative

activities of daily living using a 5-point scale during quiescent
periods when the patient feels relatively normal (left side of
each pair) and during attacks of Mnires disease (right side
of each pair). Error bars are 95% confidence intervals; LE
lower extremity.
tury to the early 21st century are not surprising. Nevertheless, subsequent studies have consistently supported
the findings of difficulties within the home, at work, to
when socializing as well as concerns about having future,
incapacitating Mnires attacks.
In a study using the DHI, 53% of patients rated
themselves as moderately to severely handicapped;
unfortunately, details from the DHI subscales were not
provided.56 That study also showed that on the MOS SF36, patients with Mnires disease had lower scores on
the emotional subscale than the physical subscales, from
which the authors surmised that the psychological effects
of the disorder are handicapping. A later report indicated
that patients with Mnires disease have lower scores on
both physical and mental subscores of a short version of
the MOS SF-36, the MOS SF-12, and on other measures,54 supporting the earlier findings.56
Similarly, using a mail survey, another group asked
subjects about their function in the preceding 6 months.57
Subjects reported generally reduced life satisfaction with
particular influence on leisure time and work. Unsteadiness, insomnia, anxiety, and lack of concentration were
all significant complaints. Mnires attacks were highly
disruptive; 82% of subjects always or often discontinued
their activities. Seventy-four percent of subjects avoided
activities such as meetings, telephone calls, dinner, and
physical activities. Thus, the majority of subjects avoided the kinds of activities involved in many jobs, social
activities, and even volunteer work, child care, and home
management.
Cohen et al.53 surveyed 51 patients with Mnires
disease by mail to learn about their independence in selfcare, mobility, and instrumental ADLs. These investiga-
405
tors found that during episodes of symptom exacerbation,

Mnires patients have difficulty using a telephone and
doing other tasks that require good hearing; they also
have particular difficulty with tasks that require good balance. At other times, they are independent (see Fig. 24.2).
In a study of patients after treatment with surgery or
gentamicin, Soderman et al.58 reported that quality of life,
as measured by several scales, was generally good or very
good. They found that vertigo, tinnitus, and hearing loss
were all related to self-rated quality of life and all had
equal influences. This difference from the Cohen study is
attributed to successful treatment of vertigo by surgical or
pharmacological intervention. When vertigo was successfully treated, patients were still bothered by the other
symptoms. Vertigo had a greater influence on physical
functional limitations, but hearing problems had a greater
influence on psychosocial problems.59 This differentiation
explains earlier findings.53,56 A subsequent study that used
structured interviews with patients with Mnires disease, however, suggests a more complicated relationship
between disability and psychological factors. The interviews revealed that many patients with Mnires disease
have phobic reactions due to fear of having a Mnires
attack or to fear of ridicule for their ataxia, which might
be mistaken for evidence of drunkenness.60
Two years after treatment with gentamicin, a group
of patients with Mnires disease had significant
improvement on the DHI; that improvement was retained
5 years later.61 In light of work showing different effects
of vertigo and hearing impairment on quality of life
measures, the omission of data from the DHI subscales in
this study is unfortunate. In a study of patients with
Mnires disease treated with gentamicin, the pretreatment DHI scores were relatively high but dropped significantly over the 2-year follow-up period.62 Interestingly in light of the findings reported by Soderman et
al.,59 scores on the Functional subscale decreased more
than the Physical or Emotional subscales, although all
subscales showed decreased scores.61 Although vertigo
also decreased, the relationship of changes in vertigo to
changes on the subscales is unclear.
Return to work by patients with Mnires disease
varies. In the study by Cohen et al.,53 most subjects who
held paid employment reported that they continued to
work, but 86% felt that their job performance suffered,
and 70% had to adapt their jobs in some way. These data
hint at the economic costs of this disorder (see Fig. 24.2).
A survey of 133 patients with Mnires disease 2 years
after their initial diagnoses, unfortunately without statistical analyses of the data, suggested that many subjects
who declined surgery but had received medication still
had improvements in their self-ratings on a 4-point scale
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of disability.63 Initially, 23% rated themselves as moderately or totally disabled, but 2 years later that number
decreased to 10%. In another large mail survey of 261
patients treated by the same surgeons, 99% of subjects
who had been working were able to return to their jobs
within 6 months, but 13% of subjects either had stopped
working or were fired, and 7% of subjects had retired.46
Thus, some individuals may have overestimated their
abilities or found that the sequelae of surgery were too
disabling. By contrast, in an interview study of 18 subjects, 9 had returned to work, 7 did not return to work,
and 2 had retired preoperatively.64
The intensity of attacks in Mnires disease varies,
and the intensity of an attack affects the individuals ability to function while it occurs. Twelve percent of subjects
surveyed by Cohen et al.53 had no safe place to rest during an attack. The availability of a safe place to rest during an attack and the unpredictability of attacks were not
correlated with whether or not the subject continued to
work. Havia and Kentala65 reported that 17% of their
subjects were able to continue their activities during
Mnires attacks, but 56% of subjects had to lie down
and 27% were completely incapacitated.
In rehabilitation, we often assess specific functional
limitations but we may ignore the important psychosocial
consequences. We may also ignore, or be unable to evaluate, individual coping styles. Nevertheless, personality
factors strongly influence recovery in rehabilitation. As
Emily Murphy wrote so clearly in the Acoustic Neuroma
section of this chapter, a positive attitude is essential.
Soderman et al.58 made the important point that quality of
life is related not only to symptoms but also to the ability to manage stress. Similarly, the interviews by
Erlandsson et al.60 revealed that stress and poor coping
strategies exacerbate the disabling and isolating effects of
the disorder. Thus, stress management interventions
might be indicated to improve quality of life in some
patients with Mnires disease.
Driving an automobile can be but is not always
problematic for patients with Mnires disease. In a mail
survey of Mnires patients, 60% of respondents reported that driving was difficult, dangerous, or both.53 In their
structured interview study on driving problems, Cohen et
al.24 found that 33% of patients with Mnires disease
report having difficulty driving under conditions of
degraded visibility, spatial challenges, and busy traffic.
Also, patients with this disorder reported having had to
pull off the road due to vertigo more often than any other
patient group. Cohen et al. found no difference in crash
rate between normals and patients with vestibular disorders, including patients with Mnires disease.24
Sindwani et al.,25 however, found that 13% of patients
with Mnires disease reported having injured themselves. The circumstances of injury were not clear. These
data suggest that having adequate public transportation
systems is important so that patients with this disorder
can avoid driving. Many metropolitan areas lack good
public transportation. Therefore, having good shoulders
on roads, where drivers can pull over in emergencies, is
essential.
Acknowledgments
Supported by NIH grant DC003602. Special thanks to
Emily K. Murphy, B.S., R.E.E.G.T., for her comments,
to Sharon Congdon, B.S., for assistance with figures, and
to Aletta Moore, B.A., Dip. Lib., for assistance with references.
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Is perception of handicap related to functional performance in persons with vestibular dysfunction? Otol
Neurotol 2004;25:139143.
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36. Yardley L, Hallam RS: Psychosocial aspects of balance

and gait disorders. In: Bronstein AM, Brandt T,
Woollacott M, eds. Clinical Disorders of Balance,
Posture and Gait. London: Arnold; 1996:251267.
37. JC: Living without a balancing mechanism. N Engl
J Med 1952;246:458460.
Physical therapy outcomes for persons with bilateral
39. Clack TD, Milburn WO, Graham MD: Ear-eye reflexes while riding in a car. Laryngoscope 1985;95:
182185.
40. Hillman EJ, Bloomberg JJ, McDonald VP, Cohen HS:
Dynamic visual acuity while walking in normals and
labyrinthine deficient patients. J Vestib Res 1999;9:
4957.
41. Weigand DA, Fickel V: Acoustic neuromathe patients
perspective: subjective assessment of symptoms, diagnosis, therapy, and outcome in 541 patients. Laryngoscope
1989;99:179187.
42. Chung JH, Rigby PL, Jackler RK, et al: Socioeconomic
impact of acoustic neuroma surgery. Am J Otol 1997;18:
436443.
43. Bateman N, Nikolopoulos P, Robinson K, ODonoghue
GM: Impairments, disabilities, and handicaps after acoustic neuroma surgery. Clin Otolaryngol 2000;25:6265.
44. Cohen HS, Kimball KT, Jenkins HA: Factors affecting
recovery after acoustic neuroma resection. Acta
Otolaryngol 2002;122:841850.
45. Nikolopoulos TP, Johnson I, ODonoghue GM: Quality
of life after acoustic neuroma surgery. Laryngoscope
1998;108:13821385.
46. Parving A, Tos M, Thomsen J, et al: Some aspects
of life quality after surgery for acoustic neuroma.
Arch Otolaryngol Head Neck Surg 1992;118:
10611064.
47. Andersson G, Ekvall L, Kinnefors A, et al: Evaluatio
of quality of life and symptoms after translabyrinthine
acoustic neuroma surgery. Am J Otolaryngol 1997;18:
421426.
48. Humphriss R, Baguley DM, Moffat DA: Change in dizziness handicap after vestibular schwannoma excision. Otol
Neurotol 2003;24:661665.
49. Yu KCY, Arriaga MA, Chen DA: Cerebellopontine angle
tumor outcomes in patients with hazardous occupations.
Laryngoscope 1997;107:16101613.
50. Irving RM, Beynon GJ, Viani L, et al: The patients perspective after vestibular schwannoma removal: quality
of life and implications for management. Am J Otol 1995;
16:331337.
51. El-Kashlan HK, Shepard NT, Arts A, Telian SA:
Disability from vestibular symptoms after acoustic
neuroma resection. Am J Otol 1998;19:104111.
52. Mruzek M, Barin K, Nichols DS, et al: Effects of vestibular rehabilitation and social reinforcement on recovery
following ablative vestibular surgery. Laryngoscope 1995;
105:686692.
53. Cohen H, Ewell LR, Jenkins HA: Disability in Mnires
disease. Arch Otolaryngol Head Neck Surg 1995;121:
2933.
54. Anderson JP, Harris JP: Impact of Mnires disease on
quality of life. Otol Neurotol 2001;22:888894.
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55. Haye R, Quist-Hanssen S: The natural course of Mnires

disease. Acta Otorhinolaryngol 1976;82:289293.
56. Kinney SE, Sandridge SA, Newman CW: Long-term
effects of Mnires disease on hearing and quality of life.
57. Hagnebo C, Melin L, Larsen HC, et al: The influence
of vertigo, hearing impairment and tinnitus on the
daily life of Meniere patients. Scand Audiol 1997;
26:6976.
58. Soderman ACH, Bergenius J, Bagger-Sjoback D, et al:
Patients subjective evaluations of quality of life related
to disease-specific symptoms, sense of coherence, and
treatment in Mnires disease. Otol Neurotol 2001;
22:526533.
59. Soderman SCH, Bagger-Sjoback D, Bergenius J, Langius
A: Factors influencing quality of life in patients with
Mnires disease, identified by a multidimensional
approach. Otol Neurotol 2002;23:941948.
60. Erlandsson SI, Eriksson-Mangold M, Wiberg A: Mnires

disease: trauma, distress and adaptation studied through
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61. Atlas J, Parnes LS: Intratympanic gentamicin for intractable Mnires disease: 5-year follow-up. J Otolaryngol
2003;32:288293.
62. Perez N, Martin E, Garcia-Tapia R: Intratympanic gentamicin for intractable Mnires disease. Laryngoscope
2003;113:456464.
63. Silverstein H, Smouha E, Jones R: Natural history vs.
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64. Pereira KD, Kerr AG: Disability after labyrinthectomy.
J Laryngol Otol 1996;110:216218.
65. Havia M, Kentala E: Progression of symptoms of dizziness in Mnires disease. Arch Otolaryngol Head Neck
Surg 2004;130:431435.
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CHAPTER
25
Assessment and
Management of Disorders
Affecting Central
Vestibular Pathways
Vestibular pathways run from the VIIIth nerve and the

vestibular nuclei through ascending fibers, such as the
ipsilateral or contralateral medial longitudinal fasciculus
(MLF), the brachium conjunctivum, or the ventral tegmental tract to the ocular motor nuclei, the supranuclear
integration centers in the rostral midbrain, and the
vestibular thalamic subnuclei. From there they reach several cortex areas through the thalamic projection. Another
relevant ascending projection reaches the cortex from
vestibular nuclei via vestibular cerebellum structures.
In the majority of cases, central vestibular vertigo
syndromes are caused by dysfunction or a deficit of sensory input induced by a lesion. In a small proportion of
cases, they are due to pathological excitation of various
structures, extending from the peripheral vestibular organ
to the vestibular cortex. Because peripheral vestibular disorders are always characterized by a combination of perceptual, ocular motor, and postural signs and symptoms,
central vestibular disorders may manifest as a complete
syndrome or with only single components. The ocular
motor aspect, for example, predominates in the syndromes
of upbeat or downbeat nystagmus. Lateral falls may occur
without vertigo in vestibular thalamic lesions (thalamic
astasia) or as lateropulsion in Wallenbergs syndrome.1
Clinical Classification
of Central Vestibular Disorders
The elementary neuronal network of the vestibular system is the di- or trisynaptic vestibulo-ocular reflex (VOR).
There is evidence for a useful simple clinical classification of central vestibular syndromes according to the three
major planes of action of the VOR (Fig. 25.1): yaw, roll,
and pitch.24
The plane-specific vestibular syndromes are determined by ocular motor, postural, and perceptual signs as
follows:
Yaw plane signs are horizontal nystagmus, past
pointing, rotational and lateral body falls, and
horizontal deviation of perceived straight-ahead.
Roll plane signs are torsional nystagmus, skew
deviation, ocular torsion, and tilts of head, body,
and perceived vertical.
Pitch plane signs are upbeat/downbeat nystagmus, forward/backward tilts and falls, and vertical deviations of perceived straight-ahead.
The defined VOR syndromes allow for a precise
topographic diagnosis of brainstem lesions as to their
level and side, as follows (Fig. 25.2):
A tone imbalance in yaw indicates lesions of the
lateral medulla, including the root entry zone of the
VIIIth nerve and/or the vestibular nuclei.
A tone imbalance in roll indicates unilateral lesions
(ipsiversive at pontomedullary level, contraversive
at pontomesencephalic level).
A tone imbalance in pitch indicates bilateral (paramedian) lesions or bilateral dysfunction of the
cerebellum, especially the flocculus.
409
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Figure 25.1 Schematic representation

of the three major planes of action of the
vestibulo-ocular reflex. yaw horizontal
rotation about the vertical z axis; pitch
vertical rotation about the binaural y axis;
roll vertical rotation about the x axis (line
of sight). (Courtesy of Alice Kniehase.)
Some vestibular disorders are characterized by a

simultaneously peripheral and central vestibular involvement. Examples are large acoustic neurinomas, infarctions of the anterior inferior cerebellar artery, head
trauma, and syndromes induced by alcohol intoxication. Others may affect the vestibular nerve root in the
brainstem, where the transition between the peripheral
and central nervous systems has been defined as the
Redlich-Oberstein zone (lacunar infarction or focal
demyelination in multiple sclerosis [MS] mimicking
vestibular neuritis).
Cortical vestibular syndromes include vestibular
seizures and lesional dysfunction with tilt of the perceived
vertical, lateropulsion, and, rarely, rotational vertigo.
There is no primary vestibular cortex, but the parietoinsular vestibular cortex (PIVC)5 seems to act as a kind of
main integration center. Dysfunction of this multisensory
and sensorimotor cortex for spatial orientation and selfmotion perception may be involved in spatial hemineglect
and rare paroxysmal room-tilt illusions.
Most central vertigo syndromes have a specific
locus (Table 25-1) but not a specific etiology. The etiology may, for example, be vascular, autoimmunological as
in MS, inflammatory, neoplastic, toxic, or traumatic.
in (Frontal) Roll Plane
The graviceptive input from the otoliths converges with
that from the vertical semicircular canals (SCCs) at the
level of the vestibular nuclei6 and the ocular motor
nuclei7,8 to subserve static and dynamic vestibular function in pitch (up and down in the sagittal plane) and roll
(lateral tilt in the frontal plane). In the normal position
in the roll plane, the subjective visual vertical (SVV) is
aligned with the gravitational vertical, and the axes of the
eyes and the head are horizontal and directed straight
ahead.
Signs and symptoms of a vestibular dysfunction in
the roll plane can be derived from the deviations from
normal function. A lesion-induced vestibular tone imbalance results in a syndrome consisting of a perceptual tilt
(SVV), vertical misalignment of the visual axes (skew
deviation), ocular torsion, or a complete ocular tilt reaction (OTR; the triad of head tilt, skew deviation, and ocular torsion).
There is convincing evidence that all of the following signs and symptoms reflect vestibular dysfunction in
the (frontal) roll plane:
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ASSESSMENT AND MANAGEMENT OF DISORDERS AFFECTING CENTRAL VESTIBULAR PATHWAYS
411
Figure 25.2 Vestibular syndromes in roll, pitch, and yaw planes: Critical areas are schematically
represented on the basis of our current knowledge of vestibular and ocular motor structures and
pathways, a lesion of which causes a vestibular tone imbalance in one of the three major planes of
action. The mere clinical sign of a vertical, torsional, or horizontal nystagmusif central-vestibular
allows a topographic diagnosis of the lesion, although the particular vestibular structures involved are
still under discussion. Whereas a vestibular tone imbalance in the roll plane indicates unilateral brainstem lesions (a crossing in the pons), vertical nystagmus indicates bilateral lesions. Two separate
causative loci are known for upbeat nystagmus, medullary and pontomesencephalic. Downbeat nystagmus indicates a bilateral paramedian lesion of the commissural fibers between the vestibular
nuclei or a bilateral flocculus lesion. Horizontal nystagmus indicates unilateral pontomedullary lesions
involving the vestibular nuclei. The differentiation of vestibulo-ocular motor signs according to the
three major planes of action of the vestibulo-ocular reflex (VOR) and their mapping to distinct and
separate areas in the brainstem are helpful for topographic diagnosis and for avoiding incorrect
assignment of clinical signs to brainstem lesions identified with imaging techniques. INC interstitial
nucleus of Cajal; MLF medial longitudinal fasciculus; VN vestibular nucleus.3
OTR
Skew deviation (skew-torsion sign)
Spontaneous torsional nystagmus
Tonic ocular torsion (monocular or binocular), if
not caused by infranuclear ocular motor disorders
Tilt of perceived SVV (with binocular and
monocular viewing)
Body lateropulsion
Ocular motor or postural tilts as well as maladjustments of SVV point in the same direction, either clockwise or counterclockwise (as seen from the viewpoint of
the examiner). The direction of all tilts is reversed if
pathological excitation of unilateral graviceptive pathways is the cause of vestibular tone imbalance in roll
rather than a lesional input deficit. The combination of
static and dynamic signs is not surprising if one considers
the functional cooperation of otoliths and vertical SCCs
owing to their neuronal convergence within graviceptive pathways. These signs and symptoms may be found
in combination or as single components at all brainstem
levels. A systematic study of 111 patients with acute unilateral brainstem infarctions showed that pathological tilts
of SVV (94%) and ocular torsion (83%) are the most sensitive signs.9 Skew deviation was found in one third and a
complete OTR in one fifth of these patients (Table 25-2).
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Table 25-1 CENTRAL VESTIBULAR SYNDROMES

Site
Syndrome
Mechanism/Etiology
Vestibular cortex
(multisensory)
Vestibular epilepsy
Vestibular seizures are auras (simple or complex partial multisensory seizures)
Volvular epilepsy
Sensorimotor vestibular rotatory seizures with walking in

small circles
Nonepileptic cortical vertigo
Rare rotatory vertigo in acute lesions of the parietoinsular

vestibular cortex
Spatial hemineglect (contraversive)
Multisensory horizontal deviation of spatial attention with

(right) parietal, temporal, or frontal cortex lesions
Transient room-tilt illusions
Paroxysmal or transient mismatch of visual and vestibular 3D

spatial coordinate maps in vestibular brainstem, parietal, or
frontal cortex lesions
Tilt of perceived vertical with

body lateropulsion (mostly
contraversive)
Vestibular tone imbalance in roll with acute lesions of the

parietoinsular vestibular cortex
Thalamic astasia
Dorsolateral vestibular thalamic lesions
Tilt of perceived vertical

(ipsiversive or contraversive)
with body lateropulsion
Vestibular tone imbalance in roll
OTR (contraversive; ipsiversive if paroxysmal)
Vestibular tone imbalance in roll (integrator: OTR with INC

lesions)
Torsional nystagmus (ipsiversive or contraversive)
Ipsiversive in INC lesions
Thalamus
Mesodiencephalic
brainstem
Contraversive in riMLF lesions

Mesencephalic
brainstem
Skew torsion (contraversive)
Vestibular tone imbalance in roll with MLF lesions
Ponto-medullary
brainstem
Upbeat nystagmus
Tone imbalance in pitch in bilateral lesions of the central

tegmental tract or the brachium conjunctivum
Tilt of perceived vertical, lateropulsion, OTR
Vestibular tone imbalance in roll with medial and/or superior

vestibular nuclei lesions
Pseudovestibular neuritis
Lacunar infarction or MS plaque at the root entry zone of the

VIIIth nerve
Downbeat nystagmus
Tone imbalance in pitch or asymmetry in the distribution of

on-directions of vertical gaze-velocity Purkinje cells
Transient room-tilt illusion
Acute severe vestibular tone imbalance in roll or pitch
Paroxysmal room-tilt illusion

in MS
Transversally spreading ephaptic axonal activity

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413
Table 25-1 CENTRAL VESTIBULAR SYNDROMES (continued)

Site
Syndrome
Mechanism/Etiology
Paroxysmal dysarthria/ataxia in MS
Transversally spreading ephaptic axonal activation
Medulla
Upbeat nystagmus
Tone imbalance in pitch in a paramedian lesion of the cerebellar loop of the central tegmental tract (nucleus prepositus
hypoglossi)
Vestibular
cerebellum
Downbeat nystagmus
Tone imbalance in pitch or asymmetry in the distribution of

on-directions of vertical gaze-velocity Purkinje cells caused
by bilateral flocculus lesions (disinhibition)
Positional downbeat nystagmus
Disinhibited otolith-canal interaction in nodulus lesions?
Familial episodic ataxia (EA1 with

myokymia and EA2 with vertigo)
EA1 autosomally dominant inherited potassium channelopathy

EA2 autosomally dominant inherited calcium channelopathy
Epidemic vertigo
Viral infection of cerebellum
INC interstitial nucleus of Cajal; MS multiple sclerosis; OTR ocular tilt reaction; riMLF right medial longitudinal fasciculus.
Table 25-2 FREQUENCY OF SUBJECTIVE VISUAL VERTICAL (SVV) TILT, SKEW

DEVIATION, OCULAR TORSION, AND OCULAR TILT REACTION (OTR)
IN ACUTE UNILATERAL BRAINSTEM AND THALAMIC INFARCTIONS
Ocular Torsion (%)
Lesion
Patients
(No.)
SVV
Tilt (%)
Monocular
Binocular
Skew
(%)
OTR
(%)
Paramedian thalamic
14
64
29*
43*
57
57
Posterolateral thalamic
17
65
13
20
Anterior polar thalamic
Mesencephalic
16
94
54
38
37.5
25
Pontomesencephalic
12
92
64
18
25
25
Pontine
34
91
47
33
26.5
12
Pontomedullary
13
100
60
20
23
7.7
Medullary (Wallenbergs
syndrome)
36
94
27
55
44
33
111
94
47
36
31
Mesodiencephalic
Total
*Additional
Slight
third nerve palsy.

torsion of about 2.8.
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Current clinical data support the following preliminary topographic diagnostic rules based on vestibular
signs and symptoms in roll3,4 (Fig. 25.3):
1. The fundamental pattern of eye-head tilt in
rolleither complete OTR or skew torsion
without head tiltindicates a unilateral peripheral deficit of otolith and vertical canal input or
a unilateral lesion of graviceptive brainstem
pathways from the vestibular nuclei (crossing
midline at lower pontine level) to the interstitial
nucleus of Cajal (INC) in the rostral midbrain.
2. Tilts of SVV, resulting from peripheral or central vestibular lesions from the labyrinth to the
vestibular cortex, are the most sensitive signs of
a vestibular tone imbalance in roll.
3. All tilt effectsperceptual, ocular motor, and
posturalare ipsiversive (ipsilateral eye lowermost) and due to unilateral peripheral or pontomedullary lesions below the crossing of the
graviceptive pathways. They indicate involvement of the labyrinth, vestibular nerve, or medial and/or superior vestibular nuclei; the last are
mainly supplied by the vertebral artery.
Figure 25.3 Vestibular syndromes in roll

plane: Graviceptive pathways from otoliths and
vertical semicircular canals mediating vestibular
function in roll plane. The projections from the
otoliths and the vertical semicircular canals to
the ocular motor nuclei (trochlear nucleus IV,
oculomotor nucleus III, abducens nucleus VI),
the supranuclear centers of the interstitial
nucleus of Cajal (INC), and the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) are shown. They subserve the
vestibulo-ocular reflex (VOR) in three planes.
The VOR is part of a more complex vestibular
reaction that also involves vestibulospinal connections via the medial and lateral vestibulospinal tracts for head and body posture
control. Furthermore, connections to the
assumed vestibular cortex (areas 2v and 3a
and the parietoinsular vestibular cortex [PIVC])
via the vestibular nuclei of the thalamus (Vim,
Vce) are depicted. Graviceptive vestibular
pathways for the roll plane cross at the pontine
level. Ocular tilt reaction (OTR) (skew torsion,
head tilt, and tilt of perceived vertical, subjective visual vertical [SVV]) is depicted schematically on the right in relation to the level of the
lesion: ipsiversive OTR with peripheral and
pontomedullary lesions; contraversive OTR
with pontomesencephalic lesions. In vestibular
thalamic lesions, the tilts of SVV may be contraversive or ipsiversive; in vestibular cortex
lesions, they are preferably contraversive. OTR
is not induced by supratentorial lesions above
the level of INC.3
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4. All tilt effects in unilateral pontomesencephalic

brainstem lesions are contraversive (contralateral eye lowermost) and indicate involvement
of the MLF (paramedian arteries arising from
basilar artery) or INC (paramedian superior
mesencephalic arteries arising from the basilar
artery).
5. OTR with unilateral (ponto) medullary lesions
(vestibular nuclei) indicates the ascending
(reflexive) type of a tone imbalance of the
VOR in roll.
6. OTR owing to rostral midbrain lesions (INC)
reflects the descending type of tone imbalance involving the neural integration center for
eye-head coordination in roll.
7. Skew deviation is always combined with ocular
torsion (skew-torsion sign). It manifests without head tilt if ascending pontomesencephalic
graviceptive pathways are affected rostral to
the downward branching of the vestibulospinal
tract.
8. Unilateral lesions of ascending vestibular pathways rostral to the INC typically manifest with
deviations of perceived vertical without concurrent eye-head tilt.
9. OTR in unilateral paramedian thalamic infarctions (paramedian thalamic arteries from basilar artery) indicates simultaneous ischemia of
the paramedian rostral midbrain, including the
INC.
10. Unilateral lesions of the posterolateral thalamus can cause thalamic astasia and moderate
ipsiversive or contraversive SVV tilts, thereby
indicating involvement of the vestibular thalamic subnuclei (thalamogeniculate arteries).
11. Unilateral lesions of the PIVC cause moderate,
mostly contraversive SVV tilts (temporal
branches of the middle cerebral artery or deep
perforators) and cortical lateropulsion.
12. An SVV tilt found with monocular but not
with binocular viewing is typical for a
trochlear or oculomotor palsy rather than a
supranuclear graviceptive brainstem lesion.10
Tilt effects caused by paroxysmal activation of
graviceptive pathways point in the opposite direction to
those caused by lesional inhibition, such as unilateral
infarction.1114 Thus, all clinical signs of vestibular dysfunction in roll can be helpful when one is determining
not only the level but also the side of the brainstem lesion.
If the level of damage is known from the clinical syndrome, the vestibular syndrome indicates the more
415
severely affected side. Conversely, if the side of damage

is clear from the clinical syndrome, the direction of OTR,
skew deviation, and SVV tilt indicates the level on the
brainstem.
Etiology
The two most common causes of tonic OTR are brainstem
ischemia (especially Wallenbergs syndrome and unilateral paramedian thalamic plus rostral mesencephalic infarctions) and brainstem tumors.11,15 We have also seen cases
with unilateral thalamic hemorrhages or lower brainstem
hemorrhages (cavernous angioma, lymphomas), after
severe brainstem concussion, in MS, or associated with
attacks of basilar migraine.
The paroxysmal OTR described in a patient with
MS13 may be a variant of the paroxysmal attacks assumed
to arise from ephaptic spreading between adjacent
demyelinated axons. We have observed repeated paroxysmal attacks of contraversive OTR with ipsiversive torsional nystagmus in the acute stage of Wallenbergs
syndrome and in neurovascular cross-compression of the
VIIIth nerve.
Natural Course and Management

The natural course and management of OTR depend on
the etiology. OTR is usually transient; in cases of hemorrhage or infarction, recovery occurs within a few days to
weeks. However, it can be permanent, as we observed in
a patient with severe brainstem concussion. Following
unilateral brainstem infarctions, all features of OTR
postural, ocular motor, and perceptualdisappear naturally and gradually within 4 to 6 weeks or months
(repeated measurements made in 7 patients over a period
of up to 1 to 3 years16) (Fig. 25.4). We found that repeated measurements of skew deviation, ocular torsion (OT),
and tilts of SVV made during a single day showed consistent tilts.9 Repeated measurements on subsequent days
showed a gradual recovery, mostly within 30 days, both
for OT and SVV (Fig. 25.5). Some patients, however,
maintained a residual OT of a few degrees without a corresponding tilt of SVV for up to 2 years.
Recovery is probably based on a functionally significant central compensation of a vestibular tone imbalance
induced by a unilateral central lesion. The mechanisms
underlying central compensation of central lesions may
be similar to those of central compensation of peripheral
vestibular lesions. Physical therapy may facilitate this
central compensation, but this possibility has not yet
been proven in a prospective study.
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Figure 25.4 (A) Patient with a left paramedian thalamic infarction presenting with a complete
ocular tilt reaction (OTR) to the right. OTR consisted of contraversive head tilt of 20 degrees
(bottom); skew deviation of 10 degrees, left eye over right eye; and ocular torsion of 15 to 20
degrees (counterclockwise from the viewpoint of the observer). (B) Natural course of ocular
torsion, skew deviation (SD), and tilt of subjective visual vertical (SVV, in degrees) shows gradual
recovery in 6 weeks. RE right eye; LE left eye.16
Figure 25.5 Two representative time courses of deviations of subjective visual vertical (SV V) and
ocular torsion (OT) (separate for the left and right eyes) in a patient with Wallenbergs syndrome on
the left (A) and a patient with unilateral lesion of the region of the interstitial nucleus of Cajal (INC)
in the rostral midbrain tegmentum (B). Note the dissociated effects in the patient with Wallenbergs
syndrome; OT and SVV are deviated most in the ipsilateral left eye. Comparison of individual OT and
SV V values in the two patients shows varying dissociations of the net tilt. Both tend to normalize
within 4 to 6 weeks, and fluctuations cannot be explained simply by methodological inaccuracy.
d days; m months; VD vertical divergence as skew deviation.9
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Paroxysmal OTR in MS has been treated effectively

with carbamazepine,13 and baclofen has been reported to
be of some therapeutic benefit in a patient with paroxysmal OTR and brainstem abscess.14
Thalamic and Cortical Astasia

Associated with Subjective
Visual Vertical Tilts
An association of SVV tilts with falls is also typical
for posterolateral (vestibular subnuclei) thalamic lesions.
Thalamic astasia17 is a condition in which patients without paresis or sensory or cerebellar deficits are unable to
maintain an unsupported, upright posture. Postural imbalance with a transient tendency to fall has been reported
after therapeutic thalamotomy and thalamic hemorrhage.18 According to our experience in some 30 patients
with thalamic infarctions, the posterolateral type may
cause contraversive or ipsiversive postural instability with
SVV tilts, whereas the paramedian type (if it extends into
the rostral midbrain) always causes contraversive falls.
Masdeu and colleagues19 have described astasia and gait
failure with damage of the pontomesencephalic (locomotor) region. Although not discussed, it could also be
explained in part by a vestibular tone imbalance in roll,
especially because skew deviation was described as a feature of the syndrome. Indeed, as seen in an imaging study
on vascular thalamic lesions,20 lesions of the posterolateral thalamus cause an interruption of the vestibular pathways to the temporoparietal vestibular cortex areas of the
affected side and also to the contralateral side.
Of 31 patients with cortical infarctions of the middle
cerebral artery territory in one study, 21 showed significant, mostly contraversive, pathological SVV tilts.21 The
overlapping area of these infarctions centered on the posterior insula, which, according to functional imaging
studies,2226 is homologous to the parietoinsular vestibular cortex in monkeys, and the adjacent superior temporal lobe.27,28 SVV tilts caused by vestibular cortex lesions
can also be associated with (a compensatory) body lateropulsion. This finding may explain some cases of the
cortical phenomenon pusher syndrome, which physical
therapists readily recognize.
Torsional Nystagmus
The graviceptive input from the otoliths converges with
that from the vertical SCCs to subserve static and dynamic vestibular function in roll. This combination of static
and dynamic effects29 is not surprising if one considers
how these functions are corroborated. Our studies on
OTR, lateropulsion, and SVV were concerned with static
effects of vestibular dysfunction in roll.3,4 These effects
417
persist for days to weeks, during which time they spontaneously subside. In the acute stage of infarction, additional dynamic signs and symptoms occur, which consist
of horizontal rotational vertigo and torsional nystagmus.30,31 Fast phases of rotational nystagmus are contraversive in pontomedullary lesions, whereas the slow
phases correspond in direction to the static deviation.
Several distinct and separate lesions (see Fig. 25.2)
have been associated with torsional nystagmus: for example, lesions of the vestibular nuclei,31,32 the lateral
medulla,30,33 in rare cases the MLF (as indicated by an
association with internuclear ophthalmoplegia),34,35 the
INC, and the riMLF.3638 Fast phases of torsional nystagmus are contraversive in pontomedullary lesions and
ipsiversive in paramedian pontine and mesencephalic
(INC) lesions (rare exception: contraversive in riMLF
lesion).
Jerk-waveform seesaw nystagmus (a torsional nystagmus with elevation of the intorting eye and depression
of the extorting eye) is induced by an inactivation of the
INC in the rostral midbrain and is also ipsiversive.38
The different locations of lesions causing different
directions of torsional nystagmus at first appear to be
confusing. They can, however, be explained by the tonic
torsional shift of eye position along the graviceptive pathways from the vestibular nuclei to the INC. A lesion of the
(medial or superior) vestibular nucleus causes an ipsiversive tonic deviation (ipsiversive ocular torsion) with compensatory fast phases of the torsional nystagmus to the
contralesional side. In view of the fact that the pathway
within the MLF crosses to the contralateral side, an MLF
lesion in the pontine and pontomesencephalic brainstem
induces a tonic contraversive deviation, and therefore, a
torsional nystagmus with the fast phases ipsilesional. The
same is true for a lesion of the INC. The only exception to
these directional rules for tone imbalance along the
vestibular graviceptive pathways is the riMLF, a lesion of
which causes a (possibly non-vestibular) ocular motor
tone imbalance in the opposite direction.
in (Sagittal) Pitch Plane
A striking difference between vestibular tone imbalance
in the roll and pitch planes is that roll dysfunction is
caused by unilateral, and pitch dysfunction by bilateral,
lesions of paired pathways in the brainstem or of the
cerebellar flocculus.4 This structural difference probably
explains why a vestibular tone imbalance in pitch frequently occurs with various intoxications or metabolic
disorders, which is unusual for tone imbalance in yaw or
roll, unless as a functional decompensation of an earlier
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(compensated) tone imbalance. Downbeat nystagmus

(DBN) and upbeat nystagmus (UBN) are not merely ocular motor disorders but disorders that also affect orientation and balance. A tone imbalance in the pitch plane
manifests as vertical upbeat or downbeat nystagmus,
fore-aft head-and-body tilt, and deviation of the subjective straight-ahead toward the direction of the slow phase
of the nystagmus.39
Clinically, DBN occurs more commonly than UBN
and is often permanent (as in Arnold-Chiari malformation), whereas UBN is usually a transient phenomenon.
Lesional sites for UBN have been more precisely confirmed by clinical studies (bilateral lesions of the pontomesencephalic junction or the medulla) than those for
DBN (bilateral pontomedullary lesions or bilateral flocculus dysfunction). DBN and UBN can result from different pathomechanisms: UBN from a perhaps-vestibular
tone imbalance of the VOR in pitch and a perhapsnon-vestibular one by a spontaneous downward ocular
drift, and DBN from an asymmetry in the distribution of
on-directions of vertical gaze velocity in the Purkinje
cells.40 Transitions between UBN and DBN have been
frequently described in paramedian pontomedullary
lesions. UBN occurs with paramedian plaques of the pontomesencephalic brainstem in MS, cerebellar degeneration, or drug intoxication. Whereas DBN is more typical
for congenital craniocervical malformations (ArnoldChiari malformation) and cerebellar degeneration, UBN
is more typical for MS, bilateral brainstem ischemia
(basilar artery thrombosis), or brainstem tumors. UBN
and DBN in the primary position of gaze may be the
result of various intoxications (without structural lesion).
Downbeat Nystagmus
Box 25-1 summarizes the information given in this chapter about the downbeat nystagmus/vertigo syndrome.
Downbeat nystagmus in the primary gaze position,
or more particularly on lateral gaze, is often accompanied
by oscillopsia and postural instability. This is a clearly
defined and, depending on the lesional site, permanent
association of symptoms, which often indicates structural
lesions of the paramedian craniocervical junction.41 DBN
is present in darkness as well as with fixation; slow-phase
velocity and amplitude increase on lateral gaze or with
head extension or head movements in the sagittal (pitch)
plane. It may be present only on downward or lateral
gaze. Slow-phase velocity is not consistently related to
vertical gaze and, contrary to Alexanders law, may even
be maximal on upward rather than downward gaze. Nystagmus is a jerk, usually with linear slow phases. It may
exhibit changes of exponential velocity in slow phases,
both increasing and decreasing.42,43 DBN may be episodic in Arnold-Chiari malformation44 or paroxysmal.32
It has been reported that reversals from DBN to
UBN can be provoked by upward gaze deviation,45 convergence,46 or transitions from sitting to supine position.47
DBN and UBN may be the directional counterparts of a vestibular tone imbalance in the pitch plane.
The close proximity of the areas causing either UBN or
DBN in the medulla agrees with the directional changes
between the two. Reversals from UBN to DBN have also
been observed.46,48,49
Patients complain of a distressing illusory oscillation of the visual scene (oscillopsia) and postural imbalance. Both are obligatory but hitherto poorly studied
symptoms of the syndrome. The retinal slip in DBN is
misinterpreted as motion of the visual scene because the
involuntary ocular movements that override fixation are
not associated with an appropriate efference-copy signal.
Oscillopsia is a permanent symptom, but the illusory
motion is less than would be expected from the amplitude
of the nystagmus; it increases with increasing amplitude;
the mean ratio between the two is 0.37.50
Oscillopsia should be expected to cause an impairment of postural balance, because retinal image motion is
a major cue for body stabilization. However, this kind of
visual ataxia cannot simply account for the typical postural imbalance, which is a striking feature of the fore-aft
body sway and includes a tendency to fall backward. This
fore-aft postural instability can be interpreted to be a
direction-specific vestibulospinal (or cerebellar) imbalance, because it can be observed when the eyes are
closed. We believe that the objective measurable backward tilt represents a vestibulospinal compensation in the
direction opposite to the perceived lesional forward vertigo that corresponds to downbeat nystagmus.50,51 When
the eyes are open, a measurable visual stabilization of
body sway is preserved, but it does not sufficiently compensate for the visual ataxia. In DBN (more aptly termed
downbeat nystagmus syndrome), the patients pathological postural sway with the eyes open depends on the
direction of gaze; it increases with increasing amplitude
of the nystagmus. Pathophysiologically, it is secondary to
a combination of both vestibulospinal ataxia and reduced
visual stabilization of posture owing to the nystagmus.
In spite of many clinical reports of DBN and UBN
and multiple hypotheses about possible mechanisms, the
pathophysiology is still not understood.40,52,53 In the light
of several clinical findings and experimental data, a
general concept is that asymmetries in the cerebellobrainstem network that normally stabilize vertical gaze
could lead to an imbalance in structures such as (1) the
vertical cerebello-vestibular neural integrator, (2) the
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Box 25-1
DOWNBEAT NYSTAGMUS (VESTIBULAR DOWNBEAT SYNDROME)

Clinical Syndrome
Downbeat nystagmus in the primary position of
gaze (no suppression by fixation), increased on
lateral gaze or head extension
Associated distressing oscillopsia and postural
imbalance with a tendency to fall backward and
vertical deviation of straight-ahead
Saccadic downward pursuit
Transitions from downbeat to upbeat nystagmus
possible
Incidence/Age/Sex
Incidence depends on etiology
No obvious preference for sex
Rare in children (congenital)
Pathomechanism
Several hypotheses under discussion: Tone imbalance due to lesions of the pathways mediating (1)
signals of the vertical cerebellovestibular neural
integrator, (2) central connections of the vertical
vestibulo-ocular reflex, including both the vertical
semicircular canal and otolith responses (pitch
plane), or (3) signals of the vertical smooth pursuit system
Structural or functional lesions involve either:
The floor of the fourth ventricle between the
vestibular nuclei
central connections of the vertical VOR, including both

the SCC and the otolith responses, or (3) the vertical
smooth pursuit system. In a review by Pierrot-Deseilligny
and Milea,54 DBN is explained by a floccular lesion that
results in a disinhibition of the pathway from the superior vestibular nucleus via the ventral tegmental tract and
thereby in a relative hyperactivity of the elevator muscles,
inducing an upward slow phase.
Etiology
The two most common causes of a downbeat nystagmus/vertigo syndrome are cerebellar ectopia (25%) (e.g.,
Arnold-Chiari malformation) and cerebellar degeneration (25%) (e.g., olivopontocerebellar degeneration). A
further 10% to 20% of patients have a variety of condi-
The vestibulocerebellar flocculus (intoxication, cerebellar degeneration)

Etiology
The two most common causes are cerebellar
ectopia and cerebellar degeneration, including
alcoholic cerebellar degeneration
Other conditions: drugs (phenytoin, carbamazepine, lithium), multiple sclerosis, tumor,
hematoma, vascular disease, encephalitis, magnesium depletion, vitamin B12 deficiency (see
Table 25-1)
Course/Prognosis
Frequently permanent when caused by structural
lesions
Usually reversible when caused by intoxication or
metabolic deficiency
Management
Medical treatment with 4-aminopyridine,
gabapentin, baclofen, or clonazepam
Differential Diagnosis
Acquired pendular nystagmus, gaze-evoked nystagmus, upbeat nystagmus, spasmus nutans
(infants), vertical congenital nystagmus, ocular
bobbing
tions,33,55 and in about 30%, an unequivocal diagnosis of

the cause cannot be established.
In cerebellar degeneration and drug-induced DBN,
an asymmetrical vestibulocerebellar disinhibition of
the Purkinje cell activity of the flocculus on the
vertical canal reflexes may be causative, evidence for
which was found in a 2005 imaging study.56 Nutritional
cerebellar syndromes due to thiamine deficiency, in particular alcoholic cerebellar degeneration (see Box
25-1), not only cause a typical 3-Hz fore-aft oscillation
of body sway57 but also DBN.55,58,59 Antiepileptic
drugs, especially phenytoin60 and carbamazepine,61,62 can
produce a reversible DBN with associated cerebellar
signs, depending on the dosage of the drugs. Other causes are lithium toxicity,55,6365 felbamate intoxication,66
and toluene abuse.67 Severe magnesium depletion68 and
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vitamin B12 deficiency69 have also been reported to result

in DBN.
Other conditions associated with DBN are MS,70
familial periodic ataxia, tumors of the posterior fossa,
cerebellar degeneration,71 paraneoplastic cerebellar
degeneration,72 infratentorial vascular diseases such as
dolichoectasia of the vertebrobasilar artery,73 hematomas,
cavernomas, syringobulbia,74 and encephalitis (see Box
25-1). Sometimes DBN is lithium-induced in preexisting
Arnold-Chiari malformation75 or is caused as an intermittent syndrome by head tilt due to vertebral artery compression76 or by a vermian arachnoid cyst with associated
obstructive hydrocephalus.77 DBN is rare in children. It
may be hereditary congenital78 as a persisting syndrome
or may occur during infancy and resolve naturally.79
Management
DBN due to drugs, magnesium depletion, or vitamin B12
deficiency is usually reversible when the intoxication or
metabolic deficiency is reversed. DBN due to structural
lesions in the posterior fossa is usually permanent,
although a surgical suboccipital decompression in
Arnold-Chiari malformation to relieve the compression of
the herniating cerebellum against the caudal brainstem
may lead to gradual improvement of some of the distressing symptoms.80 Suboccipital craniotomy,81 transoral
removal of the odontoid process in the basilar impression82 and of an osteophyte compressing the vertebral
artery,76 and surgical decompression of a syringomyelic
cyst in the medulla77,83 were able to resolve the syndrome
only in individual patients. For one patient, base-out
prisms were added to both spectacle lenses, because the
convergence both dampened the nystagmus and decreased
the oscillopsia.42 In patients with DBN85 and a stiffperson syndrome with glutamic acid decarboxylase
antibodies84 intravenous immunoglobulin was found to
improve the DBN and the ataxia.
Target symptoms for symptomatic medical treatment are distressing oscillopsia and reduced visual acuity
due to the fixation nystagmus. Postural imbalance is less
prominent and less distressing. Some studies have demonstrated effects on the DBN based on the pathomechanism that spontaneous upward ocular drift and downbeat
nystagmus are due to an asymmetry in the distribution of
on-directions of vertical gaze velocity in the Purkinje
cells.40,85 Because the inhibitory influence of gammaaminobutyric acid (GABA)ergic Purkinje cells is
assumed to be impaired in DBN, several agents that act
on this receptor have been investigated. The GABA-A
agonist clonazepam was found to improve DBN, but the
studies reporting this finding were not controlled.86,87 The
GABA-A agonist baclofen is assumed to reduce DBN,88

but only one of six patients had a response to baclofen
in a double-blind crossover trial involving only a few
patients.89 Further, in the same trial, the alpha-2-delta calcium channel antagonist gabapentin was assumed to have
a positive effect on DBN, but only one of six patients
showed improvement.89 Another study found that muscarinic antagonists, in particular the anticholinergic drug
scopolamine, reduced nystagmus in five patients with
acquired pendular nystagmus and in two patients with
downbeat nystagmus; benztropine was less effective.90
On the basis of this assumed pathomechanism, the
effects of aminopyridines were evaluated in patients with
DBN and in a subsequent study on UBN. In 17 patients
with DBN, the mean peak slow-phase velocity of DBN
was measured before and 30 minutes after randomized
oral ingestion of 20 mg of 3,4-diaminopyridine or placebo.91,92 The mean peak slow-phase velocity decreased in
10 of 17 patients by more than 50%. Moreover, an improvement of postural imbalance could be found.93 The assumed underlying mechanism is that aminopyridines
increase the activity and excitability of the Purkinje
cells as found in animal experiments94thereby augmenting the physiological inhibitory influence of the
vestibulocerebellum on the vestibular nuclei. 4-Aminopyridine improves not only DBN but also smooth pursuit
and the gain of the vertical VOR.92,95
Upbeat Nystagmus (Upbeat

Nystagmus Syndrome)
Box 25-2 summarizes the information given in this chapter about the upbeat nystagmus syndrome.
UBN in the primary position of gaze with concomitant oscillopsia and postural instability is a pendant of
DBN and probably reflects either an imbalance of vertical
VOR tone39 or a downward ocular drift by asymmetrical
smooth pursuit commands.95 It has the same causes and
involves central eye-head coordination in the pitch plane
as mediated by pathways from the vertical SCCs and the
otoliths. Because in some cases the manifestations are
typically modulated by otolithic input arising from static
head tilt, UBN can in a broader sense also be a kind of
positional nystagmus. As distinct from DBN, brainstem
lesions are often found in patients with UBN. Two separate intra-axial brainstem lesions in the tegmentum of the
pontomesencephalic junction and in the medulla near the
perihypoglossal nuclei (Fig. 25.6) are likely to be responsible for this syndrome, but there is insufficient evidence
to determine whether the cerebellar vermis is involved. In
analogy to DBN, UBN can probably indicate bilateral
lesions of the pathways mediating (1) signals of the
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Box 25-2
UPBEAT NYSTAGMUS (VESTIBULAR UPBEAT SYNDROME)

Clinical Syndrome
Upbeat nystagmus in the primary position of gaze
(no suppression by fixation), modulated by static head tilt
Associated distressing oscillopsia, postural imbalance, deviation of straight ahead
Saccadic upward pursuit
Transitions from upbeat to downbeat nystagmus
possible
Incidence/Age/Sex
Incidence depends on etiology
No obvious preference for sex
Rare in children (congenital)
Pathomechanism
Several hypotheses under discussion: Tone imbalance due to lesions of the pathways mediating (1)
signals of the vertical cerebello-vestibular neural
integrator, (2) central connections of the vertical
VOR, including both the vertical semicircular
canal and otolith responses (pitch plane), or (3)
signals of the vertical smooth pursuit system
Structural or functional paramedian lesions
involve either:
vertical cerebello-vestibular neural integrator, (2) the

central connections of the vertical VOR, or (3) signals of
the vertical smooth-pursuit system. UBM due to pontomesencephalic lesions could result from damage of the
superior vestibular nucleusventral tegmental tract pathway coursing through the ventral pons and transmitting
excitatory upward vestibular signals to the third nerve
nucleus.54 This would lead to an imbalance between
downward and upward systems and to a downward slow
phase. UBN in lesions affecting the caudal medulla could
result from damage in a feedback loop involved in upward
gaze-holding.54
Pontomesencephalic junction (ventral

tegmental tract, brachium conjunctivum?)
Medulla (perihypoglossal nuclei?)
Etiology
Brainstem tumors, infarction, hematoma, cavernoma, multiple sclerosis, encephalitis, abscess,
alcoholic degeneration (Wernickes encephalopathy), drug intoxication, nicotine (see Table 25-1)
Course/Prognosis
Depending on etiology, gradual improvement by
central compensation?
Usually reversible when caused by intoxication
Management
Medical treatment with 4-aminopyridine, baclofen
(clonazepam?)
Physical exercise (eye movements and balance
training)
Differential Diagnosis
Acquired pendular nystagmus, gaze-evoked nystagmus, downbeat nystagmus, spasmus nutans
(infants), vertical congenital nystagmus, reversed
ocular bobbing
niocervical junction and cerebellar degeneration seem to

be less common than in DBN, whereas brainstem tumors
and MS are more common. UBN can be associated with
bilateral (paramedian) vascular brainstem lesions,
hematoma, cavernoma, MS, encephalitis, abscess, or head
injury. It has been repeatedly reported in alcoholic degeneration, especially in Wernickes encephalopathy46,97 and
in single cases of Fishers syndrome,98 central diabetes
insipidus,99 and Pelizaeus-Merzbacher disease,100 and has
even been associated with middle ear disease.101 We have
seen transient upbeat nystagmus associated with various
intoxications, for example with antiepileptic drugs. UBN
can on rare occasions be congenital.102
Etiology
UBN was observed in 26 of 17,900 patients examined at
a neurotological clinic in Japan. The incidence rate was
0.145%.96 The etiology of UBN is in general similar to
that of DBN (see Box 25-2). Malformations of the cra-
Management
UBN may be associated with severe vertigo, ataxia, and
nausea, particularly at first. Affected patients may require
vestibular sedatives (e.g., dimenhydrinate or scopo-
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Figure 25.6 Partial suppression of upbeat nystagmus by medical treatment with baclofen. (Top)
Vertical electronystagmography recordings. (Bottom) Magnetic resonance image of a patient with
unilateral upbeat nystagmus and a paramedian medullary infarction affecting the area of PMT neurons near the neurons of the perihypoglossal nuclei.
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lamine) as long as nausea lasts. Depending on the etiology, the natural history of this sign usually shows gradual
improvement or disappears, in contrast to DBN, which is
frequently permanent. Physical exercise involving fixation, eye movements, and postural balance accelerates
central compensation. Medical treatment is possible with
baclofen (5 to 10 mg PO daily), which has a beneficial
effect on nystagmus amplitude, oscillopsia, and visual
acuity in some patients (Fig. 25.6).88 Carbamazepine was
found to be effective in a single case of upbeat nystagmus
due to multiple sclerosis.103 In a single patient with UBN,
Glasauer and colleagues95 have shown that 4-aminopyridine reduced the peak slow-phase velocity in light from
8.6 to 2.0 deg/sec, but UBN in darkness was not affected.
These investigators concluded that 4-aminopyridine
reduces the downward drift in UBN by augmenting
smooth pursuit commands.
Summary
These studies in UBN and DBN show that a new therapeutic principle has been developed: Aminopyridines, as
potassium channel blockers that increase the activity and
excitability of Purkinje cells, have a beneficial effect on
several disorders.85
Vestibular Disorders in
(Horizontal) Yaw Plane
The clinical signs, both perceptual and motor, of a
vestibular tone imbalance in the yaw plane include rotational vertigo, deviation of perceived straight-ahead, lateropulsion of the eyes, past pointing, rotational and
lateral body falls, and horizontal nystagmus.
Central vestibular syndromes manifesting purely in
the yaw plane occur less frequently than those due to
imbalance in the vertical pitch and roll planes, for two
reasons.4 First, the area of a lesion that can cause a tone
imbalance in yaw is comparatively small (root entry zone
of the vestibular nerve, medial and superior vestibular
nuclei, and the adjacent integration center for horizontal
eye movementsthe paramedian pontine reticular formation [PPRF]). In contrast, the area of a lesion that can
cause vestibular tone imbalance in roll or pitch covers
nearly the entire brainstem from the medulla to the rostral midbrain (see Fig. 25.2). The larger extent of the latter area is due to the greater separation of the vestibular
nuclei and the ocular motor integration centers for vertical and torsional eye movements (riMLF and INC).
Second, the area of a lesion that can theoretically cause a
pure tone imbalance in the yaw plane adjoins and over-
423
laps areas subserving vestibular function in roll and pitch

(see Fig. 25.2). There is a multisensory convergence
within the parallel neural network of the vestibular
nuclei,104 a lesion of which will cause mixed vestibular
syndromes in more than one plane. A study of vestibular
nuclei lesion in the monkey demonstrated a combined
nystagmus: Its horizontal component beat toward the
contralateral side after rostral lesions and toward the ipsilateral side after caudal lesions.105
Some of the cases described as central variants
of vestibular neuritis106110 caused by lesions of the medial vestibular subnucleus or the root entry zone of the
vestibular nerve were probably not restricted to the yaw
plane, because the case descriptions also contain signs
and symptoms of VOR tone imbalance in other planes of
action. There have been frequent reports that cerebellar
infarctions due to occlusion of the anterior inferior cerebellar artery (which may also supply the rostral vestibular nuclei) mimic vestibular neuritis.106,111 The other main
cause of confusion with disorders at the entry zone of the
VIIIth nerve is multiple sclerosis.108
Vestibular syndromes, when caused by unilateral
pontomedullary lesions, commonly result in combined
vestibular tone imbalance in more than one plane, such as
a combination of torsional and horizontal nystagmus.
This tone imbalance may manifest not only in spontaneous nystagmus but also in spontaneous or gaze-evoked
ocular deviations. There may be an inappropriate horizontal ocular deviation during attempted vertical saccades (lateropulsion in Wallenbergs syndrome) or an
inappropriate torsional deviation during attempted horizontal saccades (torsipulsion).30,112
Sometimes the clinical manifestation of a particular
ocular motor abnormality such as OTR allows one to
identify the SCC pathway affected (anterior or posterior).
The different presentation of OTR in Wallenbergs syndrome with monocular dissociation of ocular torsion
either excyclotropia of the lower eye or incyclotropia of
the upper eyeindicates involvement of the posterior or
the anterior SCC pathways.113 Lesions of the vestibular
nuclei may also result in repetitive multidirectional
paroxysmal nystagmus and vertigo, which have been
reported to respond to treatment with carbamazepine.44
The differential effects of a medullary lesion involving
more than one VOR plane are reflected not only in the
direction of eye movements but also in the preferred
direction of increased body sway. Body sway histograms
as measured by posturography are primarily diagonal in
patients with Wallenbergs syndrome and moderate body
lateropulsion (combination: roll and yaw) but primarily
lateral in patients with severe body lateropulsion (roll
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greater than yaw).113 The involvement of roll and yaw

planes is also reflected by the close correlation between
the tilt of perceived visual vertical and the severity of
body lateropulsion, both indicatorsperceptual and posturalof a vestibular imbalance in roll.114
Vestibular Cortex: Locations,

Functions, and Disorders
The two major cortical functions of the vestibular system
are spatial orientation and self-motion perception. These
functions, however, are not specifically vestibular; they
also rely on visual and somatosensory input. All three
systemsvestibular, visual, and somatosensoryprovide redundant information about the position and
motion of the body relative to the external space.
Although the vestibular cortex function is distributed
among several multisensory areas in the parietal and temporal cortices, it is also integrated in a larger network for
spatial attention and sensorimotor control of eye and
body motion in space.
Animal studies have identified several distinct and
separate areas of the parietal and temporal cortices that
receive vestibular afferents, such as area 2v at the tip of
the intraparietal sulcus,115117 area 3aV (neck, trunk, and
vestibular region of area 3a) in the central sulcus,118
PIVC at the posterior end of the insula and retroinsular
regions, 27,28 the periarcuate cortex area 6 pa,119 area 7 in
the inferior parietal lobule,120 and the ventral intraparietal
area (VIP) in the fundus of the intraparietal sulcus.121124
In view of the strong interconnections between PIVC and
the other vestibular cortex areas (mainly 3aV and 2v) as
well as the vestibular brainstem nuclei, Guldin and
Grsser5 postulate that it is the core region within the
vestibular cortical system in the monkey. About 50% of
the neurons in this region respond to vestibular stimulation in addition to somatosensory, optokinetic, or visual
stimulation. This area is involved in the processing not
only of vestibular, somatosensory, and visual information
that is generated whenever the position of the body
changes in relation to the extrapersonal space5 but also of
that generated when stationary human subjects perform
optokinetic nystagmus.125,126 Not only do most of these
cortical areas receive bilateral vestibular input from the
vestibular nuclei; they in turn directly project down to the
vestibular nuclei.5,127,128 Thus, corticofugal feedback may
modulate vestibular brainstem function.
Our knowledge about vestibular cortex function in
humans is less precise. It is derived mainly from stimulation experiments reported anecdotally in the older literature and from later brain activation studies with positron
emission tomography (PET) 20,25,119 and functional mag-
netic resonance imaging (fMRI).2224,26,125 The areas in

humans that were activated during caloric or electric
vestibular stimulation were located in the posterior insula
(first and second long insular gyri) and retroinsular
regions (representing PIVC and the posterior adjacent
visual temporal sylvian area, VTS, in the monkey), the
superior temporal gyrus, the parts of the inferior parietal
lobule representing area 7 in the monkey, the depth of the
intraparietal sulcus representing monkey area VIP, the
postcentral and precentral gyrus, the anterior insula and
adjacent inferior frontal gyrus, the anterior cingulate
gyrus, the precuneus, and hippocampus most often bilaterally (Fig. 25.7). Simultaneous with these activations,
deactivations of areas within the visual and somatosensory systems of both hemispheres were observed.22,130 Because opposite activation-deactivation patterns occurred
during visually induced self-motion perception with activations of parietal visual cortex areas and concurrent
deactivations of the multisensory (vestibular) cortex,125,131
a reciprocal inhibitory cortical interaction between the
sensory systems was assumed.131
Activation of the cortical network during vestibular
stimulation is not symmetrical in the two hemispheres.
Rather, it depends on three determinants that could be
defined in a 2003 study investigating healthy right- and
left-handers.25 The determinants were (1) the subjects
handedness, (2) the side of the stimulated ear, and (3) the
direction of the induced vestibular symptoms. Activation
was stronger in the nondominant hemisphere, in the
hemisphere ipsilateral to the stimulated ear, and in the
hemisphere ipsilateral to the fast phase of vestibular
caloric nystagmus.20,25,132 Furthermore, in right-handed
healthy volunteers, who performed allocentric visuospatial judgments (line bisection) with and without galvanic
stimulation of the right or left vestibular nerve, the most
relevant cortical area for the processing of vestibular
information was located in the posterior insula bilaterally,
right significantly more than left, including the PIVC.133
Multimodal Sensorimotor Vestibular

Cortex Function and Dysfunction
The human vestibular, visual, and somatosensory systems cooperate to determine the internal representation
of space and subjective body orientation in unique threedimensional coordinates, which are either egocentric
(body-centered) or exocentric (world-centered). This is
not a trivial process; two of the sensory systems are
anchored in the head, which moves relative to the trunk.
Retinal coordinatesdependent as they are on gaze and
head positionand head-fixed labyrinthine coordinates
would require continuous updating of the particular eye
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Right-handers
Left-handers
425
Right-handers
Figure 25.7 (A) Areas activated during caloric stimulation (warm water at 44C) of the right
ear in right-handed, and of the left ear in left-handed, healthy volunteers (group analysis ; n 12;
P .001; 15O-labeled H2O bolus, positron emission tomography). Activations were located in the
anterior and posterior insula, the superior temporal gyrus, the inferior frontal gyrus, the postcentral
gyrus, the inferior parietal lobule, and the anterior cingulum. Note that the activations were more pronounced in right-handers during irrigation of the right ear in the right hemisphere and in left-handers
during irrigation of the left ear in the left hemisphere. This finding indicates dominance of the nondominant hemisphere in the processing of vestibular information. (B) Lateral views of the surfaces of
both hemispheres showing activated areas during caloric stimulation of the right or left ear in righthanders in the superior temporal cortex, temporoparietal junction, insular cortex, and inferior frontal
cortex. Compared with the activation pattern during caloric irrigation of the right ear, caloric irrigation
of the left ear led to activations that were smaller in both hemispheres and more frequently located
within the ipsilateral left hemisphere. These results represent dominance of the ipsilateral vestibular
pathways. (Modified from Dieterich et al, 2003,25 and Bense et al, 2003 186 ).
and head positions in order to deliver reliable input for

adequate ocular motor and motor exploration of space.
Nature seems to have solved this impossible sensorimotor control of a multilink and multiaxis system through
multisensory coding of space in either common egocentric or exocentric rather than retinotopic or head-centered
coordinates. This encoding has been demonstrated for
posterior parietal neurons.134,135 Spatial information in
nonretinal coordinates allows determination of body position relative to visual space, which is a necessary prerequisite for accurate motor response. To obtain such a frame
of reference, information coded in coordinates of the
peripheral sensory organs (retina, otoliths, SCCs, and proprioceptors such as muscle spindles) must be transformed
and integrated.136 This function is most probably subserved by the temporal and posterior parietal cortex, a
lesion of which produces a visuospatial hemineglect.
Karnath and associates137,138 argued that neglect in
brain-damaged patients is caused by a disturbance of the
central transformation process that converts the sensory
input coordinates from the periphery into an egocentric,
body-centered coordinate system. The importance of the
vestibular input for spatial orientation and the continuous
updating of the internal representation of space is evident
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in the deficient spatial memory in microgravity during

spacecraft missions. Large errors are made during prolonged microgravity when subjects are pointing at memorized targets, and it is the lack of knowledge of target
position, not limb position, that is causative.139
In patients, an inappropriate vestibular input due to
peripheral or central dysfunction can cause paroxysmal
room-tilt illusions, the result of a mismatch of the two
three-dimensional visual and vestibular coordinate maps.
Furthermore, a plane- and direction-specific tilt of static
spatial orientation occurs in disorders of the VOR, such
as an eye and body lateropulsion in vestibular nuclei
lesions (e.g., Wallenbergs syndrome). Adjustments of
subjective straight-ahead also exhibit a lateral shift. Here
the tilt of perceived straight-ahead is elicited by the
asymmetrical vestibular tone in the brainstem, which
reaches the cortex by ascending projections. Vestibular
syndromes caused by only cortical lesions have not yet
been well defined. Static cortical spatial disorientation
may occur as any of the following:
Paroxysmal room-tilt illusion in parietal or
frontal lobe lesions
Contralateral spatial hemineglect in temporoinsular, inferior parietal, or frontal lobe lesions
Vertical neglect below the horizontal meridian in
bilateral parieto-occipital lesions
Tilts of perceived vertical (mostly contraversive)
and body lateropulsion in unilateral temporoinsular (e.g., PIVC) lesions
Dynamic cortical spatial disorientation with apparent motion or rotational vertigo may occur (1) in vestibular epilepsy with temporoparietal foci and (2) rarely as a
transient vertigo in acute lesions of the vestibular cortex.
Spatial Hemineglect:
a Cortical Vestibular Syndrome?
Spatial hemineglect impairs focal attention toward space
on the contralesional side. It is most often induced by
acute brain damage of the inferior parietal lobule of the
right hemisphere140 and occurs less commonly with acute
right or left lesions of the frontal premotor cortex.141 One
case report described a patient who had sequential strokes
in both hemispheres. After suffering a right-sided parietal
infarct, he had a severe unilateral spatial neglect, which
abruptly disappeared after a second, left-sided frontal
infarct.142 Other studies have described single patients
with bilateral inferior parietal lobe lesions that manifested in vertical neglect of the lower half-space below the
horizontal meridian.143,144 Mesulam145 hypothesized that
there is a cortical network for directed attention, in which
the inferior parietal lobule modulates the shift of attention

within extrapersonal space, and the dorsolateral frontal
area is responsible for generating exploratory motor
behavior. In summary, anatomical findings of the imaging
studies and the observation of a right hemisphere dominance for processing vestibular input have obvious parallels with anatomical findings in patients suffering from
spatial neglect. Damage to the right inferior parietal lobule and temporoparietal junction (TPJ)140,146,147 as well as
the inferior frontal gyrus141,148 have been observed to correlate with spatial neglect. In addition, four studies have
found the right superior temporal cortex and the right
insula to be critically related to spatial neglect.149152
Studies showing that vestibular (caloric) stimulation
significantly improved spatial functioning have stressed
the important role of the vestibular system in neglect.153,154 When vestibular stimulation was combined
with neck muscle vibration, the horizontal deviation combined linearly, adding or neutralizing the effects observed
during application of both types of stimulation.136 This
study also showed that the patients with neglect displaced
subjective body orientation ipsilesionally, a behavior that
does not result from a disturbed primary perception or
disturbed transmission of the vestibular or proprioceptive
input from the periphery. Karnath and associates137,138
argued that the transformation process converting the sensory input coordinates from the periphery into egocentric
(body-centered) coordinates is the critical mechanism
leading to hemineglect. This process must involve multisensory integration and motor behavior, including eye and
hand movements as well as walking trajectory.155 Spatial
hemineglect also includes the back space of the body.156
Vestibular Epilepsy
Vestibular epilepsy (vestibular seizures or auras) is a rare
cortical vertigo syndrome secondary to focal epileptic
discharges in either the temporal lobe or the parietal association cortex157159; multiple areas of both receive bilateral vestibular projections from the ipsilateral thalamus.
If vestibular seizures arise from different areas, the
sensorimotor symptomatology may differ as regards
apparent rotation or tilt,160 with or without associated eye,
head, and body deviation or epileptic nystagmus. Clinical
data on the directions of apparent self-motion or surround-motion are mostly incomplete and imprecise. If the
description is exact, as in rotatory seizures (volvular
epilepsy), then the topographic localization of the underlying pathology is too inexact to permit its allocation to
known vestibular areas.
An acute unilateral functional deficit of the vestibular cortex (e.g., in medial cerebral artery infarction)
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rarely manifests with vertigo,161,162 unlike lesions in the

vestibular area of the brainstem. It is not the functional
loss but the focal discharge that causes central vertigo.
This has been repeatedly demonstrated by stimulation
experiments. Electrical stimulation of the human thalamus during stereotactic neurosurgical procedures induced
sensations of movement in space, most frequently described as horizontal or vertical rotation or sensations of
falling or rising.163 These sensations were similar to those
induced by stimulation of the vestibular cortex.157,158
Vertigo has long been considered a manifestation of
epileptic auras.164,165 Most information on auras (vestibular epilepsy), including case descriptions, comes from
older textbooks, for example, those by Bumke and
Foerster166 and Penfield and Jasper,158 or from review
articles.167,168
In a later study searching for the human representation of vestibular cortex, Kahane and associates169 retrospectively investigated patients with epilepsy who had
undergone stereotactic intracerebral electroencephalogram recordings before surgery and looked for patients in
whom an illusion of rotation was induced. The investigators stimulated at 44 different loci in the temporal and
parietal cortex and found that electrical stimulation of an
area in the temporo-peri-Sylvian cortex particularly
elicited rotatory sensations. This area included Brodmann
areas 40, 21, and 22. Of these, the superior temporal
gyrus (STG) and middle temporal gyrus (MTG) preferentially caused illusions of rotation around the subjects yaw
axis, whereas the parietal operculum elicited pitch plane
illusions. Kahane and associates169 thus confirmed earlier
findings by Penfield and coworkers,158,170,171 who had
observed sensations of dizziness and rotary bodily movements especially during electrical stimulation of the STG
in epileptic patients.
Epileptic nystagmus usually beats contraversive to
the seizure focus and may be of vestibular, visual (optokinetic), or cortical ocular motor origin.172
Management
Vestibular seizures respond to antiepileptics. First-line
drugs are gabapentin, sodium valproate, and lamotrigine.173 If necessary and possible, surgical procedures
may be considered.174
Paroxysmal Central Vertigo

Nonepileptic paroxysmal vertigo or other vestibular syndromes may result from pathological excitation of various
vestibular structures.175 Most of them occur in multiple
sclerosis, but others may be associated with a brainstem
abscess (paroxysmal OTR14) or an arteriovenous malfor-
427
mation with previous bleeding (repetitive paroxysmal

nystagmus and vertigo32) or brainstem infarction.
The following manifestations of paroxysmal vestibular syndromes of the brainstem have been described in
MS:
Paroxysmal dysarthria, ataxia, and vertigo176
Paroxysmal OTR13
Paroxysmal room-tilt illusion177
Central Vestibular Falls Without Vertigo

There are a few instances of what is probably central
vestibular dysfunction. In such cases, patients without
paresis or sensory or cerebellar deficits are unable to
maintain an unsupported upright stance. They do not,
however, complain of vertigo. Their conditions include
thalamic astasia, lateropulsion in Wallenbergs syndrome
or in PIVC lesions, and ocular-tilt reaction in pontomedullary or rostral midbrain lesions.
Thalamic Astasia
Postural imbalance with a transient tendency to fall has
been noted after therapeutic thalamotomy.178180 It has
been attributed to muscle hypotonia or neglect and
has also been observed after thalamic infarctions181 and
hemorrhages.18,182 Masdeu and Gorelick17 described 15
patients with thalamic astasia, in the absence of motor
weakness, sensory loss, and cerebellar signs, due to
lesions of different causes, all primarily involving superoposterolateral portions of the thalamus but sparing the
rubral region. Typically, when asked to sit up, rather than
using the axial muscles, these patients would grasp the
side rail of the bed with the unaffected hand or with both
hands to pull themselves up.17 Thalamic astasia is transient and lasts for days or weeks, with the dorsothalamic
region being the critical locus. Because posterolateral
thalamic infarctions cause tilts of the perceived vertical
that are either ipsiversive or contraversive,16,20 thalamic
astasia and tilts of perceived vertical may both reflect a
vestibular tone imbalance. Furthermore, what Masdeu
and colleagues19 described as astasia and gait failure with
damage of the pontomesencephalic locomotor region
involving the right pontine peduncle area may be associated with vestibular dysfunction in roll. Their patient presented with a contraversive skew deviation of 10 degrees.
Thalamic hemiataxia differs from thalamic astasia
and rarely occurs in isolation; it is usually associated with
hemisensory loss without hemiparesis183 or hemisensory
loss and hemiparesis.184 The lesions involve the ventral
lateral nucleus of the thalamus and the adjacent posterior
limb of the internal capsule and the mid- to posterior thal-
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amus containing the dentatorubrothalamic and ascending

pathways.183,184
Lateropulsion in Wallenbergs Syndrome

Lateropulsion of the eyes and the body is a well-known
transient feature of dorsolateral medullary infarction.
Affected patients have irresistible, ipsiversive falls but
generally no subjective vertigo. Different brainstem
lesions from midbrain to medulla cause ipsiversive deviation of the subjective vertical.9,113,185 Transient OTR and
ipsiversive deviations of SVV, which indicate a pathological shift in the internal representation of the gravitational
vector, are typically found in Wallenbergs syndrome.15,113
We hypothesized that the subjective vertigo is missing in patients with this syndrome (despite a striking tendency to fall sideways) because individual multisensory
postural regulation is adjusted to the deviated vertical.
Lateropulsion then represents postural compensation of
an apparent body tilt contraversive to the lesioned side.
Despite the resulting postural imbalance and the conflicting true vertical, the body is continuously adjusted toward
what the central nervous system erroneously computes as
vertical.15,113 This hypothesis could explain why patients
fall without vertigo or warning signals from the multisensory spatial orientation system. Lateropulsion without
hemiparesis also occurs in cortical lesions. Patients with
infarctions of the middle cerebral artery territory are well
known to physiotherapists, who call them pushers. It
has been demonstrated that acute lesions of the PIVC
cause contraversive tilts of the perceived visual vertical,21
making it most likely that the cortical lateropulsion is also
due to a vestibular tone imbalance in the roll plane.
Lateropulsion in both dorsolateral medullary lesions
and posterior insular lesions spontaneously recovers
within days to weeks.113 The recovery process might be
facilitated by physical therapy.
Summary
Central vestibular syndromes are characterized by ocular
motor, postural, and perceptual signs. In a simple clinical
classification they can be separated according to the three
major planes of action of the VOR: yaw, roll, and pitch.
A tone imbalance in yaw is characterized by horizontal
nystagmus, lateropulsion of the eyes, past-pointing, rotational and lateral body falls, and lateral deviation of the
perceived straight-ahead. A tone imbalance in roll is
defined by torsional nystagmus, skew deviation, ocular
torsion, and tilts of head, body, and the perceived vertical. Finally, a tone imbalance in pitch can be characterized by some forms of upbeat or downbeat nystagmus,
fore-aft tilts and falls, and vertical deviation of the perceived straight-ahead. The thus defined syndromes allow
for a precise topographic diagnosis as regards their level
and side. Most signs and symptoms of central vestibular
disorders resolve spontaneously within weeks to months
owing to either recovery of the lesion or central compensation and substitution. The predominantly benign course
of these syndromes may be facilitated by physical and
drug therapy.
Acknowledgment
The authors wish to thank Ms. J. Benson for copyediting
the manuscript.
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CHAPTER
26
Non-vestibular Dizziness
and Imbalance: From
Disuse Disequilibrium to
Central Degenerative
Disorders
Non-vestibular imbalance, defined as imbalance that is

not due to an inner ear or vestibular nerve disorder, can
be very frustrating to the clinician, because the symptoms
are often vague and the vestibular test results are normal.
This chapter discusses the more common causes of
imbalance that respond to rehabilitation. Disuse dysequilibrium with fear of fall, the most common cause of
imbalance, readily responds to gait and balance therapy.
Other disorders that cause imbalance are leukoaraiosis,
normal-pressure hydrocephalus (NPH), progressive
supranuclear palsy, Parkinsons disease, large-fiber
peripheral neuropathy, and cerebellar ataxia. Many of
these disorders are associated with disuse dysequilibrium
and therefore respond to physical therapy (PT). Some
individuals with these disorders do not have disuse dysequilibrium or are too incapacitated to perform PT; in
these individuals, one must concentrate on reducing fall
risk through the use of assistive devices and education.
It is best to have any patient with chronic imbalance
first assessed by a physician in order to determine the
diagnosis. After this assessment, PT can be started the
same day or as soon as possible. During PT, there is an
initial assessment to identify the patients specific

problems. Then the patient is started on a daily home
gait and balance program that is reviewed and revised by
the physical therapist every week for four visits. At
each visit, outcomes scores are re-assessed. The patient is
then reevaluated by the physician with the physical therapist present, and the outcomes scores are reviewed to
determine whether the patient needs more rehabilitation and/or a follow-up appointment in 6 to 12 months.
The latter is especially useful in patients who have
progressive problems (spinocerebellar degeneration, progressive peripheral neuropathy, and progressive supranuclear palsy).
Disuse Disequilibrium
and Fear of Fall
Description
In elderly individuals, there is progressive decline in
muscle bulk, joint range of motion, and reflex time.1
Increased exercise can reduce the rate of this decline.
433
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Many individuals stop walking and exercising because of

recent surgery, fatigue, chronic illness, or a fall to the
ground or a near fall. Lack of exercise in the elderly leads
to disuse dysequilibrium.2 Fear of fall can occur as a
result of disuse dysequilibrium and can also exacerbate
disuse dysequilibrium by reducing the patients willingness to participate in a home exercise program.3
Figure 26.1 shows the age distribution of fear of fall
and disuse disequilibrium in patients at our Dizziness and
Balance clinic. The diamonds indicate all patients seen in
the clinic (left axis) based on decade of age of the patient.
The squares indicate the percentage of patients seen
within each decade with fear of fall (FOF) and disuse
dysequilibrium (DD) (right axis).
Useful Outcome Tests

Imbalance in individuals with disuse disequilibrium and
fear of fall readily responds to gait and balance PT.
Outcome measurements that are useful in patients with
disuse dysequilibrium are shown in Table 261. In each
column of this table, the PT fills in the date and the
results of each of the outcome measurements. A full
description of these outcome measurements can be found
in Chapter 19. They are as follows:
Fall risk assessments: Tinetti Fall Risk
Assessment, Dynamic Gait Index (DGI)
Timed Gait Tests: 8-ft Get Up & Go test, gait
speed, Modified Timed Up and Go
Standing balance tests: computerized dynamic
posturography or similar force platform test to
quantify standing balance sway
Subjective tests of gait and balance: ActivitiesSpecific Balance Confidence (ABC) Scale for
A description of posturography SOT can be found in

Chapter 8 (pg 135 and Figure 8.17A).
Management
A daily home exercise program that increases endurance,
balance, and lower extremity strength frequently resolves
the problem.4 Success depends on compliance by the
patient and support from the family or friends. Case
Study 1 in this chapter describes a patient with disuse
dysequilibrium and fear of fall.
Leukoaraiosis and NormalPressure Hydrocephalus

Description
Leukoaraiosis and NPH are discussed together because
they both manifest with symptoms of cognitive impairment, imbalance, and urinary dysfunction.57 In severe
cases, patients with these disorders have gait apraxia, gait
initiation defects, and severe retropulsion.
The etiology of leukoaraiosis (ischemic white
matter disease) is believed to be significant small vessel
disease.8 Age, hypertension, diabetes mallitus, and lacunar strokes are the major determinants of this entity,
and smoking and hypercholesterolemia pose additional
risks. Extensive white matter high signal intensity is
found in the in the corona radiata and sometimes in the
pons on T2-weighted magnetic resonance imaging (MRI)
of the head.
50%
800
Total Dizzy
confidence in balance, Dysequilibrium Visual

Analogue Scale (VAS)
Others: Activities of Daily Living (ADLs)
40%
600
30%
400
%FOF
20% DD
200
10%
0%
0
0-9
40-49
60-69
20-29
80-89
70-79
10-19
90-99
30-39
50-59
Decade
Figure 26.1 Age distribution of disuse disequilibrium and fear of fall in

patients seen in a dizziness and balance clinic. See text for explanation.
Gait speed (ft/sec)
Dynamic Gait Index

Score (DGI)
Disequilibrium
Visual Analogue Scale
(010, 10 worse)
Activities-Specific
Balance Confidence
Score (ABC)
(nl80%)
Assistive device
inside/outside
Activities of Daily
Living (ADLs)
Max=15
Posturography: Number of
falls on SOT
Posturography: Sensory
Organization Test (SOT)
Composite Score
Age:
Gender:
Diagnosis:
History :
1:54 PM
8ft Up & Go
Normal=8.5s
Patient Name:
2/16/07
Tinetti Fall Risk

Assessment
Balance=25
Gait=12
Date:
Treating P.T.:
Table 26-1 USEFUL OUTCOME MEASUREMENTS FOR IMBALANCE
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In NPH, there is a triad of symptoms consisting

of dementia, imbalance, and urinary incontinence, with
communicating hydrocephalus found on computed
tomography (CT) or MRI of the head.6 Many patients
with NPH also have parkinsonian features, including masked facies and cogwheel rigidity, but usually
no tremor. Cerebrospinal fluid (CSF) pressure measured by lumbar puncture or lumbar drain during the
daytime is normal, but at night there are marked CSF
pressure elevations that usually occur during periods of
sleep apnea. Some patients with NPH may benefit
from insertion of a permanent shunt system to drain the
hydrocephalus. 9 The shunt is inserted only if cognitive
and gait tests performed after a large-volume CSF
drainage procedure have a positive outcome compared
with baseline.

Patients with imbalance and cognitive decline should
undergo outcome measures similar to those listed in
Table 261, with additional tests that assess cognitive
function along with tests of balance and gait during multitasking. Individuals with dementia have more problems
with gait and balance during multitasking than with simple gait tasks. A useful form that the Dizziness and
Balance Center at Emory University developed to document outcome scores in this group of patients is shown in
Table 262.
They are as follows:
Cognitive tests: Mini-Mental State Examination
[MMSE], Trails tests
Timed gait tasks with various levels of multitasking: average gait speed, Timed Up & Go (TUG)
test, Walk While Talk (WWT) test
Fall risk assessments: DGI
Standing balance tests: computerized dynamic
posturography or similar force platform to quantify standing balance sway
Test for retropulsion (a tendency to fall backwards when the hips are gently shoved
backwards)
Two of the measurements test the ability of the
subject to allocate attention toward balance when performing multiple tasksthe Modified Timed Up and
Go test and the Walk While Talk test. Several studies
suggest that an impaired ability to allocate attention to
balance during dual-task situations may contribute significantly to falls in older adults. One study of assisted
living residents revealed that the inability to walk while

talking was highly predictive of a future fall: 83% of
those who stopped walking while talking (WWT)
experienced a subsequent fall.10 The same prediction is
also applicable to nondemented, community-dwelling
older adults.11 This study revealed a 71% positive
predictive value for walking while reciting every other
letter of the alphabet (WWT-complex) versus 42% for
walking only. In the Modified Timed Up and Go test,
the patient first sits in a chair and is instructed to
stand up and walk as quickly and as safely as for 3
meters, turn around, walk back to the chair, and sit
down. Then the patient is instructed to perform the test
while counting backward by threes from a randomly
selected number between 20 and 100 (TUG cognitive).
Finally, the patient is asked to perform the test while carrying a full cup of water (TUG manual). A difference
between TUG manual and TUG (TUG manual TUG)
4.5 sec indicates fall risk
In the Walk While Talk test, subjects are timed
while they walk at self-selected speed 20 feet, turn
around and return (40 feet total). On the second trial
(WWT-simple) the subject walks the same course and
recites letters of the alphabet. On the third trial (WWTcomplex) the subject walks the same course and recites
every other letter of the alphabet (e.g., a-c-e). The gait
speed for each of those trials can indicate risk for falling
as follows:
WWT (40 ft):
18 s at risk for falls
WWT-simple:
WWT-complex:
Table 262 lists two columns for data insertion. For patients with NPH, we use the table as it
exists. Drain in the headings refers to performance
of a large-volume CSF drainage procedure, as described
earlier. For patients with leukoaraiosis, one can substitute
the following headings: Pre-PT, 1 week of PT, and
4 weeks of PT.
Management
Improvement rates in cognition and balance in patients
with NPH after insertion of a shunt vary from 65% to
77%.12 Unfortunately, there is no standard for outcome
assessment, and randomized, prospective clinical trials
are lacking.
Current evidence suggests that in patients with
leukoaraiosis, vigorous treatment of cardiovascular
disease risk factors may prevent the development or
progression of the process as well as the associated
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Chapter 26
Table 26-2 OUTCOME MEASURES

USED IN PATIENTS
WITH IMBALANCE
AND DEMENTIA
Pt Name: Age: Gender: Diagnosis: History :
Pre-drain
Date
2hrs post-drain
Date
Mini-Mental State
Exam (MMSE)
Times gait
task (TUG)
TUG cognitive
TUG manual
diff TUG (TUG
manualTUG)
Average gait speed
(ft/s)
Walk While Talk
(WWT) (40 ft)
WWT-simple
WWT-complex
Fall history
Dynamic Gait
Index (DGI)
Posturography:
SOT composite
score
Retropulsion on
Clinical Exam
cognitive and balance decline.13 Therefore, hypertension,

elevations of cholesterol, diabetes mellitus, and smoking
should be controlled in these patients. Unfortunately,
there are no prospective trials to determine whether
improved blood flow to the brain stabilizes or improves
function.
All patients with NPH and leukoaraiosis should be
referred for PT. These patients are usually at high risk for
falls, especially backwards. For patients with leukoaraiosis, some balance improvement may occur with PT, but
NON-VESTIBULAR DIZZINESS AND IMBALANCE
437
many patients must be given an aid (cane, walker, or rollator) when ambulating inside or outside the house. A
home health evaluation may also be necessary to reduce
the risk for falls at home. This may be true for patients
with NPH as well if shunting does not improve balance.
Case Study 2 describes a patient with NPH, and Case
Study 3 a patient with leukoaraiosis.
Progressive Supranuclear
Palsy, Parkinsons Disease,
Large-Fiber Peripheral
Neuropathy, and
Spinocerebellar Ataxia
Description
The neurological disorders progressive supranuclear
palsy, Parkinsons disease, large-fiber peripheral neuropathy, and spinocerebellar ataxia are usually progressive and are associated with imbalance and falls.
Supranuclear palsy (PSP) and Parkinsons disease
are due to degeneration of different portions of the
basal ganglia and forebrain. Both manifest as rigidity and
masked facies. Retropulsion is mild in Parkinsons
disease but severe in PSP. To perform the retropul sion
test, the examiner has the patient stand with feet slightly
apart and instructs the patient to take no more than one
step backward when the examiner suddenly pulls the
patient backwards at the hips using a mild force. The
result is positive if the patient must take three or
more steps backward or falls backwards like a log. A
resting and sometimes action tremor is found in
Parkinsons disease but is absent in PSP. Both disorders
have some degree of upgaze defect, but it is profound
in patients with PSP. PSP can be devastating because
the average life span of affected patients is 7 years,
death being due to aspiration or complications from falls
to the ground.
Large-fiber peripheral neuropathy results in loss of
vibration perception and proprioception. Severe loss of
proprioception, especially in the ankles, leads to severe
imbalance. Individuals with this disorder are extremely
dependent on vision to maintain balance. They usually
have a positive Romberg test result on clinical examination. Common causes of large-fiber neuropathy are diabetes mellitus, alcohol abuse, inflammatory neuropathy,
and hereditary neuropathy.
Spinocerebellar ataxia (SCA) is a very heterogeneous group of disorders that can affect different
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portions of the cerebellum and structures outside the

cerebellum, including peripheral nerve and brainstem structures. Some patients with SCA type 3 have
bilateral vestibular hypofunction as well. Other patients
with SCA have normal vestibular function but are
not able to cancel their vestibulo-ocular reflex (VOR)
owing to a defect in the cerebellar vermis; this inability
can cause greater motion sensitivity during head
movements.

Most patients with the neurological disorders discussed here do not have cognitive decline at onset, so
we usually use the outcome measures listed in Table
261. Patients with PSP and some with Parkinsons disease demonstrate cognitive decline as the disease progresses, so the outcome measures in Table 262 then
become more relevant.
Management
Patients with these degenerative disorders often need a
longer course of treatment than those who have disuse
dysequilibrium. Compliance with the home exercise program is often a problem.
Several excellent medications are used to treat

Parkinsons disease, including carbidopa-levodopa
(Sinemet), which also helps mobility and balance.
Eventually, many patients no longer show response to
medication and require deep brain stimulation. It is not
clear whether deep brain stimulation improves balance.
Some patients experience disuse dysequilibrium and
require PT.
There is a treatment overlap between patients with
PSP and those with Parkinsons disease. A 4-week trial of
low-dose Sinemet should be tried to improve gait and
balance in patients with PSP, but most cases do not
respond to medication. There is no surgical treatment for
this disorder. Gait and balance PT should be prescribed.
Patients undergoing PT often need a rollator to prevent
backward falls.
Patients with proprioception defects due to peripheral neuropathy or dorsal root/dorsal column disease
are encouraged to use visual cues while standing and
walking.
Patients with SCA and disuse disequilibrium
or VOR defects have a good response to PT. Some
patients with VOR cancellation defects do well with
habituation exercises. Case Study 4 describes a patient
with SCA.
CASE STUDY 1
Mrs. T, 73 years old, fell from a 3-foot ladder
9 months ago. Although she had no significant
injury, she has had chronic dizziness since. She
loses her balance occasionally but denies falling.
Before she fell from the ladder, she walked 3 miles a
day, but now she is afraid to walk. On examination, she has no significant orthopedic or neurological problems. Vestibular findings are normal. She
cannot walk tandem and shows fear of fall when
standing with eyes closed. She touches the walls
while walking in the clinic. The Tinetti Fall Risk
Assessment score was 27, identifying this patient
as being at moderate risk for fall (Fig. 26.2).
This assessment is excellent for patients at risk for
fall.14
Comment
The history and examination findings are consistent
with disuse disequilibrium and fear of fall. Mrs. T
started on a daily home exercise program coordinated
by a physical therapist with a specialty in geriatrics.
She saw the therapist in clinic once a week for 4
weeks. During each clinic visit with the therapist, her
balance was assessed and her exercises were made
more difficult. The exercises included progressive
static balance with eyes opened and closed, progressive gait exercises with and without head movements,
and eventually, a walking program that increased from
1 to 3 miles a day. At the end of the fourth week, Mrs.
Ts Tinetti Fall Risk Assessment score improved to
normal range (score 35/37), she returned to her normal activities and she was discharged from the clinic.
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Patient MT 64-57-08
TINETTI FALL RISK ASSESSMENT
Date 03/26/99
Sitting Balance
(2) Steady, stable

(1) Holds onto chair to keep upright
(0) Leans, slides down in chair
Arising from chair
(2) Steady without holding on

(1) Uses arms of chair
(0) Unable without help or multiple attempts
Immediate standing balance
(2) Steady w/o support

(1) Steady, w/ support
(0) Unsteady (grabbing moves feet, etc)
Standing
(2) Steady w/ feet together

(1) Steady, feet apart
(0) Unsteady or holds on
Balance w/eyes closed
(2) Steady, feet together

(1) Steady, feet apart
(0) Unsteady; holds on
Sternal nudge light pressure 3 times
(2) Steady
(1) Moves feet by keeps balance
(0) Begins to fall
Turning (360)
(2) Continuous steps no grabbing or staggering

(1) Discontinuous, puts foot down completely before raising the other
(0) Unsteady or holds on
Neck turning
(2) Horizontal and vertical (at ceiling), steady

(1) Decreased ability but no unsteadiness or pain or dizziness
(0) Unsteady or is symptomatic
One-legged stance, eo
(1) Able 5 sec w/o holding on

(0) Unable
Back extension ask to lean backwards
(2) Good extensions w'o holding on, staggering

(1) Tries but decreased ROM or holds on
(0) Will not attempt or staggers
Reaching up high
(2) Able to take down object w/o holding on or becoming unsteady

(1) Able to reach but needs to hold on
(0) Unable or unsteady
Bending down
(2) Able, single attempt, doesn't hold on

(1) Able, single attempt but holds on
(0) Unable or multiple attempts
Sitting down
(2) Able, one smooth motion

(1) Needs to use arms, not smooth
(0) Falls into chair, misjudges distance
Gait
Initiation of gait
(1) Begins immediately, single smooth motion

(0) Hesitates, multiple attempts, not smooth
Step height
(1)
(1)
(0)
(0)
Completely clears, 1-2 inches, right

Completely clears, 1-2 inches, left
Does not clear, right
Does not clear, left
Step length
(1)
(0)
(1)
(0)
Right foot passes left foot by foot length

Right foot does not pass left by full foot length
Left foot passes right foot by foot length
Left foot does not pass right by full foot length
Step symmetry
(1) Same or nearly same on both sides

(0) Varies, or advances with same foot on every step
Step continuity
(1) No breaks or stops in stride

(0) Stops between steps, step length varies
Path deviation
(1) Foot follows straight line

(0) Foot deviates side to side or in one direction
Trunk stability
(2) Normal
(1) Knees or back flexed, arms not abducted to assist
(0) Marked sway
Walk stance
(1) Normal base of support

(0) Widened base of support
Turning around while walking
(1) Normal, continuous

(0) Staggers or stops to turn
Author
Herdman
Total Balance (25) = 20
Total Gait (12) = 7
Total = 27 (37) (> 31 OK; 26-31 = moderate risk; < 25 high risk)
Fig. #
Docum
F26-2
F26-0
4/29/99
Total Score = 35
Artist
Figure 26.2 Example of the use of the Tinetti Fall Risk Assessment.
Kate Margeson
439
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CASE STUDY 2
Mr. G is an 85-year-old man with a 2-year history
of cognitive decline, imbalance with falls to the
ground, and urinary incontinence. He brought
MR images of his head with him (Fig. 26.3).
No obstruction of CSF flow was found in any
of the ventricles, consistent with a diagnosis
of communicating hydrocephalus. Table 263 lists
the outcome measures as discussed in Table 262 in
the text. The left column of Table 263 lists the
measure and the normal range, column two (Pre LP)
lists the measure before a lumbar puncture,
and column three (2 Hrs LP) lists the measures after
removal of 40 cc of CSF by lumbar puncture.
For example, a mini-mental (MMSE) of <24 is
considered cognitively impaired. This test was 19
in Mr. G before the LP was 19 and after the LP
was 21. Therefore, his cognition did improve after
the LP.
Comment
On the basis of history, lumbar puncture, and head
MRI findings, this patient has NPH. His outcome
scores before the LP document dementia, impaired
balance and gait, and fall risk. At baseline (pre-drain),
his average gait speed, TUG, and WWT scores indicated slight impairment, but his gait speed during
multitasking (TUG cognitive and WWT-complex)
showed significant impairment.
After the large-volume lumbar puncture, Mr. G
showed no significant improvement in cognition,
gait, or balance. He and his family elected not to
proceed with a shunt. Instead, he was given a
4-week course of gait and balance PT. There
was modest improvement, but he was still at risk for
fall. Therefore, a walker was prescribed. He was
instructed to continue with the exercises, and a 6month follow-up appointment was scheduled.
Table 26-3 OUTCOME SCORES FOR A PATIENT WITH NORMAL-PRESSURE

HYDROCEPHALUS AFTER LARGE-VOLUME CSF DRAINAGE
PROCEDURE (CASE STUDY 2)
Pt Name:
Age: 85
Mr. G
Gender:
Pre Drain
Date: 03/31/06
2 Hrs Post-Drain
03/31/06
MMSE ( 24 cognitively impaired)
19
21
TUG ( 11.8 sec M 2 SD nonfallers)
13.21
11.77
TUG cognitive ( 14.3 sec M 2 SD

nonfallers)
25.15
22.75
TUG manual ( 12.9 sec M 2SD)
17.83
17.30
diff TUG (TUG manual TUG)

(diff TUG : 4.5 sec at risk for falls)
4.62
5.53
Average gait speed (ft/sec) (normal age/

gender 3.08)
2.32 ft/sec
2.20 ft/sec
WWT (40 ft) ( 18 sec at risk for falls)
18.24
21.64
WWTsimple ( 20 sec at risk for falls)
26.62
28.53
WWTcomplex ( 33 sec at risk for falls)
41.08
32.53
Fall risk: ( DGI 19 fall risk)
15
16
Posturography (normal for age 63.8)
32
36
Dx:NPH
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Chapter 26
441
Figure 26.3 Magnetic resonance image of the head in

the horizontal plane illustrating hydrocephalus.
CASE STUDY 3
Sixty-year-old Mrs. S complains of chronic imbalance. Her legs feel heavy, like lead. She has had
several falls backwards with injury. She has diabetes
mellitus, hypertension, and an elevated cholesterol
value. On examination, she has masked facies, mild
rigidity, and gait apraxia. When given shoves backwards, she falls like a log, indicating a poor righting reflex. She does not have tremor or cogwheel
rigidity. She has not shown improvement with a trial
of Sinemet. An MRI of her head shows leukoaraiosis
(Fig. 26.4). She is referred to PT for gait and balance
exercises.
Comment
This patient has significant risk factors for small vessel disease of the brain. She has parkinsonian features
but does not have Parkinsons disease (no tremor and
had no response to Sinemet). She was started on a
daily home exercise program and was seen 1 day
each week in PT for 4 weeks. There was no significant improvement in fall risk or posturography
scores, so she was prescribed a rollator with seat, basket, and hand brakes to improve her independence.
She was also instructed in changes she could make in

her home to improve her safety.

the horizontal plane showing extensive white matter ischemic
changes otherwise known as leukoaraiosis.
26Herdman(p2)-26
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CASE STUDY 4
Ms. P, 50 years old, has had progressive imbalance
for 3 years and several spells of spontaneous vertigo
lasting for a few seconds while walking. She has fallen three times, and she fractured her left ankle while
going down her stairs. She has used a cane for a year.
Her father, two sisters, and brother all have the same
problem. Examination shows bilateral vestibular
weakness based on head thrust, downbeat nystagmus,
dysarthric speech, and cerebellar ataxia in the lower
extremities. Head MRI shows cerebellar and pontine
atrophy (Fig. 26.5). Genetic screening is consistent
with SCA type 3, a dominant form of SCA.
Comment
Some patients with SCA type 3, like this patient, have
a central cause for bilateral vestibular loss. The physical therapist performed an initial evaluation and identified multiple problems. These included decreased
gaze stability during head movements, poor balance
in stance when visual cues were diminished and when
the support surface was uneven, difficulty maintaining balance when walking on anything other than a
firm, flat predictable surface and a risk for falling. In
addition, the patient was unable to successfully perform tasks such as stepping over an object and walking quickly enough to cross a street. The physical
therapist instructed Ms P in exercises for eye gaze stability, balance, strengthening, and gait that is updated
weekly. Balance retraining was performed with various sensory conditions (e.g. static balance with eyes
open and then closed). The patient practiced balanc-
ing on foam with eyes open/closed with supervision

as well as modified single-leg stance activities. The
walking program for Ms. P began on level surfaces
with cane (walking forward, backwards, and sideways. Eventually, walking while making head turns
slowly side-side and walking through an obstacle
course stepping over small obstacles, on grass, and
slight slopes were added. Strengthening exercises
included performing sit to stand without upper
extremity assistance and bridges on bed with added
hip abduction/adduction to increase hip control.
Vestibular adaptation exercises included X1viewing
(see Chapter 20) while sitting, moving her head both
horizontally and vertically and using both near and
distant targets She performed these 35 times each
day but had 1 or 2 days of increased visual blurring;
therefore, the range of head movements was
decreased and exercises were changed to only 3 times
per day. She progressed to standing position, performing exercises for 1 minute, 3 times per day. The
patient was seen weekly for 9 visits. She then continued therapy less frequently with follow-up visit 3
weeks later. Table 264 shows the improvement in
outcome scores with PT for Ms. P. This table is the
same as Table 261. See page 432 for description.
Table 26-4 OUTCOME SCORES

IN A PATIENT WITH
CEREBELLAR ATAXIA
(CASE STUDY 4)
Score At
Initial
Evaluation
Score on Day
of discharge
from PT
8-ft Up& Go Test
22.4 sec
with cane
11.4 sec without cane
SOT composite
score on computerized dynamic
posturography
36/72; 6/6
falls
70/72; 1/6
falls
DGI
3/24
17/24
ABC Scale Score
11.2%
71%
Outcome
Test

the sagittal plane in a patient with spinocerebellar atrophy
type 3.
Visual Analogue
9.5/10
Scale (Disequilibrium)
3.1/10
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Chapter 26
References
1. Bloem BR, Boers I, Cramer M, et al: Fall in the elderly, I:
Identification of risk factors. Wien Klin Wochenschr 2001;
113:352362.
2. Bortz WM II: Disuse and aging. JAMA 1982;248:
12031208.
3. Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI:
Fear of falling and fall-related efficacy in relationship to
functioning among community-living elders. J Gerontol
Med Sci 1994;49:M140M147.
4. Campbell AJ, Robertson MC, Gardner MM, et al:
Randomized controlled trial of a general practice program
of home based exercise to prevent falls in elderly women.
BMJ 1997;315:10651069.
5. Sakakibara R, Hattori T, Uchiyama T, Yamanishi T:
Urinary function in elderly people with and without
leukoaraiosis: Relation to cognitive and gait function.
J Neurol Neurosurg Psychiatry 1999;67:658660.
6. Relkin N, Marmarou A, Klinge P, et al: Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery
2005;57(Suppl):S4S16.
7. van Straaten EC, Fazekas F, Rostrup E, et al: LADIS
Group: Impact of white matter hyperintensities scoring
method on correlations with clinical data. The LADIS
study. Stroke 2006; 37:836840.
443
8. Basile AM, Pantoni L, Pracucci G, et al; LADIS Study

Group: Age, hypertension, and lacunar stroke are the
major determinants of the severity of age-related white
matter changes. The LADIS (Leukoaraiosis and Disability in the Elderly) Study. Cerebrovasc Dis 2006;21:
315322.
9. Bergsneider M, Black PM, Klinge P, et al: Surgical management of idiopathic normal-pressure hydrocephalus.
Neurosurgery 2005;57(Suppl):S29S39.
10. Lundin-Olsson et al: Stops walking when talking as a
predictor of falls in elderly people. Lancet 1997; Mar
1;349(9052):617.
11. Verghese et al: Validity of divided attention tasks in predicting falls in older individuals: a preliminary study.
J Am Geriatr Soc. 2002 Sep;50(9):1572-1576.
12. Klinge P, Marmarou A, Bergsneider M, et al: Outcome of shunting in idiopathic normal-pressure hydrocephalus and the value of outcome assessment in
shunted patients. Neurosurgery 2005;57(Suppl):
S40S52.
13. Schwartz GL, Fornage M, Mosley T, Turner ST:
Treatment of leukoaraiosis. Curr Treat Options
Cardiovasc Med 2005;7:173177.
14. Tinetti ME, Speechley M, Ginter SF: Risk factors for falls
among elderly persons living in the community. N Engl J
Med 1988;319:17011707.
27Herdman(p2)-27
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27
Assessment and
Management of the
Patient with Traumatic
Brain Injury and
Vestibular Dysfunction
This chapter discusses the array of vestibular disorders

associated with traumatic brain injury (TBI). Many of
these vestibular deficits occur spontaneously or in association with viral or vascular lesions that have been discussed in other chapters. Because of the confounding
influence of TBI, however, we assess and treat patients
with it differently from patients with peripheral vestibular system pathology alone. TBI also affects ultimate
recovery from vestibular deficits. What distinguishes the
patient with TBI from other patients with peripheral
vestibular disease is the mechanism of vestibular injury
and the high incidence of other neurological deficits
complicating the recovery process.
Recognizing and treating symptoms of vestibular
dysfunction, including dizziness and imbalance, and distinguishing the etiology of those symptoms from other
non-vestibular causes are essential parts of TBI rehabilitation. Many therapists involved in rehabilitating patients
with TBI are familiar with approaches to treating imbalance but lack strategies to treat complaints of dizziness.
As a result, therapists often try to avoid provoking dizziness when treating patients with TBI. However, avoiding
the movements that provoke dizziness can actually delay
444
recovery from vestibular system dysfunction, resulting in

persisting symptoms.1,2 Persisting symptoms complicate
recovery and contribute to long-term loss of functional
independence.35
The objectives of this chapter are to discuss mechanisms of traumatic injury producing peripheral vestibular
system disorders in TBI. Strategies for assessing and
treating symptoms of peripheral vestibular system dysfunction are reviewed. In addition, the chapter discusses
the effect of other traumatically induced sensory, motor,
and cognitive deficits on strategies for treating the patient
with TBI and associated vestibular system pathology.
Vestibular Pathology
As many as 30% to 65% of patients with TBI suffer
symptoms of traumatic vestibular pathology at some point
during their recovery.49 Symptoms of peripheral vestibular system dysfunction can include vertigo, eye-head
dyscoordination affecting the ability to stabilize gaze during head movements, and imbalance affecting the ability
to maintain stability when standing and walking.10 The
specific constellation of symptoms found in individual
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Chapter 27 ASSESSMENT AND MANAGEMENT OF THE PATIENT WITH TRAUMATIC BRAIN INJURY AND VESTIBULAR DYSFUNCTION
patients varies according to the type and extent of injuries

to both vestibular and central neural structures. Understanding peripheral vestibular pathology and its effect on
gaze, postural, and perceptual functions is essential
because treatment varies with the patients symptoms and
diagnosis.11
445
the vestibular nerve. Contusions and hemorrhage can

damage the brainstem, cerebellum, or cerebral hemispheres. There can be pain and dysfunction of the neck
resulting in dizziness (see Chapter 29). Finally, a variety
of psychological responses may cause or increase dizziness and may contribute to a persons level or restriction
of participation.
Mechanism of Injury and Resulting

Concussion
Trauma can induce vestibular-related symptoms through

damage to the inner ear itself, to the vestibular nerve, or
to central structures and pathways (Table 27-1). These
mechanisms, discussed in detail in Chapter 6, are summarized briefly here. Many of the vestibular deficits associated with TBI also occur spontaneously or are associated
with viral or vascular lesions that have been discussed in
other chapters. Other deficits are specific sequelae of the
head trauma itself. The actual mechanism of labyrinthine
damage may be the concussive force itself, rupture of the
membranous labyrinth, or hemorrhage. Temporal bone
fracture can disrupt the bony or membranous labyrinth or
Inner ear concussion injury is the most common vestibular sequela of TBI.8,12,13 Symptoms of concussive-type
VIIIth cranial nerve or labyrinthine injury can include
high-frequency sensorineural hearing loss, benign paroxysmal positional nystagmus/ vertigo (BPPN/V), postural dyscontrol, and gait ataxia. BPPV in TBI is believed
to occur because of the intense acceleration of the utricular otolithic membrane, which results in displacement of
otoconia to the posterior semicircular canal. Displaced
otoconia, adhering to the cupula or free-floating in the
long arm of the posterior canal, may result in displacement of the cupula in response to gravity in specific posi-
Table 27-1 SITES AND MECHANISMS OF HEAD TRAUMAINDUCED DIZZINESS

Site
Syndrome
Mechanism
Inner ear
Benign paroxysmal positional vertigo
Dislodging of otoliths, cupulolithiasis or

canalithiasis
Post-traumatic endolymphatic hydrops
Decreased endolymphatic flow
Rupture of round or oval window or of

membranous labyrinth
Labyrinthine concussion
Endolymphatic hemorrhage
Temporal bone fracture
Disrupts bony or membranous labyrinth
Vestibular nerve
Temporal bone fracture
Disruption of VIIIth cranial nerve
Brainstem or
vestibulocerebellum
Downbeat, upbeat, and torsional nystagmus

Central positional vertigo
Ocular tilt response
Postconcussive syndrome
Contusion or hemorrhage of brainstem or

cerebellum
Cerebral cortex
Tornado epilepsy
Post-traumatic seizures
Neck
Whiplash
Flexion-extension injury
Psychological
Panic disorder; chronic anxiety

Depression
Somatization
Compensation neurosis
Psychogenic
27Herdman(p2)-27
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tions.14 BPPV produces a transient positional nystagmus

and vertigo in a characteristic head-dependent position.
In addition, patients with BPPV complain of transient
vertigo when lying down and rolling over to the affected
side, or when looking up or down (see Chapter 17).
Changes in intracranial pressure can produce ruptures in the round or oval window and a perilymph fistula (PLF) between the middle and inner ear.8,11,1517 PLF
can result in fluctuating hearing loss, episodic vertigo,
and gait and balance disturbances. In addition, patients
with PLF may have a number of cognitive symptoms,
including memory, concentration, and attention deficits.18
The incidence of PLF in patients with head injury is
uncertain.16,1820
Vascular injuries, including hemorrhage into the
membranous labyrinth, can injure the endolymphatic system, producing a post-traumatic hydrops or Mnires
diseasetype syndrome, with corresponding symptoms
of tinnitus, hearing loss, vertigo, and imbalance.8,11
Fractures
Traumatic fractures of the temporal bone can produce unilateral or bilateral vestibular hypofunction. Longitudinal
fractures account for approximately 80% of all temporal
bone fractures and are associated primarily with blows to
the parietal and temporal regions of the skull.12,21 Anatomic damage associated with longitudinal fractures
primarily occurs to middle ear structures, leading to conductive hearing loss. Associated vestibular symptoms are
considered secondary to a concussive injury to the membranous labyrinth.
Transverse fractures account for approximately 20%
of all temporal bone fractures and are reported to result
most frequently from blows to the occiput.12,21 Transverse
fractures of the temporal bone produce a unilateral loss of
vestibular function that can be either partial or complete.
Functional effects of a unilateral loss of vestibular function include spontaneous nystagmus and vertigo (acute
stage only), head movementprovoked vertigo, problems
with gaze stabilization, and disequilibrium affecting the
ability to maintain stability in sitting and especially in
standing and while walking.22 Functional effects of a
bilateral loss of vestibular function include oscillopsia
(inability to stabilize gaze during head movements) and
severe imbalance affecting stance and gait.

Traumatic head injury can also damage central vestibular
structures.3,13,23 Multiple petechial hemorrhages in the
brainstem that damage central vestibular structures have
been reported in both the mildly (no loss of consciousness) and moderately head-injured patient. Symptoms
include spontaneous nystagmus and oculomotor problems
including ocular dysmetria, cogwheeling during smoothpursuit eye movements, and marked optokinetic asymmetries. Spontaneous and/or provoked vertigo may or may
not occur in the patient with central vestibular lesions.
Vestibular rehabilitation is a comprehensive approach to
assessing and treating symptoms of vestibular system
pathology.19,20,24 The overall goal of assessment is to document the patients functional problems and the many
sensory, motor, and cognitive limitations contributing to
loss of functional independence. Specific evaluation of
vestibular system pathology, summarized in Box 27-1,
focuses on assessment of vertigo, control of eye-head
coordination for stabilizing gaze, and musculoskeletal
and neural components of postural control underlying the
ability to maintain stability and orientation when sitting,
Box 27-1
VESTIBULAR REHABILITATION
ASSESSMENT
Vertigo
Spontaneous
Provoked:
Positional
Movement
Oculomotor controlsaccade and smooth pursuit
Gaze stabilization during head movements
Gaze fixation suppression
Postural Control in Sitting,
Standing, and Walking
Functional status
Underlying impairments:
Biomechanical constraints
Neuromuscular constraints
Sensory/perceptual constraints
Other Limitations
Pain
Cognitive and behavioral constraints
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standing, and walking. Sorting out the relative contribution of vestibular system pathology to overall loss of
function can be difficult, because functional deficits after
TBI are usually due to a combination of many interacting
factors.
Vestibular rehabilitation uses exercise to decrease
dizziness, improve gaze stabilization, and retrain sensory
and motor aspects of postural control. In most instances
exercises are designed to facilitate central nervous system (CNS) compensation rather than alter underlying vestibular disease. The exception is treatment of
BPPV, which is aimed at altering the underlying mechanism that produces the symptoms rather than facilitating
CNS adaptation. Strategies for treating vestibular system
dysfunction are individualized to each patients problems and focus on both remediating underlying impairments and improving functional skills.19,20 Vestibular
rehabilitation programs are often modified in the patient
with TBI owing to the frequency of both physical and
cognitive problems after trauma. Modifications include
the following:
Providing physical assistance to accommodate
movement problems
Ensuring greater supervision to accommodate
cognitive and behavioral problems
Progressing through the stages of exercises more
slowly because of the multiplicity of the patients
problems
The following sections discuss clinical strategies for
assessing and treating symptoms of vestibular system
disorders, including vertigo, eye-head coordination, and
postural dyscontrol, in the patient with TBI.
Vertigo
Assessment
When assessing vertigo, the therapist notes whether dizziness symptoms are spontaneous or provoked and determines the situations and conditions that precipitate
complaints of dizziness.19,20,25 Characteristics of vertigo
are noted, such as latency of onset, duration, intensity,
and the effect of repeating the movement. Associated
autonomic symptoms, such as nausea, sweating, and pallor, are noted. The presence and type of nystagmus are
recorded. Head movements are repeated in sitting, standing, and walking. In addition to subjective complaints
of dizziness, episodes of staggering and disequilibrium
associated with complaints of dizziness are recorded, particularly in standing and walking.
The patient with unilateral vestibular hypofunction
(partial or complete) experiences both spontaneous and
447
provoked vertigo in the acute stage. Often by the time a

patient with TBI and concomitant unilateral loss of vestibular function enters a rehabilitation program, spontaneous complaints have resolved. Patients continue,
however, to complain of vertigo, lasting from seconds to
minutes, that is provoked by head movements in all
planes. Vertigo in the patient with BPPV lasts 30 to 45
seconds and is provoked by placing the patient in the
Dix-Hallpike position. Patients with BPPV may also
report having vertigo while lying down and rolling to the
affected side, while looking up, or while leaning over.26,27
Treatment
Habituation exercises are used to diminish dizziness in
patients who have movement-provoked symptoms of vertigo. Habituation exercises involve repeating the movements that provoke vertigo between 5 and 10 times, two
to three times a day. When a patient is residing in an inpatient rehabilitation facility, habituation exercises are
incorporated into twice-daily physical therapy treatments, usually at the end of each exercise session. As
mentioned previously, habituation exercises are routinely
modified to accommodate both movement and cognitive
limitations in patients with TBI. Written exercise sheets
are used, and patients are given logs to record exercise
sessions. Because of the high frequency of behavioral
and cognitive problems, including attention and memory
deficits, in patients with TBI closer supervision and physical assistance are more often required in the rehabilitation of vestibular dysfunction in such patients than in
patients with other types of vestibular dysfunction.
The canalith repositioning maneuver (CRM) developed by John Epley26 has been shown to be an effective treatment for patients with BPPV (see Chapter 19).
An alternative to the CRM is the liberatory maneuver
described by Semont and colleagues27 for management
of BPPV. When the CRM has been used in an inpatient
who is undergoing rehabilitation, the nursing staff must
be given information regarding the necessary follow-up
precautions in order to ensure that the patient is consistent in adhering to these precautions (see Chapter 17).
Inability or failure to adhere to follow-up precautions can
make the procedure ineffective.28
Assessment
Eye movements from both the visual and vestibular systems used to keep gaze stable during voluntary and involuntary movements of the head are also examined.20,24
Gaze stabilization is tested with the patient seated, stand-
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ing unsupported, and walking. Visually generated eye

movements, including smooth-pursuit and saccadic eye
movements, are assessed. The patients ability to maintain
a stable gaze during horizontal and vertical head motions
of varying speed is examined. Finally, the patients ability to keep gaze fixed on an object moving in phase with
the head is used to test visual suppression of vestibulardriven eye movements. Subjective complaints of dizziness, blurred vision, and oscillopsia are noted.
Following TBI, eye-head dyscoordination can result
from (1) damage to the vestibular system that disrupts
vestibulo-ocular reflex (VOR) function, (2) deficits within the visual system, including loss of ocular motility,
visual acuity/field deficits, and visual perceptual deficits,
(3) orthopedic injuries that limit cervical motion, and (4)
damage to cerebellar structures resulting in loss of visual
suppression of the VOR.29,30
Treatment
Exercises are used to improve gaze stabilization when the
head is still and in motion. Saccadic and smooth-pursuit
tracking exercises are performed initially if the patient
has dizziness during these eye movements. Next the
patient is asked to keep the gaze fixed on a central target
while moving the head either horizontally or vertically for
a progressively longer period of time. Finally, patients
are given exercises to improve visual modulation of
vestibulo-ocular responses (see Chapter 20).16,24,31 The
patient repeats these exercises first in a supported sitting
position and then progresses to performing them while
standing and walking.
Because so many of the exercises used to treat symptoms of vestibular system disorders involve movement of
the head and neck, treatment of cervical complaints is
essential to recovery of function. Vestibular rehabilitation
exercises combined with physical modalities and orthopedic manual skills have produced excellent results.32
Postural Control Underlying Stability

The ability to maintain a stable position is critical to independence in most functional skills. Stability is defined as
the ability to maintain the center of body mass within limits determined principally by the extent of the support
base.33 Stability requires a continuous interaction between
the individual and the environment, and involves many
bodily subsystems collectively referred to as the postural
control system (see Chapter 3).
Assessment
Because postural control is complex, involving the interaction of many systems, its assessment must be multi-
Figure 27.1 Categories of constraints on stability after traumatic brain injury.
dimensional. Assessment focuses on documenting the

ability to perform functional skills requiring posture control as well as investigating the underlying impairments
that constrain the maintenance of postural stability.
Impairments are limitations within the individual that
restrict sensory and motor strategies for postural control.34 As shown in Figure 27.1, impairments affecting
postural stability after TBI can be musculoskeletal, neuromuscular, sensory/perceptual, or cognitive.
The information gained through assessment is used
to develop a comprehensive list of problems, establish
short- and long-term goals, and formulate a plan of care
for retraining posture control. A thorough assessment
must include review of the patients medical and social
history as well as of current symptoms and concerns.34
Procedures for assessing the multiple levels of postural
control have been described in detail elsewhere3436 and
so are only briefly reviewed here.
Functional Status
A number of tests are available to measure functional
skills related to postural control. Our outpatient program
uses three tests to document functional balance and
mobility skills. The Berg Balance Scale, shown in Box
27-2, rates performance from 0 (cannot perform) to 4
(normal performance) on fourteen different tasks, including the ability to safely and independently sit, stand,
reach, lean over, turn and look over each shoulder, turn in
a complete circle, and step.37 The total possible score on
this scale is 56, indicating excellent balance. The Berg
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449
Box 27-2
BERG BALANCE SCALE

1. Sitting to Standing
Instruction: Please stand up. Try not to use your
hands for support.
Grading: Please mark the lowest category that
applies:
(4) Able to stand, no hands and stabilize independently.
(3) Able to stand independently using hands.
(2) Able to stand using hands after several tries.
(1) Needs minimal assistance to stand or to
stabilize.
(0) Needs moderate or maximal assistance to
stand.
2. Standing Unsupported
Instruction: Stand for 2 minutes without holding on.
applies:
(4) Able to stand safely 2 minutes.
(3) Able to stand 2 minutes with supervision.
(2) Able to stand 30 seconds unsupported.
(1) Needs several tries to stand 30 seconds
unsupported.
(0) Unable to stand 30 seconds unassisted.
If subject is able to stand 2 minutes safely, score full
marks for sitting unsupported. Proceed to position
change standing to sitting.
3. Sitting Unsupported, Feet on Floor
Instruction: Sit with arms folded for 2 minutes.
applies:
(4) Able to sit safely and securely 2 minutes.
(3) Able to sit 2 minutes under supervision.
(2) Able to sit 30 seconds.
(1) Able to sit 10 seconds.
(0) Unable to sit without support, 10 seconds.
4. Standing to Sitting
Instruction: Please sit down.
applies:
(4) Sits safely with minimal use of hands.

(3) Controls descent by using hands.
(2) Uses back of legs against chair to control
descent.
(1) Sits independently but has uncontrolled descent.
(0) Needs assistance to sit.
5. Transfers
Instruction: Please move from chair to bed and back
again. (One way toward a seat with armrests and one
way toward a seat without armrests.)
applies:
(4) Able to transfer safely with only minor use of
hands.
(3) Able to transfer safely with definite need of
hands.
(2) Able to transfer with verbal cueing and/or
supervision.
(1) Needs one person to assist.
(0) Needs two people to assist or supervise to be
safe.
6. Standing Unsupported with Eyes Closed
Instruction: Close your eyes and stand still for 10
seconds.
applies:
(4) Able to stand 10 seconds safely.
(3) Able to stand 10 seconds with supervision.
(2) Able to stand 3 seconds.
(1) Unable to keep eyes closed 3 seconds but stays
steady.
(0) Needs help to keep from falling.
7. Standing Unsupported with Feet Together
Instruction: Place your feet together and stand without holding on.
applies:
(4) Able to place feet together independently and
stand 1 minute safely.
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BERG BALANCE SCALE

(3) Able to place feet together independently and
stand for 1 minute with supervision.
(2) Able to place feet together independently but
unable to hold for 30 seconds.
(1) Needs help to attain position but able to stand
15 seconds feet together.
(0) Needs help to attain position and unable to
hold for 15 seconds.
The following items are to be performed while
standing unsupported:
8. Reaching Forward with Outstretched Arm
Instruction: Lift arm to 90 degrees. Stretch out
your fingers and reach forward as far as you can.
(Examiner places a ruler at end of fingertips when
arm is at 90 degrees. Fingers should not touch
the ruler while reaching forward. The recorded
measure is the distance forward that the fingers
reach while the subject is in the most forwardlean position.)
applies:
(4) Can reach forward confidently 10 inches.
(3) Can reach forward 5 inches safely.
(2) Can reach forward 2 inches safely.
(1) Reaches forward but needs supervision.
(0) Needs help to keep from falling.
9. Pick Up Objects from the Floor
Instruction: Pick up the shoe/slipper placed in
front of your feet.
applies:
(4) Able to pick up slipper safely and easily.
(3) Able to pick up slipper but needs supervision.
(2) Unable to pick up but reaches 12 inches from
slipper and keeps balance independently.
(1) Unable to pick up and needs supervision while
trying.
(0) Unable to try/needs assistance to keep from
falling.
10. Turning to Look Behind/Over

Left and Right Shoulders
Instruction: Turn to look behind you over/toward left
shoulder. Repeat to the right.
applies:
(4) Looks behind from both sides and weight
shifts well.
(3) Looks behind one side only; other side shows
less weight shift.
(2) Turns sideways only but maintains balance.
(1) Needs supervision when turning.
(0) Needs assist to keep from falling.
11. Turn 360 Degrees
Instruction: Turn completely around in a full
circle. Pause. Then turn a full circle in the other
direction.
applies:
(4) Able to turn 360 degrees safely in 4 seconds
each side.
(3) Able to turn 360 degrees safely one side only in
4 seconds.
(2) Able to turn 360 degrees safely but slowly.
(1) Needs close supervision or verbal cueing.
(0) Needs assistance while turning.
Dynamic weight-shifting while standing
unsupported:
12. Count Number of Times Step-Touch
Measured Stool
Instruction: Place each foot alternately on the stool.
Continue until each foot has touched the stool 4
times.
applies:
(4) Able to stand independently and safely and complete 8 steps in 20 seconds.
(3) Able to stand independently and complete
8 steps in 20 seconds.
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BERG BALANCE SCALE

(2) Able to complete 4 steps without aid, with
supervision.
(1) Able to complete 2 steps; needs minimal
assistance.
(0) Needs assistance to keep from falling/unable
to try.
13. Standing Unsupported, One foot in Front
Instruction (demonstrate to subject): Place one foot
directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far
enough ahead that the heel of your forward foot is
ahead of the toes of the other foot.
applies:
(4) Able to place foot tandem independently and
hold 30 seconds.
(3) Able to place foot ahead of other independently and hold 30 seconds.
(2) Able to take small step independently and
hold 30 seconds.
(1) Needs help to step but can hold 15 seconds.

(0) Loses balance while stepping or standing.
14. Standing on One Leg
Instruction: Stand on one leg as long as you can
without holding on.
applies:
(4) Able to lift leg independently and hold
10 seconds.
510 seconds.
3 seconds.
(1) Tries to lift leg; unable to hold 3 seconds but
remains standing independently.
(0) Unable to try or needs assistance to prevent
fall.
(From Berg, 1993.37)
Balance Scale has been shown to have excellent interrater reliability and relatively good concurrent validity.
It has shown to be an effective predictor of fall risk in
community-dwelling older adults.38 Its ability to predict
fall risk in patients with TBI is unknown.
Self-selected walking speed has been used as a
measure of a patients ability and confidence in walking.39
There is a paucity of information on what constitutes
independent functional mobility. One study reported that
in order to perform instrumental activities of daily living
(ADL) skills, the average person must be able to (1) walk
a minimum of 1000 feet, (2) achieve a velocity of 80
meters per minute for 13 to 27 meters in order to cross a
street safely, (3) negotiate a 7- to 8-inch curb independently, and (4) walk and turn the head without loss of balance.40 In our clinic, two methods are used to assess
functional mobility. The first is the Three-Minute Walk
Test, which requires subjects to walk at their preferred
pace for 3 minutes over a 524-foot indoor course.34 The
course is carpeted and involves four different turns.
Distance walked in the 3 minutes is recorded, as is the
number of times the patient moves outside a 15-inch

walking path. The second test of functional mobility is the
Dynamic Gait Index, which is used to evaluate the ability
to adapt gait to changes in task demands such as changing speeds, head turns in the vertical or horizontal direction, stepping over or around obstacles, and stair ascent
and descent. The test involves eight tasks that are scored
from 0 to 3, for a total of 24 points.34
New research suggests that dual-task methods of
assessing balance and mobility may be more sensitive
indicators of functional mobility problems than tests that
focus on single-task performance.41,42 The use of dualtask measures may be particularly important in patients
with TBI owing to the frequency of cognitive impairments such as disorders in attention, memory, and judgment. Kerns and Mateer43 report an example of a patient
with TBI who, when given the task of grating cheese, was
noted to progressively slump down and forward until his
forehead touched the counter. This patient was unable to
successfully divide attention between two tasks, maintaining a vertical posture and grating cheese.44 We have
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found that in patients with mild to moderate head injury,

postural control is particularly compromised during the
simultaneous performance of cognitive tasks requiring
visual processing.43 The development of dual-task methods of assessing functional balance and mobility skills is
just beginning.41 However, their usefulness in documenting functional limitations in patients with TBI is very
promising.
Impairments Limiting Postural Stability

Evaluation of motor impairments involves an assessment
of muscle tone, strength, range of motion, cerebellar coordination, static postural alignment in sitting and standing, and examining coordinated multijoint movements
used to recover stability after perturbations of different
size, amplitudes, and directions.34 Although not performed routinely in the clinic, electromyography and
kinematic analysis of associated body movements can be
used to quantify dyscoordination in stance and gait as
well as improvements during recovery.
Weakness, particularly hemiparesis, is frequently a
primary neuromuscular impairment affecting balance in
the patient with TBI. Traumatic injury to the cerebellum
or deep hemorrhagic lesions in the basal ganglia can
affect the timing and scaling of muscles working synergistically for postural control. Clinical indicators of muscular dyscoordination during postural tasks include
asymmetrical use of limbs for movement control and
excessive movements at the joints, including excessive
flexion of the hip and loss of knee control.
Assessment of sensory impairments involves evaluating sensation (vibratory sense, stereognosis, and peripheral visual acuity), determining the patients ability to
remain oriented under different sensory conditions, and
evaluating whether perceptions relevant to stability are
accurate.20,23 Moving platform posturography is one
approach to examining the organization and selection of
senses for postural control.45 Posturography uses a moving force-plate in conjunction with a moving visual surround to determine the patients ability to correctly select
from among visual, somatosensory, and vestibular inputs,
the most appropriate sense for orientation (see Chapter 3).
Alternatively, the Clinical Test for Sensory Interaction in Balance (CTSIB) tests the patients use of alternative sensory cues for orientation, using procedures
similar to those of posturography.46 This test, originally
described in 1986, used six sensory conditions to examine a persons ability to maintain stability under altered
sensory contexts. These six sensory conditions are shown
in Figure 27.2. In our clinic, we have modified this test
and now use only four sensory conditions, eliminating

the dome conditions (3 and 6) but maintaining the two
foam conditions (4 and 5). The dome was originally created to identify patients with visual motion sensitivity
a heightened sensitivity to motion in the environment,
such as is found in crowded shopping centers. The dome
has not proved to be sensitive or specific enough in
identifying visual motion sensitivity.47 Compliant foam
(medium-density Sunmate Foam) is used to reduce the
effectiveness of support surface somatosensory inputs for
orientation. Procedures for administering the CTSIB are
detailed elsewhere.48
Sensory impairments affecting orientation after TBI
can result from pathology within the peripheral vestibular system or within central structures that organize
sensory information for postural orientation. Although
both posturography and the CTSIB test can identify
and quantify functional problems in selecting sensory
inputs for postural control, they cannot determine the
anatomic location of the injury producing these functional problems.
Treatment
Treatment of instability involves remediating impairments and improving sensory and motor strategies essential to ensuring stability in functional tasks performed in
sitting, standing, and walking.19,20,24 Biomechanical limitations and movement disorders are a particular concern
in the patient with a vestibular deficit because they limit
the patients ability to move in ways that are necessary
for compensation of the deficit.
Treatment of biomechanical limitations involves
physical modalities, such as heat and ultrasound, as well
as exercises to improve range of motion, joint flexibility,
and body alignment.34,49 Treatment of neuromuscular
problems varies according to the nature of the problem.
Strengthening exercises are used to improve impaired
force generation. Therapy for muscular dyscoordination
consists of functional electrical stimulation, electromyographic biofeedback, and neuromuscular facilitation
exercises.34
Exercises to improve sensory function for orientation require the patient to maintain balance during progressively more difficult movement tasks while the
therapist varies the availability and accuracy of one or
more senses for orientation.19,20 For example, during
exercises to decrease sensitivity to visual motion cues,
the patient performs balance and movement tasks while
visual cues are reduced or absent (with eyes closed or
while wearing blinders or a blindfold) or are inaccurate
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453
Figure 27.2 The six positions used to

test sensory interaction in balance. (From
Shumway-Cook and Horak, 1986.46)
for orientation (use of prism glasses or optokinetic stimuli, and within a large moving visual surround).50 During
these exercises, accurate orientation cues from the surface are essential.
In contrast, exercises to improve use of vestibular
inputs for postural control in the patient with partial loss
of vestibular function involve decreasing the availability
of both visual and somatosensory input for orientation.
An example would be asking the patient to reach for an
object while wearing blinders and standing unsupported
on a piece of foam or a thick piece of carpet.
Patients who have had a complete bilateral loss of
vestibular function are taught to rely on visual and/or
somatosensory cues for postural control. Because these
patients have no residual vestibular function available to
them, the goal of therapy is sensory substitution for, rather
than enhancement of, remaining vestibular function.
In summary, treatment of postural dyscontrol in the

patient with TBI and associated vestibular system pathology is directed at helping the patient reestablish effective
sensorimotor strategies for balance control. Therapy
focuses on practicing functional tasks such as standing
unsupported while reaching, leaning, or turning, and
moving from sit to stand. In addition, treatment seeks to
remediate specific deficits in musculoskeletal and sensorimotor systems underlying postural dyscontrol.
Time Course for Recovery

The time course for recovery from traumatic vestibular
lesions is different from that in vestibular lesions of other
etiologies.51 In the patient with TBI and vestibular system
pathology, concomitant CNS lesions impair the compensatory process itself. As a result, recovery from traumatic
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vestibular lesions is often protracted. Pfaltz and Kamath51

compared recovery in patients with a unilateral loss of
vestibular function due to various causes, including trauma, Mnires disease, labyrinthectomy, and other diseases. At 6 months, only one third of the patients with
unilateral loss due to trauma were symptom free; the
majority of the other patients had achieved compensation
and were symptom free. At 18 months, many of the
patients with traumatic vestibular loss continued to show
persisting symptoms of vestibular system disorder.
Berman and Fredrickson3 studied 321 mildly and
moderately head-injured patients with vestibular system
pathology. Vertigo was reported in 34% of mildly headinjured patients and in 50% of moderately head-injured
patients. Sixty percent to 70% of patients with central
vestibular dysfunction had persisting symptoms 5 years

after injury. Almost half of these patients never returned
to work.
These and other studies suggest that the typical time
course for recovery from vestibular system disorder in
patients with TBI is protracted, requiring one to three
times longer than in patients with vestibular system
disorders from other causes. Many patients with traumatic vestibular dysfunction show persisting symptoms
of dizziness and disequilibrium several years after trauma. The extent to which specific exercise interventions
can influence the time course of recovery from vestibular
system dysfunction in the patient with TBI is an important theoretical and clinical question currently under
study.
CASE STUDY
Case Report
S.D. is a 31-year-old man admitted for rehabilitation
1 month after a closed-head injury. He fell 40 feet,
striking the left side of his head, and experienced a
brief ( 5 minutes) loss of consciousness. He was
admitted to the hospital with a Glasgow Coma Scale
score of 13. Computed tomography showed multiple
left parietal-occipital cerebral contusions. Associated
trauma included three fractured ribs and a contusion
of the left hip. There was no previous history of medical or neurological problems.
Otological evaluation involved both a clinical
examination and electronystagmography, including
tests for gaze and positional nystagmus, oculomotor
function (saccade, smooth-pursuit, and optokinetics),
and VOR function using rotational chair testing.
Results of this examination indicated the presence of
post-traumatic BPPV. Other test results were within
normal limits, suggesting no evidence for vestibular
hypofunction or a central vestibular lesion.
Assessment
On assessment, the patient was found to have moderate to severe imbalance (score 46 out of 56 on the
Berg Balance Scale). The patient had difficulty maintaining stability when moving from sit to stand, when
standing with eyes closed or with a reduced base of
support, and when reaching, leaning, or turning while
standing. The patient used a cane and required standby assistance for safety when walking. On the ThreeMinute Walk Test, he walked 135 feet and had four
significant path deviations. Gait pattern abnormalities

included an equinovarus foot position at foot strike,
circumduction of the right leg during the swing phase
of gait, and hyperextension of the right knee during
the stance phase of gait. He had significant problems
with adapting his gait to changing task demands,
scoring 13 out of 24 on the Dynamic Gait Index. He
required minimal assistance to maintain his balance
when walking with head turns (horizontal or vertical)
and when stepping over obstacles.
Sensorimotor constraints were as follows:
1. Positional vertigo in the left Hall pike position as well as vertigo during gait with vertical head motions.
2. Postural dyscontrol, including:
Right hemiparesis and dyscoordination.
Limitation of range in right ankle.
Asymmetries in weight-bearing, primarily in stance and during gait.
Difficulty organizing sensory inputs for
balance and effectively using vestibular
inputs for orientation in the absence of
visual and somatosensory cues.
3. Other problems:
Pain due to fractured ribs and contusions on the left hip
Moderate cognitive impairments
including memory and attention
deficits
Decreased awareness of his limitations,
raising a number of safety issues.
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Treatment
Treatment focused on eliminating positional vertigo,
balance retraining to improve ability to perform functional skills in sitting and standing, and gait retraining to improve gait pattern, endurance, and adaptive
capability when walking.
The CRM was used to eliminate BPPV. Balance
retraining involved exercises to improve strength,
range of motion, and coordination in the right extremities as well as postural sway biofeedback to
reduce weight-bearing asymmetries in standing and
improve range of center of mass movements over the
hemiparetic leg. Manual cues and feedback were
used to improve joint coordination at the knee and hip
while the patient practiced voluntary sway in standing, while moving from sit to stand, and during gait.
The patient also practiced maintaining balance during
such functional tasks as reaching, leaning, and turning in the standing position. In order to improve his
ability to use vestibular inputs for postural control,
the patient practiced a variety of stance balance tasks
while standing on foam or various grades of carpets
while wearing blinders or with eyes closed.
Outcomes after 4 months of rehabilitation (1 month
as an inpatient, 3 months as an outpatient) were as
follows:
The BPPV was successfully eliminated by the
CRM. Postural control underlying stability in sitting,
standing, and walking had improved; the patient was
transferring and walking independently and no longer
needed a cane to walk. Results of posturography testing examining sensory aspects of postural control in
S.D. before and after rehabilitation are shown in
Figure 27.3.
Figure 27.3 compares S.D.s performance on balance tasks under altered sensory conditions at 1
month and 6 months after his TBI. Peak-to-peak center-of-gravity angle, in degrees, is plotted for individual trials in the six conditions, conditions 3 through 6
have three trials each (see Chapter 3). Encompassing
individual trials is a larger histogram that shows the
upper limits of normality, established using the 95th
percentile from 250 normal control subjects ages 8 to
70.52 At one month, S.D. lost balance (indicated in

Fig. 27.3 by test stopped) when either visual or surface cues for orientation were reduced or inaccurate
(conditions 3, 4, 5, and 6). At 6 months after injury,
he fell on the first trial only when deprived of both
visual and surface cues simultaneously (conditions
5 and 6).
Figure 27.3 Recovery of sensory organization aspects

of postural control is shown by comparing body sway during altered sensory conditions at 1 month and 6 months
after traumatic brain injury (TBI). See text for details.
455
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Summary
Assessment and treatment of vestibular system pathology
are essential parts of rehabilitating the patient with TBI.
However, after TBI, injuries to other parts of the CNS can
complicate recovery from vestibular system dysfunction
in the following ways:
1. Associated trauma can produce pain and restrict
movements.
2. Musculoskeletal and neuromuscular problems
can affect the patients ability to move in
ways that are necessary to achieve CNS
compensation.
3. Damage to visual and somatosensory systems
may limit the availability of these senses as
alternatives to lost vestibular inputs.
4. Cognitive and behavioral problems make
compliance with a vestibular exercise program
difficult.
5. Intracranial injury can damage neural structures
important to the compensatory process, resulting in persisting symptoms and a protracted
recovery.
A comprehensive treatment plan that incorporates
vestibular rehabilitation exercises that have been modified to adjust for the preceding limitations is an effective
way to enable patients with TBI to gain functional independence and minimize persisting and disabling symptoms of vestibular system pathology.
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1983;30:335.
52. Peterka R, et al: Age-related changes in human postural
control: sensory organization tests. J Vestib Res 1990;1:73.
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28
and Imbalance:
Suggestions for Patients
With Migraine and
Mal de Dbarquement
Disequilibrium
Definition of
There are numerous causes for patients to complain of
symptoms related to vertigo, disequilibrium, lightheadedness, and/or unsteadiness and combinations thereof.
Although the majority of these complaints arise in association with direct insults limited to the peripheral vestibular apparatus, other sites of origin with specific disorders
can manifest symptoms of a similar nature. Vestibular and
balance rehabilitation programs are symptom-driven for
both entrance criteria and the development of the treatment plans, not specific to the site of lesion or the diagnosis. Therefore, management of the patient with balance
disorder by means of vestibular and balance rehabilitation
programs to control and/or eliminate the symptoms is
potentially applicable to a wide variety of etiologies and
lesion sites.13 Scattered results in the older literature has
suggested that the approach utilized for the stable periph458
Annamarie Asher, PT
eral vestibular insult (i.e., no complaints of spontaneously occurring symptoms) may be applied with success to
the patient with non-vestibular balance problems.4
There is now a growing literature addressing the use
of vestibular and balance rehabilitation therapy (VBRT)
techniques in patients with other than direct peripheral or
central vestibular lesions.512 The purpose of this chapter
is, therefore, to review the outcomes of patients with
non-vestibular balance disorders to whom VBRT techniques have been applied. This will be accomplished
via review of published population studies for migraine
and anxiety/panic disorders. Our experience of patients
with mal de dbarquement is also presented. The bulk
of the chapter concentrates on migraine and anxietyassociated dizziness. These two disorders individually or
as comorbidities are known to be commonly direct causes of dizziness and balance complaints and frequent cause
of lack of progression in otherwise stable unilateral
vestibular lesions.
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NON-VESTIBULAR DIZZINESS AND IMBALANCE: SUGGESTIONS FOR PATIENTS WITH MIGRAINE
The three groups of patients discussed here have

been identified as having symptoms suggesting that a
VBRT program may be applicable. Inclusion in therapy
programs of this type is considered appropriate if the
patients symptoms are:
1. Provoked by head or visual motion.
2. Constant and exacerbated by head or visual
motion.
3. Functional deficits identifiable for balance
and/or gait even though head or visual motion
does not interfere.
These criteria describe a stable condition, one that
does not vary in its overall character with time, as would
occur with patients describing symptoms that occur only
in a spontaneous manner, without provocation or warning.
Those patients with complaints of spontaneous events
of disequilibrium, with or without vertigo, are considered
either inappropriate or have a poor prognosis for the
use of vestibular and balance rehabilitation secondary to
presence of their spontaneous events.2 Of the three
groups of patients reviewed, those with migraine are
the group that is likely to experience spontaneous events
of vertigo or lightheadedness/imbalance symptoms.
Therefore, in evaluating the effectiveness of VBRT for
this group, it is important to recognize whether the study
subjects otherwise met the general criteria previously listed for use of VBRT.
Mal de Dbarquement
Most individuals exiting from a ship (and, occasionally,
a train or after long car excursions) after a cruise of a
day or longer experience a continuing sensation of rocking and/or other forms of linear shipboard movement.
These perceptions are especially prominent when the
individual is sitting or standing still and typically abate
after 12 to 36 hours.5,13 For a small percentage of otherwise healthy persons, the feeling of movement does
not resolve after the usual interval; they are said to
have mal de dbarquement (MDD). This perseveration
of dominantly linear movement sensations when the
patient is still or is involved with ambulation has been
suggested to result from a variety of causes, with the
specific theme that of the central system being slow
in readapting to a nonmoving support surface for
standing, sitting, or lying.5,14 On the basis of a case study,
Lewis14 suggests that the frequency and acceleration characteristics of the stimulating vehicle are
mimicked in the expression of symptoms by the patient
with MDD.
459
In general, balance function testing of a traditional

nature does not show results outside normal ranges in the
patient with MDD. Specific testing of the otolith organs
has only recently become more accessible to the routine
balance center, and as yet, no studies have been reported
on the directly measured status of the otolithic organs in
MDD. The implication is that this disorder does not
involve identifiable malfunction of the peripheral mechanism, especially that of the semicircular canals. Although
postural control abilities are usually within normal limits
from a clinical perspective, Nachum and colleagues15
have shown, in a prospectively designed control-group
study of navy crew members, that postural control abilities were poorer in the group susceptible to MDD.
The natural history of this disorder is spontaneous
resolution within 6 to 12 months, although some patients
continue to have symptoms for considerably longer. There
is a female preponderance in the general MDD population.5 Because the majority of the patients do not have
specific head motionprovoked symptoms but do have the
perception of balance deficits, the therapy programs provided to the these patients involve balance activities.
Patients with MDD are a small population, one
of the largest series, that of Hain and colleagues,5 reporting on 27 subjects. Therefore, we describe a small group
of patients from our own experience6 patients seen in
our clinic during a 4.5-year intervalto look at the efficacy of applying VBRT in this population. Each of the
patients met the previously listed criteria regarding their
symptom presentation for use of a VBRT program. In
order to rule out the possibility of unstable peripheral
system involvement, we excluded any patients with complaints of spontaneous events. Site-of-lesion determination was based on a full series of studies including, but
not limited to, electronystagmography (ENG), extensive
ocular motor evaluation, rotational chair testing, and
dynamic posturography.16 No indications were obtained
that would imply peripheral system involvement. The
patients in our small sample were not treated with medications during the time they were undergoing VBRT.
Therapy outcome was indicated by two global measures,
disability score and post-therapy symptom score.
Additionally, a single specific measure of sensitivity to
head movement, the Motion Sensitivity quotient (MSQ),
and dynamic posturography for postural control were
used.2 Results of the specific measure of dynamic posturography were normal and unchanged in all patients
before and after therapy. We assigned disability scores on
the basis of questioning each patient as to the effect of the
symptoms on daily activities. The disability scores are
defined as follows:
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Score
Description
0
1
2
No disability; negligible symptoms.

No disability; bothersome symptoms.
Mild disability; performs usual work
duties but symptoms interfere with
outside activities.
Moderate disability; symptoms disrupt
performance of both usual work duties
and outside activities.
Recent severe disability; on medical
leave, or had to change job because of
symptoms; off work for less than 12
months.
Long-term severe disability; unable to
work for more than 1 year or has
established permanent disability with
compensation payments.
A post-therapy symptom score was assigned to each

patient at the time he or she was started on a maintenance
program. The score was determined by responses to a
series of specific questions asking the patient to compare
symptoms at the end of active therapy with those prior to
therapy. The scores are defined as follows:
Score
Description
No symptoms remaining at the end of

therapy.
Marked improvement in symptoms;
mild symptoms remaining.
Mild improvement; definite persistent
symptoms remaining.
No change in symptoms relative to
pre-therapy period.
Symptoms worsened with therapy
activities on a persistent basis relative
to pre-therapy period.
1
2
3
4
The findings from this small sample, shown in Table

28-1, contrast with those reported by Hain and colleagues.5 Fifteen of their 27 patients undertook a VBRT
program whose results were described as being of limited productivity. The outcome measures shown in Table
28-1 indicate consistent improvement in symptoms and
disability from before to after therapy in our 4 patients
with follow-up. As with any disorder in which the natural history is that of spontaneous resolution, caution must
be exercised in drawing conclusions from a 4-person
sample of improvement. With the lack of head movementprovoked symptoms and of any problems with
vestibulo-ocular reflex function, habituation and adaptation activities were not used. Instead, the program con-
Table 28-1 THERAPY OUTCOME

PARAMETERS FOR FOUR
OF SIX PATIENTS WITH MAL
DE DBARQUEMENT
Disability
Score Change
[Pre-Therapy
Score]
Case 1
1 [2]
Case 2
2 [3]
Case 3
3 [4]
Case 4
1 [2]
Change
in MSQ
3.3
Post-Therapy
Symptom
Score
1
1
0.8
centrated on walking with head movements and the slow

balance movements like those used in tai chi.
The difference between our experience and that of
Hain and colleagues5 may relate to the fact that the larger
study used a questionnaire, so that the use of VBRT was
simply reported on by the participants and not a controlled event. The participants came from various areas of
the United States, so details of the focus of their VBRT
programs are not available. In general, the application of
traditional vestibular rehabilitation techniques of adaptation and habituation would not be expected to affect this
population. Those with MDD are basically without symptoms when in motion at a reasonable speed. It is when
they are still or moving slowly that they experience the
symptoms. Therefore, although only anecdotal, the evidence shown in Table 28-1 suggests that activities related
to balance in a slow format, such as that of tai chi, may be
of some use in patients with MDD while they await the
natural resolution process. Additionally, the study by
Hain and colleagues5 suggests that the use of benzodiazepines separately or with a customized VBRT program
have a positive effect on symptoms of MDD, but traditional vestibular-suppressive medication (meclizine or
scopolamine) are not helpful.
Migraine-Associated Dizziness
Epidemiological studies demonstrate a significantly
greater prevalence of vestibular symptoms in patients
with migraine,17,18 and a significantly higher incidence of
migraine in patients with dizziness complaints than is
found in the general, unscreened population.19 It is
reported that in 30% to more than 50% of patients with
migraine, symptoms of dizziness are inconsistently associated with a headache or are completely independent of
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head pain.17,2023 The frequency of abnormal test findings

on ENG, rotational chair testing, and posturography reported by numerous studies is summarized by Furman
and colleagues.24 They found an average of 9.9% of a
total of 534 patients with spontaneous nystagmus and up
to 54.2% with abnormal asymmetry on rotary chair testing. A number of studies indicate a sensorineural loss of
auditory sensitivity in patients diagnosed with migraineassociated dizziness (MAD).25 In general, the losses of
sensitivity were typically in the mild to moderate range
and of a variety of configurations. From these statistics it
is apparent that the relationship between migraine and
dizziness is significant.
There are two major ways that migraine can cause
problems with balance and dizziness. First, migraine can
cause the symptoms of dizziness and imbalance in a
patient who does not have a peripheral or central vestibular deficit, fitting our definition of non-vestibular
dizziness. Second, migraine may be comorbid with a
peripheral vestibular lesion. In this second situation, the
migraine condition may well cause a slowing of the central compensation process and result in reduced effectiveness with the use of a VBRT program. Although this
second situation is not strictly a non-vestibular condition,
interaction of a non-vestibular condition that causes a
prolongation of symptoms of dizziness, and the common
occurrence of migraine in conditions of dizziness, make
consideration of this situation worthwhile in this context.
We now consider the role of vestibular and balance rehabilitation in both situations.
Whitney and associates6 conducted a retrospective
study of 14 patients with MAD (no indications of peripheral or central vestibular involvement) and 25 patients
with peripheral vestibular involvement and self-reported
history of migraine to investigate the effect of customized
VBRT over 1 to 11 months of active therapy. Multiple
outcome measures were used that involved physical ability for gait (Dynamic Gait Index [DGI]); self-perceived
symptom intensity (scale from 0 to 100), self-perceived
disability (Dizziness Handicap Inventory [DHI]), with
three subscales for emotional, physical and functional
impact of symptoms; and confidence scaling in performing activities of daily living (Activities-Specific Balance
Confidence Scale [ABC]) (detailed discussions of these
tools are found elsewhere in this text). A composite score,
using a weighted combination of the ABC, DHI and DGI
scores, was used to give a global measure of performance.
This process was validated, showing a strong correlation
with the disability score of Shepard and Telian.26 Overall,
there was a significant improvement (P .05) for all outcome measures from before to after therapy. However,
within the MAD group, although the physical measure of
461
gait ability (DGI), perceived physical ability (functional

and physical subscales of DHI), and composite score
showed significant changes in perceived intensity of
symptoms, the emotional impact of symptoms (emotional
subscale of DHI) and, to a lesser extent, confidence in performance of daily activities (ABC; P .06) did not show
significant improvement after therapy. In contrast, the
group with peripheral disorders and a history of migraine
showed significant post-therapy improvement or a trend
for significant improvement on all outcome measures
(physical and functional subscales of the DHI; P .06).
Whitney and associates6 approached the issue of
medication use by comparing outcomes for all patients
undergoing antimigraine medication therapy (7 of the
MAD group and 10 of the migraine history group) with
those not taking concomitant medication. This comparison showed statistically greater improvement for the
medication group on composite score, DHI, and DGI.
However, when this same comparison was performed
within the MAD and migraine history groups, only the
MAD group showed more improvement in those on medication. Medication use had no significant effect on the
migraine history group.
Collectively, the results of this study suggest that for
patients with MAD, change in physical performance does
not result in perceived improvement unless the underlying
causative disorder of migraine is being successfully
addressed. The findings also imply that a simple history of
migraine with a peripheral disorder does not necessarily
constitute a comorbidity of significance that would influence either compensation or the effectiveness of VBRT.
To address the implication that a simple history of
migraine may not be an influential factor in effectiveness
of VBRT, the same group of investigators conducted a
second retrospective study involving 31 patients with
peripheral or central vestibular diagnosis (other than that
of MAD) and a history of migraine.7 Historical controls
were selected via chart review to match with the experimental group on the basis of age 5 years, diagnosis, and
vestibular function test values but no indications of
migraine. Both groups underwent customized VBRT
with outcome measures as described for the previous
study, with the addition of the Timed Up and Go Test,
which quantifies the speed at which a person is able to
stand, walk 3 meters, turn, and return to the seated position (see discussion elsewhere in this text). The mean
change in all of the outcome measures showed statistically significant improvement (P .05) after therapy for
both groups. A significantly greater change was noted in
the DHI for the control group than in the migraine group,
with all other outcomes showing no significant difference
between groups. When a comparison of the number of
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patients from each group who had what they defined as a

clinically significant improvement in the outcome measures, statistical differences were noted for ABC and DGI
results, showing that more patients in the control group
improved than in the migraine group. The other outcome
measures again did not demonstrate a significant difference, although for all outcome measures, more of the
control group had clinically significant improvements
than the migraine group. Although it has been demonstrated that in a group of patients with vestibular problems but without history of migraine or anxiety, their
perception of handicap is related in a correlative manner
to their functional impairment.27 This was not the case
with the cohort of migraine patients in the second study
reported by the Whitney group.7
In summary, VBRT programs do appear to have a
role to play in the treatment of dizziness produced by the
migraine condition or in situations in which the comorbidity of vestibular system impairment and migraine may
interact synergistically. It seems clear that although the
VBRT programs are of positive assistance, the overall
results in the patients with MAD or with a simple associated history of migraine are not as effective as in patients
without migraine complications. This appears to be partly due to the reduced correlation between improvement in
physical ability and the patients perception of disability,
perhaps caused by ongoing headaches even though the
dizziness component may have been reduced or eliminated. The implication is that the underlying disorder
of migraine must be treated simultaneously with the use
of a VBRT program for maximum results. Given that
patients with migraine have a significant sensitivity to
motion (referred to as space motion discomfort),24 the use
of active head movement exercises in a patient with active
migraines may be counterproductive, and this sensitivity
may limit the use of various VBRT techniques.
Treatment of the migraine condition with behavioral
and/or pharmacological methods has the opportunity to
enhance the effectiveness of a simultaneous VBRT program. To more definitively address these implications, a
prospectively designed study of patients with MAD, identified as meeting strict definitional criteria for MAD,19
involving a controlled comparison between simultaneous
treatment of the migraine condition during VBRT, to use
of VBRT without the migraine treatment is needed.
Primary Anxiety and Panic

The association of psychiatric disorders in general, and
anxiety, panic, and agoraphobia in particular, has prevalence in an unselected population of dizzy patients that is
significantly greater than in the general population.2830
The interested reader is referred to summaries of the documentation of this relationship and possible mechanisms
of cause and effect that are beyond the scope of this chapter.3133 As with migraine, anxiety, panic, and phobic
avoidances can be related to dizziness as a direct cause or
as a means of interfering with the natural compensation
process.3436 Several mechanisms by which psychological disorders may stall the compensation process, even
with the use of VBRT efforts to promote the process,
have been proposed.34 First, and likely the most common,
would be the natural avoidance of situations and movements that provoke symptoms of dizziness or disorientation that are currently produced or were initially
produced by a lesion of the peripheral vestibular system.
These behavioral reactions to an initial set of symptoms
are counterproductive to the activities needed for natural
central vestibular compensation. The behavioral changes
are fueled by a fear of danger from the symptoms experienced as well as the embarrassment of appearing out of
control when symptoms occur. If the behavioral changes
continue in an uninterrupted manner, they can develop
into actual psychiatric illness not unlike agoraphobia
and/or lead to a self-generation of a portion of the original symptoms even though the initiating disorder, such as
benign paroxysmal positional vertigo, has resolved.32,34
A second consequence of the natural avoidance of
situations and movements is a subconscious reduction in
the reliance on information from the vestibular and proprioceptive system leading to an obligatory use of visual
information. This change in the cognitive, motor, and
perceptual responses to symptoms then leads to further
incidences of disequilibrium in conditions in which visual information is inappropriate for the maintenance of
stance or orientation. This vicious circle leads to further
avoidance of and hypersensitivity to visual motion as a
provoking event for symptoms of imbalance and disorientation.11,34 This hypersensitivity to normal daily
inputs may lead to yet another mechanism of interference
with the compensation process. In this case, the heightened arousal leads to conditioned autonomic responses
from the anxiety produced by the daily exposure to normal visual, proprioceptive, and vestibular stimuli. The
somatic expressions of the anxiety (e.g., nausea, perception of abnormal sway when standing, fear response) fuel
the already altered perceptual, motor, and avoidance
changes.34
In the counseling of patients as to the possibility that
a major portion or all of their ongoing symptoms may be
related to anxiety disorder, it is clearly helpful to explain
the mechanisms by which this could occur secondary to
an initial neurotological insult to the vestibular system.
This issue is also clarified by the information summa-
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rized in the review works relating the direct anatomic

pathways between the vestibular system and those portions of the brain known to be involved with anxiety,
panic, and fear avoidance reactions.3133 Although little is
known as to the direct effects of neurotransmitters and
other chemical actions in the compensation process,
some evidence has been found that simple stress alone
interferes with compensation in unilateral labyrinthectomized rats that may be partially accounted for by
changes in the concentration of a steroid biosynthesis
enzyme.35 Information of this nature helps patients
accept the concept that anxiety, panic, and avoidance
behaviors have a physical basis and that the problem is
not just in the head, relieving concerns about the stigma that accompanies psychiatric disorders.
The preceding discussion dealt primarily with psychiatric disorders as secondary developments of an insult
to the peripheral or central vestibular system, producing
a situation in which the compensation process is retarded
or the anxiety disorder is conditioned on the initiating
symptoms and then produces symptoms modeled after
those from the insult. Although these two situations may
be considered non-vestibular, more germane to this
chapter would be the situation in which a psychiatric disorder is the primary disorder that manifests in the form of
complaints of vague dizziness and imbalance.
A study by Staab and Ruckenstein 36 approached the
question of how often this latter situation occurs compared with development of psychopathology secondary
to a neurotological insult. These investigators also explored whether the psychological disorders have different
general characteristics and risk factors. This retrospective
review of 132 patients found that the subjects could be
divided into three groups according to what was believed
to be the initiating cause of the symptoms of dizziness.
First were those patients in whom anxiety disorder was
the only cause of the symptoms of dizziness. Second was
the group for whom an identifiable neurotological disorder of the peripheral vestibular system or diagnosis of
MAD, considered a neurotological disorder in this study,
exacerbated a preexisting anxiety disorder. Third was the
group in whom a peripheral vestibular insult or MAD
provoked an anxiety disorder that interfered with recovery from the initial insult (the types of patients discussed
previously). One of the surprising findings was that of
this total cohort of patients, all of whom were referred
initially for the complaints of dizziness, a full third of the
patients met the diagnostic criteria set by Staab and
Ruckenstein for anxiety disorder or panic as the sole
cause of the complaints of dizziness. In the other two
thirds, the exacerbation or development of anxiety disorder was stimulated by a primary neurotological disorder,
463
each in equal proportion. Therefore, each group accounted for a third of the total cohort. This finding alone supports the contention that anxiety and dizziness are a
two-way communicating relationship,33 with each primary disorderanxiety or neurotological insultable to
stimulate the other. The other dominant finding was that
patients with prodromal anxiety conditions were much
more likely to experience full panic attacks and/or major
anxiety disorders. Those without the anxiety risk factors
before the vestibular insult or development of MAD were
more likely to have mild anxiety disorders and minor
avoidance behaviors.36 The recognition of this difference
from a diagnostic prospective may be of assistance in the
development of a treatment plan for patients with these
problems.
Considerations of treatment of patients with combinations of dizziness and anxiety, independent of whether
anxiety or an insult to the peripheral vestibular system
is the primary lesion, start with the tools available for
this population. Medications have been shown to be modestly effective in controlling both the dizziness and the
psychiatric condition, primarily serotonin reuptake inhibitors.33,37 These same medications are also suggested
in the patient with anxiety, dizziness, and migraine
together.33,38 From a therapy standpoint, the development
of cognitive and behavioral therapies has been shown
effective for mild depressive and anxiety disorders when
compared with medication.32 The cognitive techniques
work to help a patient recognize thought processes that
would initiate, amplify, or sustain an anxiety or phobic
behavior. The use of exposure and desensitization were
part of the initial techniques for behavioral therapy. The
two therapies have clear overlap and complement each
other to the extent that they are often used together.32
VBRT techniques involve a significant amount of
exposure activity, similar to that used in behavioral therapy. Although the use of VBRT is proposed primarily for
promoting the compensation process, it may well serve
as a desensitization technique and a form of behavioral
therapy, especially in patients with mild primary anxiety
disorder resulting in dizziness complaints.4,32 The combination of cognitive, behavioral, and vestibular rehabilitation therapy techniques would appear to be a logical
manner in which to deal with the complex symptom complaints in this patient group.
An attempt to test this contention was shown in a
prospective, randomized control group study that used
cognitive-behavior therapy combined with VBRT.9 The
cognitive-behavioral techniques were added to see
whether it was feasible to combine such techniques in a
group of elderly patients who were otherwise suitable
candidates for a vestibular rehabilitation program. There
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were significant improvements in the treatment versus no

treatment control group for walking time and DHI value.
Unfortunately, no changes were seen in measures of anxiety or depression. Although this study showed no detrimental effect of the combination of the therapy
techniques, it is difficult to evaluate any effectiveness of
the addition of cognitive-behavioral aspects because the
comparison was to a no-treatment control.
A second study separated the effects of behavioral
therapy and of VBRT by treating the patients with behavioral therapy first and then treating them with VBRT in
an effort to see what each therapy had to offer patients
with agoraphobia and vestibular dysfunction.10 The principle outcome was an improvement in a global measure
of intensity of symptoms with the behavioral therapy and
no change in adjunctive indicators of anxiety and mobility. Yet after VBRT, further change in the global indicator
was seen along with the adjunctive measures. This result
supports the use of VBRT in patients with anxiety disorders, even though the indications for direct peripheral or
central vestibular involvement are minimal.10
Indications to support use of general VBRT in populations of patients with the comorbidities of anxiety,
panic, agoraphobia, and dizziness at the primary care
level by a therapist or by a primary care nurse have been
shown in two large, prospectively designed, randomized,
controlled studies.8,12 In both studies, significant changes
were noted for the treatment group in physical measures
and measures of well-being, including those of anxiety
and depression, in comparison with the control groups.
Lastly, the form that a vestibular rehabilitation
program takes may make a significant difference in the
effectiveness of VBRT in patients with significant
perceptual-motor changes such as those previously
discussedrelated to the obligatory reliance on visual
cues. In a prospectively designed, controlled study, two
groups of patients, all of whom had undergone a conventional form of VBRT without improvement, were started
on customized vestibular rehabilitation programs. The
experimental group received supplemental therapy work
directed at desensitization of visual stimuli through direct
exposure to a variety of provocative visual motion events
under differing support conditions ranging from sitting to
walking.11 The results showed that both groups improved
on all measures of outcome. However, the experimental
group had a greater improvement as well as a statistically greater improvement on measures related to visual
sensitivity. Although both groups improved on measures
of anxiety, these improvements were seen to correlate
with improvement in visual sensitivity, explaining the
greater improvement in direct anxiety measures seen in
the experimental group.11 The implication of this study is

that incorporation of techniques that may be difficult to
develop or control in a traditional, customized home program may require a repeat-visit format for specialized
stimulus exposure in specific patients, especially those
with comorbid anxiety and a clear over-reliance on visual stimuli.
In summary, although the entire arena of treatment
of dizziness comorbid with psychiatric disorders is just in
its infancy, there appears to be reasonable support for the
use of VBRT in some manner. As was the situation for
migraine-related dizziness, attention in some form has to
be paid to the comorbid psychiatric condition, which
must be addressed directly for effective resolution of the
symptoms of dizziness being expressed. It is possible that
the use of VBRT alone may serve this role when it acts as
a form of behavioral therapy for mild conditions of anxiety or minimal avoidance without complications of panic
or agoraphobia.
Methodological Considerations
for Assessment and Treatment
Development
Although current data on the use of vestibular rehabilitation techniques in the conditions discussed as
non-vestibular are just appearing in the literature in
well-performed studies, there are no indications at present that the assessment process used to develop VBRT
programs should be altered for the situations discussed.
The assessment process used for unilateral and bilateral
vestibular hypofunction (described in this text) has
focused on determination of provocative activities in the
form of eye/head and/or visual motion stimuli that would
cause symptoms and identification of functional deficits
of balance and gait. This process also recognizes deficits
of balance and gait that are the primary complaint, without the presence of transient or constant symptoms of
vertigo or lightheadedness. Therefore, the use of a consistent format for assessment of these patients is appropriate in general. What does need special attention in the
conditions described previously is the taking of the
patients history in whom evidence for MDD, MAD, or
psychiatric disorders would first appear. Being familiar
with the profile for MDD, having structured questioning
for suspected MAD,19,24 and touching on the general historical and characteristic behaviors for anxiety, panic,
and phobic avoidance 31,32 will allow the therapist to
further customize the overall management plan to coordinate with other recommended treatment activities
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(see other discussion in this text on these disorders). It is

not unreasonable, on the basis of referral patterns, that
the therapist may be the first to recognize MDD or the
comorbidity of migraine and/or a psychiatric condition as
a significant contributor to the patients symptoms. This
recognition should prompt discussion with the referring
physician for a broadening of the overall treatment plan.
Identification of patients for whom the symptom
complaints are not the direct result of an insult to the balance system per se does not prevent use of a vestibular
and balance rehabilitation program as an adjunct treatment for those patients. It does, however, require counseling of the patient for realistic goals and appropriate
emphasis on what should be the primary treatment
modality. For disorders with a natural history of spontaneous resolution, such as MDD, one must be cautious
about assuming the effects of a therapy program.
Although VBRT is being shown effective, further
efforts are needed to develop a better understanding of
how VBRT can be integrated with other treatment methods for patients with non-vestibular system disorders.
Changes in treatment programs could benefit the patients
with multisensory deficits, such as those with disequilibrium associated with aging or with head trauma considered elsewhere in this text. Also possible is that new
combined treatment strategies may have improved outcomes for the traditional patient with a peripheral vestibular lesion.
References
1. Black FO, Pesznecker SC: Vestibular adaptation and
rehabilitation. Curr Opin Otolaryngol Head Neck Surg
2003;11:355.
2. Shepard NT, Telian SA: Vestibular and balance rehabilitation: program essentials. In: Cummings CW, Haughey
BH, Thomas JR, et al, eds. Cummings Otolaryngology:
Head and Neck Surgery, 4th ed. Philadelphia: Elsevier
Mosby; 2005.
3. Whitney SL, Rossi MM: Efficacy of vestibular rehabilitation. Otolaryngol Clin North Am 2000;33:659.
4. Shepard NT, Telian SA: Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg 1995;112:173.
5. Hain TC, Hanna PA, Rheinberger MA: Mal de debarquement. Arch Otolaryngol Head Neck Surg 1999;125:615.
Physical therapy for migraine-related vestibulopathy and
vestibular dysfunction with history of migraine. Laryngoscope 2000;110:1528.
7. Wrisley DM, Whitney SL, Furman JM: Vestibular rehabilitation outcomes in patients with a history of migraine.
8. Yardley L, Beech S, Zander L, et al: A randomized controlled trial of exercise therapy for dizziness and vertigo
in primary care. Br J Gen Pract 1998;48:1136.
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9. Johansson M, Akerlund D, Larsen HC, Andersson G:

Randomized controlled trial of vestibular rehabilitation
combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg 2001;
125:151.
10. Jacob RG, Whitney SL, Detweiler-Shostak G, Furman
JM: Vestibular rehabilitation for patients with agoraphobia
and vestibular dysfunction: a pilot study. J Anxiety Disord
2001;15:131.
11. Pavlou M, Liingeswaran A, Davies RA, et al: Simulator
based rehabilitation in refractory dizziness. J Neurol
2004;251:983.
12. Yardley L, Donovan-Hall M, Smith HE, et al: Effectiveness of primary care-based vestibular rehabilitation for
chronic dizziness. Ann Intern Med 2004;141:598.
13. Gordon CR, Spitzer O, Doweck I, et al: Clinical features
of mal de dbarquement: adaptation and habituation to sea
conditions. J Vest Res 1995;5:363.
14. Lewis RF: Frequency-specific mal de dbarquement.
Neurology 2004;63:1983.
15. Nachum Z, Shupak A, Letichevsky V, et al: Mal de dbarquement and posture: reduced reliance on vestibular and
visual cues. Laryngoscope 2004;114:581.
16. Shepard, N.T., Telian, S.A.: Practical Management of the
Balance Disorder Patient. San Diego: Singular Publishing
Group, Inc., 1996.
17. Kayan A, Hood JD: Neuro-otological manifestations of
migraine. Brain 1984;107:1123.
18. Bayazit Y, Yilmaz M, Mumbuc S, Kanlikan M: Assessment of migraine-related cochleovestibular symptoms.
Rev Laryngol Otol Rhinol (Bord) 2001;122:85.
19. Neuhauser H, Leopold M, von Brevem M, et al: The
interrelations of migraine, vertigo, and migrainous
vertigo. Neurology 2001;56:436.
20. Cutrer FM, Baloh RW: Migraine-associated dizziness.
Headache 1992;32:300.
21. Cass SP, Furman JM, Ankerstjerne JKP, et al: Migrainerelated vestibulopathy. Ann Otol Rhinol Laryngol
1997;106:182.
22. Johnson GD: Medical management of migrainerelated dizziness and vertigo. Laryngoscope 1998;108
(Suppl 85):1.
23. Reploeg JD, Goebel JA: Migraine-associated dizziness:
patient characteristics and management options. Otol
Neurotol 2002;23:364.
24. Furman JM, Marcus DA, Balaban CD: Migrainous vertigo: development of a pathogenetic model and structured
diagnostic interview. Curr Opin Neurol 2003;16:5.
25. Battista RA: Audiometric findings of patients with
migraine-associated dizziness. Otol Neurotol 2004;
25:987.
Neurol Clin 1990;8:459.
27. Whitney SL, Wrisley DM, Brown KE, Furman JM: Is perception of handicap related to functional performance in
persons with vestibular dysfunction? Otol Neurotol
2004;25:139.
28. Jacob BG, Furman JM, Durrant JD, Turner SM: Panic,
agoraphobia, and vestibular dysfunction. Am J Psychiatry
1996;153:503.
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29. Yardley L, Burgneay J, Nazareth I, Luxon L:

Neuro-otological and psychiatric abnormalities in a community sample of people with dizziness: a blind, controlled investigation. J Neurol Neurosurg Psychiatry
1998;64:679.
30. Yardley L, Owen N, Nazareth I, Luxon L: Panic disorder
with agoraphobia associated with dizziness: characteristic
symptoms and psychosocial sequelae. J Nervous Ment
Dis 2001;189:321.
31. Yardley L: Overview of psychologic effects of chronic
dizziness and balance disorders. Otolaryngol Clin North
Am 2000;33:603.
32. Staab JP: Diagnosis and treatment of psychologic
symptoms and psychiatric disorders in patients with
dizziness and imbalance. Otolaryngol Clin North Am
2000;33:617.
33. Furman JM, Balaban CD, Jacob RG, Marcus DA:
Migraineanxiety related dizziness (MARD): a new dis-
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2005;76:1.
Yardley L, Redfern MS: Psychological factors influencing
recovery from balance disorders. J Anxiety Disord 2001;
15:107.
Yamamoto T, Yamanka T, Matsunaga T: The effect of
stress application on vestibular compensation. Acta
Staab JP, Ruckenstein MJ: Which comes first? Psychogenic dizziness versus otogenic anxiety. Laryngoscope
2003;113:1714.
Staab JP, Ruckenstein MJ, Solomon D, Shepard NT:
Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol 2002;128:554.
Staab JP, Ruckenstein MJ: Venlafaxine for migraineassociated dizziness. Oral presentation at the 40th
Annual Spring Meeting of the American Neurotology
Society, Boca Raton, Fla, May 14-15, 2005.
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29
Non-vestibular Diagnosis
and Imbalance:
Cervicogenic Dizziness
Cervicogenic dizziness is a controversial subject at best.

The term tends to be used to describe a variety of entities,
some of which are theoretically more likely than others,
including cervical ataxia, cervical nystagmus, and cervical vertigo. Because vertigo is defined as the illusion of
movement (rotation, tilt, or linear displacement) and is
therefore restrictive, the term cervicogenic dizziness,
rather than the older term cervical vertigo, is used in
this chapter to refer to symptoms of dizziness (including
vertigo, disequilibrium, and lightheadedness) arising
from the cervical spine.
Several different processes have been hypothesized
to be the cause of cervicogenic dizziness. These pathophysiological mechanisms include irritation of the sympathetic vertebral plexus, vertebrobasilar insufficiency
(VBI), and altered proprioceptive afferent signals from
the upper cervical spine. This latter potential cause of
dizziness is of particular interest because of the large
number of patients with either whiplash injuries or neck
pain that are seen by physical therapists. This particular
cause of dizziness is also perhaps the most controversial.
One of the major problems in identifying patients
with cervicogenic dizziness is the lack of a concrete test
that is sensitive and specific to this entity. From a therapeutic standpoint, however, the controversy surrounding
cervicogenic dizziness may be academic. If an individual
presents with cervical symptoms as well as dizziness, the
holistic approach would be to treat the cervical problem
as well as the dizziness. The aim of this chapter is to
review the anatomical and physiological bases for cervicogenic dizziness, to summarize the scientific findings
related to cervicogenic dizziness, to address the clinical
methods of assessing cervicogenic dizziness, and to discuss possible management strategies for this condition.
Proposed Etiologies
Posterior Cervical
Sympathetic Syndrome
Barr1 suggested that cervical problems could irritate the
sympathetic vertebral plexus, leading to constriction of
the internal auditory artery and decreased perfusion of
the labyrinth, which would induce vertigo. There is little
objective evidence, however, to support this hypothesis.
In addition, the intracranial circulation is controlled independently of the cervical sympathetic system. Therefore,
it is difficult to see how a cervical injury could lead to
restricted blood flow to the inner ear.
Vertebrobasilar Insufficiency
Another possible cause of dizziness arising from the cervical spine is occlusion of the vertebral arteries by
osteoarthritic spurs2 or occipitoatlantal instability.3 VBI
and vertebrobasilar ischemia can arise from a variety of
causes, including embolism, large artery atherosclerosis,
small artery disease, and arterial dissection, and can occur
467
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at numerous sites along the course of the vertebral and

basilar arteries.4 There are two sites where physical occlusion, or in the extreme, dissection of the vertebral artery
can occur. One is in the upper cervical spine, after the vertebral artery exits the transverse foramen and courses
around the mobile upper cervical vertebrae. The other
potential site for occlusion is in the initial segment of the
vertebral artery before it enters the transverse foramen.5
In theory, the vertebral arteries can be compressed during
cervical rotation or extension, as occurs when a person
reaches for an object on an overhead shelf, turns the
head while backing up a vehicle, or undergoes cervical
spine manipulations. In normal individuals, the carotid
arteries provide sufficient collateral circulation to prevent
symptoms.6 In individuals with atherosclerotic vascular
disease, the cerebrovascular circulation may be compromised to the extent that compression of the vertebral
arteries could lead to VBI.
Although there is an anatomical substrate that could
link cervicogenic dizziness with VBI, it is not clear that
the symptoms of VBI match those of cervicogenic dizziness. The symptoms associated with VBI can be quite
diverse. In a study of 65 patients diagnosed with VBI,
Williams and Wilson7 found that vertigo was the initial
symptom in 48% of the cases. Vertigo due to VBI is generally abrupt in onset, is of short duration (several minutes), and may be associated with nausea and vomiting.8
These symptoms are similar to those of someone with a
vestibular deficit, but the vertigo in patients with VBI is
generally associated with other symptoms related to
ischemia in areas supplied by the posterior circulation
typically including visual hallucinations, loss of vision,
ataxia, drop attacks, numbness or weakness affecting
both sides of the body, visceral sensations, visual field
defects, diplopia, and headaches.7,9
Vertigo may be an isolated initial symptom but is
typically intermixed with the other symptoms of VBI.10
Of the more than 400 patients with vertebrobasilar
ischemia whose data are entered in the New England
Medical CenterPosterior Circulation Registry, fewer
than 1% presented with a single sign or symptom (not
necessarily vertigo or dizziness).4,11 Individuals with vertebrobasilar ischemia secondary to stenosis or occlusion
of the vertebral arteries typically experience transient
ischemic attacks (TIAs) with symptoms of dizziness,
impaired vision, and loss of balance, which are consistent
with ischemia in the vestibulocerebellum and medulla.12
In cases of dissection of the vertebral artery, the primary
symptom is posterior cervical pain that may radiate to the
shoulder region. In addition, these individuals typically
experience occipital headaches, dizziness, diplopia, and
lateral medullary and cerebellar signs.5,13
Given the typical mixed signs and symptoms of

VBI, the presence of episodic, isolated bouts of vertigo in
the absence of associated symptoms for more than 3
weeks is believed to be rarely caused by vertebrobasilar
disease.9 In addition, drop attacks, which have been
attributed to transient ischemia of the posterior circulation, were never found in isolation in the New England
Medical CenterPosterior Circulation Registry cases.4,11
In summary, although it is unlikely that dizziness as the
sole symptom arises from vertebrobasilar ischemia, the
possibility of VBI should at least be considered on the
basis of the patients history and symptoms. Clinical tests
for VBI, and their utility, are described in detail later in
this chapter.
Altered Proprioceptive Signals

The mechanism by which cervical pain or dysfunction
could lead to symptoms of dizziness has not been identified. One hypothesis is that inflammation or irritation of
the cervical roots or facet joints would lead to a mismatch
among vestibular, visual, and cervical inputs. This multisensory mismatch would lead to the symptoms attributed
to cervicogenic dizziness, and the symptoms would be
most apparent during head movements (Fig. 29.1). In
theory, once the central nervous system (CNS) has adapt-
Figure 29.1 Schematic diagram of the multisensory mismatch hypothesis. Peripheral inputs (vestibular, cervical, and
visual) converge on central vestibular structures and affect oculomotor function, balance function, vestibulo-ocular reflex
(VOR), and perceptions of dizziness. Cervical dysfunction (represented by the curved line) would lead to a mismatch among
vestibular, visual, and cervical inputs. This multisensory mismatch
would lead to the symptoms attributed to cervical dizziness.
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NON-VESTIBULAR DIAGNOSIS AND IMBALANCE: CERVICOGENIC DIZZINESS
ed to the altered somatosensory inputs (just as the system

is capable of adapting to altered vestibular inputs), the
symptoms of cervicogenic dizziness would abate even
though the underlying dysfunction remained. Because
the symptoms attributed to cervicogenic dizziness can
continue for extended periods, this explanation, although
enticing, remains controversial. The following sections
review the literature that addresses the role of altered cervical proprioceptive signals in the generation of signs and
symptoms of dizziness.
Anatomy and Physiology

There is a convergence of cervical proprioceptive and
vestibular information throughout the spinal cord, brainstem, cerebral cortex, and cerebellum.14 A detailed review
of the anatomical evidence is beyond the scope of this
chapter; however, a brief review of the pertinent physiological evidence, which suggests that cervical inputs may
play a role in dizziness, is warranted. Cervical proprioceptive signals important for postural neck reflexes arise
from the joint and tendon receptors located in the deep
structures of the upper cervical spine.15 McCouch and
colleagues15 demonstrated that the tonic neck reflexes in
cats were mediated through the joint receptors rather than
the cervical musculature. The role of the deep paravertebral muscle spindles in this region is not clear and may be
species dependent.1621
In addition to its influence on postural neck reflexes, upper cervical spine proprioception is thought to be
responsible for the generation of the cervico-ocular reflex
(COR), which, when present, complements the vestibuloocular reflex (VOR) at lower frequencies of movement.22
Rubin and associates23 recorded from neurons in the
vestibular nucleus of cats that responded to both vestibular stimulation (whole-body rotation) and movements of
the trunk on a fixed head. Further support for the hypothesis that cervical proprioception can influence vestibular
function comes from the work of Hikosaka and Maeda.24
These investigators reported that, in the cat, vestibular
excitation of the abducens nerve was inhibited by
contralateral and facilitated by ipsilateral electrical stimulation of the cervical dorsal roots or facet joints. In addition, they reported that these effects were seen with
stimulations at C2 and C3 but not with stimulations at C5
or lower.
These studies indicate that cervical proprioception,
particularly from the upper cervical spine, may play a
role in postural control and may have an effect on
vestibular function. It is important to remember that the
studies were performed in anesthetized or decerebrate
animal preparations and that responses in awake, normal-
469
ly functioning humans may be entirely different. In light

of the physiological findings and the anatomical convergence of cervical and vestibular inputs, the following sections explore whether cervical proprioceptive signals can
contribute to symptoms of vertigo or disequilibrium and
influence vestibular system function or postural stability.
Findings after Cervical Spine Lesions

A number of studies in animals and humans have investigated oculomotor and balance changes following either
experimentally induced lesions in the upper cervical
spine, or cervical injuries.
With regard to the cervical injuries, the primary
research focus has been on whiplash associated disorders
(WADs), a diverse set of symptoms (including headache,
dizziness, paresthesia, anesthesia, as well as cervical,
thoracic, lumbar and upper extremity pain) that occur
after a flexion-extension cervical injury.25 Although most
individuals recover from WAD, the symptoms, which can
be severe, persist in a significant proportion of these individuals. On the basis of the findings of various studies,
cervical injury seems to have little effect on the oculomotor and vestibular system but may lead to disturbances
in postural control.
Oculomotor Findings
Cervical proprioceptive ablation has been performed
by both sectioning of the dorsal roots and injection of
local anesthetics into the neck. Igarashi and coworkers26
reported on the oculomotor effects seen after both local
anesthetic injections and unilateral transection of the
C1 and C2 dorsal roots in squirrel monkeys. Lidocaine
(Xylocaine) (1 mL of 1% solution) without epinephrine
was injected into the deep neck regions unilaterally in the
experimental animals, and into either the superficial posterior neck region or abdominal wall in control subjects.
The animals were placed in the dark, and their eye movements were recorded. There was no evidence of spontaneous nystagmus in either the experimental or control
groups after injection. Optokinetic nystagmus was used as
a measure of vestibular function in this study. Optokinetic
nystagmus, the reflexive eye movement response to a
moving full-field visual stimulus, is a visually mediated
response that travels through the accessory optic system,
a subcortical neural pathway, to the vestibular nuclei.
Here the signals are processed in conjunction with the
vestibular afferent input to generate compensatory eye
movements. Optokinetic nystagmus was measured preinjection and post-injection in 10 animals by means of a
rotating optokinetic stimulus (1 deg/sec2 acceleration up
to 200 deg/sec). Igarashi and coworkers26 reported bidi-
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rectional declines in both the slow component and fast

component eye velocities of the optokinetic nystagmus in
the experimental subjects. The control groups also
demonstrated declines in the slow-component eye velocity post-injection. The investigators stated that there was a
statistically significant difference in slow component eye
velocity changes between the experimental and control
groups, and they infer from this finding that cervical proprioception contributes to oculomotor behavior.
Two issues raise questions about their conclusion.
First, the investigators reported a statistically significant
difference using a P value equal to 0.066, which exceeds
the generally accepted probability level for statistical significance. Most investigators would not reject the null
hypothesis that there is no difference between groups
with this P value. Second, the declines in velocity of the
fast component of the nystagmus in the experimental
group and in the velocity of the slow component of the
nystagmus seen in the control groups would argue that
the local anesthetic has a diffuse, systemic effect on the
nervous system rather than a specific effect on the
vestibular or optokinetic system through cervical proprioceptive pathways. If the anesthetic were to have a
localized effect on vestibular function mediated through
the cervical proprioceptive pathways, one would not
expect to see changes in the fast component of the nystagmus, which is not mediated through the vestibular system. In addition, one would not expect to see changes in
the control groups, in which the anesthetic was administered at a site distant from the deep cervical structures.
The same group of investigators recorded similar
measures in five monkeys following left C1 and C2 dorsal root section. They reported no spontaneous nystagmus
but did observe asymmetrical optokinetic responses as
compared to preoperative responses, which had been
symmetrical. Slow component eye velocity was diminished during clockwise optokinetic stimulation (P values
ranging from 0.03 to 0.09). The post-rotatory nystagmus
(rotation velocity 200 deg/sec) was measured in four
monkeys preoperatively and after left C1 and C2 dorsal
root sections. During the first 2 postoperative days, the
monkeys demonstrated a decrease in the maximum slow
component eye velocity after counterclockwise rotations.
The investigators state that this was a statistically significant decrease, and that the effect was likely due to the loss
of proprioceptive input from the cervical spine to vestibular nuclei. As in the previous experiment, however, they
used a P value equal to 0.06 as the level of significance.
This response difference was short-lived. By the fifth day
after the dorsal root section, the slow component eye
velocity responses were greater than the control values
and there was no apparent asymmetry in the responses.
In addition to the questionable statistical significance, the responses these investigators noted to the
optokinetic stimuli and the rotational stimulus were not
consistent. Clockwise optokinetic stimulation induces
nystagmus with slow component eye velocity to the right
and the fast component eye velocity to the left (leftbeating nystagmus). In humans, this stimulation also
induces a sense of rotation in a counterclockwise direction. The post-rotatory nystagmus following counterclockwise rotation is right-beating (slow component eye
velocity to the left and fast component eye velocity to the
right) and it would be accompanied by a sense of clockwise rotation in humans. If the dorsal root sections were
to a have an asymmetrical affect on vestibular function,
one would expect that the response to optokinetic stimulation would be diminished during clockwise rotations
and that post-rotatory nystagmus would be diminished
after a clockwise rotation of the chair. Both of these conditions would elicit left-beating nystagmus as well as
inducing a sense of leftward rotation in humans. Although
Ishigara and coworkers26 suggest that their findings support the role of cervical proprioception in normal oculomotor and vestibulo-ocular function, their interpretations
should be taken cautiously in light of the data.
On the basis of the anatomical convergence of
vestibular, cervical proprioceptive, and visual signals
from the accessory optic tract on type II neurons in the
vestibular nuclei,27,28 Karlberg and Magnusson29 proposed that asymmetrical cervical proprioception may
affect optokinetic after-nystagmus (OKAN), the nystagmus present in the dark following the cessation of the
optokinetic stimulus. These researchers measured OKAN
in normal, healthy individuals with the head in neutral,
passively rotated 70 degrees to either side, and actively
rotated 60 to 70 degrees to either side. They found that
initial velocity, duration, and cumulative eye position of
OKAN were significantly decreased when the optokinetic stimulus was rotated in the direction of passive head
rotation in comparison to the OKAN with the head in
neutral. When the optokinetic stimulus was in the direction opposite to the head rotation, there was no decrease
in the OKAN response. A similar decrease in OKAN
duration and cumulative eye position occurred during
active head rotation. The researchers suggest that this
cervical influence on OKAN may play a role in the
provocation of symptoms of dizziness in individuals with
cervical pain and dysfunction.
Although Karlberg and Magnusson29 conducted
their study in normal humans, the results may support the
findings of Igarashi and coworkers26 after unilateral C1
and C2 dorsal root section. Recall that these latter investigators reported a decrease in the slow component eye
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Chapter 29
velocity of post-rotatory nystagmus when the slow component was directed toward the side of the dorsal root
section. Karlberg and Magnusson29 reported a decrease
in slow component velocity when the optokinetic nystagmus was in the same direction as the head rotation. If one
assumes that head rotation to the left induces an asymmetrical input from the cervical proprioceptors (greater
on the right than the left because of stretching of the muscle spindles), the results of the two studies are qualitatively similar. In both cases the slow phase eye velocities
were decreased toward the side of decreased cervical proprioceptive input. Whether this asymmetrical OKAN test
can be used to identify individuals with cervicogenic
dizziness remains to be seen.
Several other studies have assessed oculomotor and
vestibular function in humans after flexionextension
injuries to the cervical spine. Oosterveld and colleagues30
conducted electronystagmographic (ENG) studies in 262
patients who had symptoms of cervical or cervical and
upper extremity pain after experiencing acceleration
injuries to the cervical spine. Eighty-five percent of these
patients had symptoms of lightheadedness or a floating sensation. The investigators report that none of the
patients had rotational vertigo. Spontaneous nystagmus
was reported in 165 patients (63%); 110 of these patients
(67%) also had positional nystagmus. On the basis of the
pattern of spontaneous and positional nystagmus in these
165 patients, the nystagmus was thought to be of central
origin in 159 cases (96%). Central oculomotor findings,
including direction-changing nystagmus, saccadic smooth
pursuit, and impaired visual suppression of the VOR,
were found frequently. The incidence of individual central
signs ranged from 26% to 43%. The investigators also
reported that cervical nystagmus was present in 168
patients, which may simply be the normal manifestation
of the COR. Because there is no indication of the incidence of cervical nystagmus in normal individuals, one
can not ascertain whether this finding is abnormal. On the
basis of results of their oculomotor studies, the investigators contended that cervical whiplash injuries induce diffuse, rather than well-localized, lesions within the CNS.
Toglia31 reported ENG and rotational chair results in
309 patients who had primary symptoms of dizziness
after flexionextension acceleration injury to the cervical
spine. Of these patients, 57% had abnormal caloric test
results (40% had significant canal paresis, and 22.5% a
significant directional preponderance) and 51% had
abnormal rotational test results. These data support the
idea that peripheral vestibular system disease is frequently present in individuals who experience whiplash
injuries. One might make the argument that the caloric
weaknesses and rotational asymmetries were due not to
471
peripheral vestibular dysfunction but to impaired cervical

input to the vestibular nuclei. This possibility is unlikely,
however, given the relatively small input from the cervical
spine to the vestibular nuclei compared to the input from
the vestibular labyrinth. In addition, because there was no
cervical movement during the caloric or rotational tests,
one would have no physiological reason to expect that the
asymmetrical responses arose from the cervical spine.
The smooth pursuit neck torsion test (SPNT) has
been proposed to identify cases of cervicogenic dizziness.
This test evaluates the smooth pursuit eye movement system and is conducted with the neck in neutral and rotated
45 degrees to the left and to the right. Smooth pursuit eye
movements are recorded in each position. The gain (the
ratio of eye velocity to target velocity) of the response is
determined for each neck position, and the difference
between the smooth pursuit gain in neutral and the average gain in the rotated positions is calculated (the SPNT
difference). Several studies have demonstrated a significant increase in the SPNT difference values between subjects with WAD and normal subjects, as well as between
subjects with WAD and those with Mnires disease or
central vertigo.3234 In addition, these studies have shown
a significantly greater increase in the SPNT difference in
subjects with WAD and concurrent complaints of dizziness as compared to subjects with WAD but no dizziness,
suggesting that the dizziness is a critical component.
It is possible that the severity of cervical pain is the
critical component in the SPNT difference values. Both
Tjell and Rosenhall32 and Treleaven and colleagues34
noted that patients with WAD and dizziness had greater
complaints of pain than patients with WAD but no dizziness. Treleaven and colleagues34 evaluated the role of pain
levels in their analyses of the SPNT. They found mixed
results: If they grouped data from all patients with WAD,
there was a weak but statistically significant correlation
(Spearman rank correlation [] 0.27) between pain levels and SPNT differences, such that with increasing pain
levels, there was an increase in the SPNT difference. On
the other hand, there was a significant negative relationship between SPNT differences and reported levels of
pain/disability in patients with WAD but no dizziness,
such that those with greater pain tended to have a smaller
SPNT difference. Although the changes in SPNT difference are greatest in patients with WAD, there are significant changes in the SPNT difference in individuals with
other causes of cervical pain, such as cervical spondylosis
and fibromyalgia, compared with normal individuals.33
Regardless of the exact etiology of the changes in SPNT,
either nociceptive or proprioceptive factors, the results do
suggest a relationship between cervical pain, cervical proprioception, and CNS oculomotor control.
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Attempts have been made to determine the sensitivity and specificity of the SPNT, but the studies have
design flaws that raise questions about their validity. Tjell
and Rosenhall32 determined the sensitivity and specificity of the SPNT using 2 standard deviations from the
mean of the SPNT value found in healthy controls as the
threshold to determine a normal/abnormal test result. For
the control group, they combined the healthy controls,
subjects with Mnires disease, and those with central
vertigo, as there were no differences in the results among
these groups. Comparison of individuals with WAD and
dizziness with the normal group gave the SPNT a sensitivity of 90% and a specificity of 91%. Comparing the
individuals with WAD but no dizziness with the normal
group gave the SPNT a sensitivity of 56% and a specificity of 91%. One of the problems with this study is that
it used a post hoc analysis of sensitivity and specificity,
as the subjects had been diagnosed as being normal or
having WAD with dizziness, and WAD but no dizziness
prior to the actual testing. To appropriately determine the
sensitivity and specificity of the SPNT, the test should be
conducted in a blinded fashion on a mixed population
that has not been previously selected and categorized as
to diagnosis. In addition, in calculations of sensitivity and
specificity of a test, the threshold level for normal/abnormal test results should be determined independent of data
from the tested population. The SPNT test, therefore,
suggests that there is some correlation between severity
of WAD and changes seen in the test, although the exact
nature of this correlation is not known at this time. The
SPNT test shows promise, but it has not been adequately
validated for use in identifying individuals with cervicogenic dizziness.
Care must be taken in extrapolating from the animal
studies cited here to humans, because there appear to be
species specific differences. Injection of local anesthetics
in the posterior, upper cervical musculature in animals
and humans yields different oculomotor responses.
De Jong and associates35 reported that injection of a local
anesthetic in the cat, monkey, and rabbit induced nystagmus. The induced nystagmus in the cat and rabbit
lasted from several minutes to an hour or more. The nystagmus in the monkey lasted for only several minutes
and was suppressed by vision. In rabbits with bilateral
labyrinthectomies, injection of the local anesthetic did
not induce nystagmus, indicating that the nystagmus is
generated through the vestibular system.36 In monkeys,
the local anesthetic had no effect on optokinetic nystagmus, optokinetic after-nystagmus, or caloric nystagmus.
These investigators also injected local anesthetic into two
human subjects and observed no nystagmus in either subject. Therefore, the nature of the cervical-induced nystagmus appears to be species specific.
In summary, while there are known cervical inputs

to the vestibular nuclei and a convergence of cervical,
visual, and vestibular inputs in the CNS, it does not
appear that ablative cervical lesions have a profound
effect on the oculomotor or vestibular systems in humans.
Cervical disorders have been shown to induce changes in
smooth pursuit, but the studies to date have not been able
to differentiate between individuals with cervical pain
only and those with cervical pain plus dizziness.
Balance and Proprioceptive Findings
In contrast to the inconclusive results of various oculomotor tests in individuals with suspected cervicogenic
dizziness, the tests of balance and cervical kinesthetic
sense may be more beneficial in the diagnosis of this disorder. De Jong and associates35 described ataxia in all
species following injections of a local anesthetic in the
cervical region. Cats demonstrated ataxia and hypotonia
ipsilateral to the injection and had a tendency to fall to
that side. Rabbits also displayed a complex behavior after
unilateral injection; they first fell and rolled to the side of
the injection, then developed lateropulsion, and then
demonstrated ipsilateral hypotonia. Similarly, when unilateral cervical root sections were performed in rabbits
that had previously undergone unilateral labyrinthectomy, the rabbits fell to the side of the labyrinthectomy and
rolled along the long axis of their bodies. The direction of
the rolling depended on the side of the labyrinthectomy
and was independent of the side of the cervical root
section. Although the nystagmus induced by the local
anesthetic in monkeys was small compared with that in
the cat, the ataxia was greater. The monkeys displayed a
head and trunk tilt of approximately 10 degrees toward
the side of the lesion and marked ataxia of the ipsilateral
limbs. Injection of a local anesthetic in human subjects
resulted in lightheadedness and a sense of lateropulsion. There was a deviation of stance toward the side of
the injection as well as ipsilateral past-pointing. When
human subjects were in supine, the injection produced a
sense that the bed was rolling over toward the side of
the injection. Although the injection of local anesthetic
was no doubt an unusually potent stimulus, it yielded
both postural and perceptual findings that one might
expect to see in cases of altered cervical proprioceptive
inputs.
Several studies have examined balance control in
individuals with cervical symptoms both with and without associated complaints of dizziness. These studies
have used various manipulations and measurement
modes to determine the role that cervical pain may play
in standing balance and to establish a test for cervicogenic dizziness. For the most part, these studies have documented that cervical pain leads to a disruption of
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standing balance, which has been postulated to be due to

a disruption of the proprioceptive inputs.
Alund and colleagues37 measured standing balance
in patients with chronic cervical pain and associated
symptoms of vertigo or imbalance, which were compared
to those obtained in age-matched, normal healthy controls and to patients with chronic cervical pain but no
associated vertigo or imbalance. Postural sway was measured with dynamic posturography (Equitest, Neurocom
International Inc, Clackamas, OR). The subjects were
tested with eyes open in both stable and sway-referenced
platform conditions (sensory organization tests 1 and 4).
The subjects performed the tests with the cervical spine in
neutral, flexion, extension, lateral flexion to the right and
left, and rotation to the right and left. The subjects with
cervical pain also performed the tests with the cervical
spine in the most painful position. When the subjects performed the tests on a stable platform, there was no difference among groups or test positions. However, with the
test performed on a sway-referenced platform, the
researchers found differences between groups as well as
with different cervical positions. All three subject groups
generally demonstrated increased sway when the cervical
spine was out of anatomically neutral position. The
patients with cervical pain and dizziness had significantly greater sway than the healthy controls when the cervical spine was in neutral. The subjects with cervical pain
and dizziness had greater sway than subjects with cervical pain but no dizziness when the cervical spine was held
in the most painful positions. On the basis of these findings, the researchers concluded that dynamic posturography may be an appropriate method of determining the
presence of cervicogenic dizziness. They did not determine the specificity and sensitivity of the test, which must
be examined before the test can be clinically useful.
Karlberg and colleagues38,39 have described changes
in postural control in individuals with suspected cervicogenic dizziness and in individuals with cervical and radiating upper extremity pain. They did not mention whether
the individuals with upper quarter pain had complaints of
dizziness or imbalance. Postural control in these studies
was assessed using a force platform and measuring the
motion (sway velocity and sway variance) of the center of
pressure. These investigators induced body sway with
vibrators attached to the gastrocnemius muscles or the
posterior cervical musculature. Compared with age- and
sex-matched controls, the individuals with upper quarter
pain had greater velocity and increased variance of sway
with eyes closed when either site was vibrated.39
In a subsequent study, Karlberg and colleagues38
evaluated postural dynamics (measures of swiftness,
stiffness, and damping determined from an inverted pendulum model of stance control) for three groups. Using
473
the vibration-induced body sway described previously,

they measured the postural control parameters in individuals with suspected cervicogenic dizziness, individuals
with a recent bout of vestibular neuritis, and in normal
healthy individuals. The group with a suspected cervical
cause of dizziness demonstrated lower values of stiffness
than either the normal or vestibular neuritis groups. In
addition, the cervicogenic dizziness group had higher
values for damping than the normal group. Using Fisher
linear discriminant analysis and the swiftness, stiffness,
and damping values, the investigators were able to distinguish subjects with cervicogenic dizziness from both
the normal subjects and those with vestibular neuritis.
They were also able to differentiate the subjects with
vestibular neuritis from the normal subjects.
The results of these two studies give further support
to the hypothesis that cervical disorders in general lead to
disturbances in postural control, possibly through distortion of the proprioceptive information. Karlberg and colleagues38 report that a nave tester using this method could
correctly classify 78% of individuals with cervicogenic
dizziness, so evaluation of postural control may be a test
for cervicogenic dizziness. However, as the investigators
note, the specificity of the test has not yet been determined. Two other points should be raised regarding this
test. First, the sensitivity of this test was calculated using
data from individuals previously identified with cervicogenic dizziness, rather than in a mixed population, with
the examiner blinded to the diagnosis. Second, although
this test may hold promise as a diagnostic tool, it incorporates computations and measures that are not currently
part of commercially available balance assessment tools.
Finally, Treleaven and colleagues40 assessed standing balance using the Clinical Test for Sensory Interaction
in Balance in normal individuals and individuals with
WAD, half of whom had associated complaints of imbalance and dizziness. The amount of postural sway was
recorded by means of a force platform and analyzed with
wavelet analysis. As a group, the individuals with WAD
had greater sway than the age-matched normal individuals. In addition, the individuals with WAD and complaints
of dizziness had greater sway than the individuals with
WAD but no dizziness. As noted previously by these
investigators, individuals with WAD and dizziness had
greater complaints of pain than individuals with WAD but
no dizziness. The investigators noted statistically significant, moderate correlations (Spearmans rho correlation
coefficients 0.320.41, P 0.01) between pain levels and
sway energy in the various test conditions for the individuals with WAD (combined dizzy and nondizzy groups).
No attempt was made to determine sensitivity or specificity for this test. The results of this study further support
the proposition that altered cervical proprioceptive input
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or cervical pain can lead to disturbed balance responses.

Care should be taken in interpretation of these results,
however, as vestibular lesions were not ruled out in the
subjects of the study except by patient history.
Another line of investigation provides additional
support to the hypothesis that cervical problems, WAD in
particular, can lead to altered cervical kinesthetic sense.
Several studies have demonstrated a decrease in cervical
kinesthesia in individuals with complaints of cervical
pain. Revel and coworkers41 reported that subjects with
chronic cervical pain, compared with normal subjects,
had a diminished ability to relocate the head on the trunk
(in the absence of visual cues) after an active head
rotation. Using a threshold value of 4.5 degrees, these
researchers determined that the test had a sensitivity of
86% and a specificity of 93%. In a subsequent study,
Revel and coworkers42 showed a decrement in cervical
kinesthesia in patients with chronic cervical pain. In
addition, they found that patients enrolled in a kinesthetic retraining program in combination with medical analgesic therapy experienced improvements in kinesthetic
sense and cervical rotation range as well as a decrease in
pain in comparison with patients who received only medical analgesic therapy. The training program used in this
study is described later in this chapter.
Subsequent studies have assessed cervical kinesthesia in individuals with WAD and dizziness. Similar to the
findings reported by the Revel group, Heikkil and
Wenngren43 found that individuals with WAD had greater
cervical repositioning errors than normal individuals.
They also noted that individuals with WAD and complaints of dizziness had greater cervical repositioning
errors than individuals with WAD and no complaints of
dizziness. It is not clear whether this greater error is due
to the associated dizziness (and presumed influence on
the vestibular system) or the increased cervical pain that
is typically found in individuals with WAD and dizziness.
Heikkil and Wenngren43 did not report the pain levels in
the two subgroups with WAD. They did observe, however, that individuals with WAD and radicular symptoms
also had greater cervical repositioning errors than individuals with WAD and no radicular symptoms, suggesting that the extent of injury, and the resulting pain levels,
may be the critical factor in determining the extent of the
cervical repositioning errors.
Treleaven and colleagues44 also noted greater cervical repositioning errors for rotation as well as extension in
individuals with WAD than in normal individuals. When
these investigators compared results in individuals with
WAD and dizziness and individuals with WAD but no
dizziness, they noted that the individuals with the associated dizziness had significantly greater cervical repositioning errors (4.5 degrees vs. 2.9 degrees) for rotation in
one direction. The difference in cervical repositioning

errors between these two groups approached statistical
significance (3.9 degrees vs. 2.8 degrees) for rotation in
the opposite direction. There was no difference between
the two WAD groups in the repositioning error for cervical extension movements. These investigators reported
that the subjects with WAD plus dizziness had higher
scores on the neck pain index, but made no attempt to correlate the level of pain with the extent of the cervical
repositioning error.
The results of these studies suggest that cervical
kinesthesia is disturbed after injury to the cervical spine.
Similar kinesthetic impairments have been reported with
pain or injury to other joints, such as the ankle,45
knee,46,47 and shoulder.48 The disruption of cervical kinesthetic sense has been used as a possible explanation
for the mechanism behind cervicogenic dizziness.
Although this is a plausible mechanism for cervicogenic
dizziness, the fact that not all individuals with WAD and
impaired cervical kinesthesia have complaints of dizziness detracts from the argument. Certainly the extent of
the injury and the level of cervical kinesthetic impairment
may be a factor in determining which individuals experience dizziness.
The lesion-induced ataxia in humans, the changes
seen in stance control in individuals with cervical pain,
and the cervical repositioning errors associated with cervical disorders lend support to the hypothesis that cervical proprioception has a role in balance control and,
possibly, cervicogenic dizziness. The mechanism of the
postural disturbance is unresolved. There are several possible explanations for the observed balance/proprioceptive deficits. First, individuals with cervical spine disease
or cervical disc disease may have compression of the
spinal cord and the spinal tracts relaying the proprioceptive information from the lower extremities, which could
cause the observed postural disturbances. Many of the
individuals with cervical pain or dizziness, however, have
no findings of spinal cord compression on radiological or
clinical examination, making this finding an unlikely
cause of the postural deficits.49
Second, inaccurate proprioceptive input from sensitized receptors in either the joint capsules or the cervical
musculature could create a sensory mismatch between
the vestibular and proprioceptive inputs, which could
lead to symptoms of dizziness and altered postural control.50 Third, rather than creating a sensory mismatch, the
altered cervical kinesthetic sense could lead to inaccurate
representation of head position relative to the trunk.
Because the vestibular system is physically located in the
head, the output of the vestibular system must be modulated in relation to head position on the trunk to properly
control balance. If the CNS receives inaccurate informa-
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tion about head position relative to the trunk, the modulation of the vestibular responses may be inappropriate,
resulting in the observed imbalance. In both of these
instances, the symptoms would be greatest during head
movements, when vestibular and cervical proprioceptive
inputs would be changing.
Finally, it may not be disruption of the cervical
kinesthetic receptors, but the actual pain in the cervical
region, that leads to the observed balance and proprioception deficits. Studies by Rossi and colleagues51,52 have
shown that chemically induced tonic muscle pain can
alter the position sense of the affected limb in the absence
of any actual damage to muscle or joint receptors. The
studies have also demonstrated changes in somatosensory-evoked potentials at a cortical level, rather than at
the spinal cord, following chemical induction of muscle
pain.52 On the basis of the nature of the stimuli used and
the measured effects, these researchers concluded that
alteration in the somatosensory-evoked potentials reflected changes in the proprioceptive pathways. A third study
demonstrated inhibition of both cortical and spinal level
motor excitability as a result of chemically induced muscle pain.53
From the results of these studies, one could hypothesize that cervical pain will alter the proprioceptive sense
in the neck, leading to inappropriate control of the head
on the trunk. Recall from the previously discussed clinical studies that the postural control deficits and cervical
repositioning errors increased with rising levels of cervical pain. Regardless of the actual mechanisms involved,
it appears that cervical disorders can lead to alterations in
balance and cervical position sense that may be related to
symptoms of dizziness. It remains to be seen, however,
whether any of these tests can be used to identify individuals with cervicogenic dizziness.
Examination
With the lack of a definitive test for cervicogenic dizziness, the diagnosis is based on the individuals signs and
symptoms and on the absence of otologic or neurologic
causes for the clinical findings. A patient with suspected
cervicogenic dizziness typically presents with disequilibrium or lightheadedness, cervical pain, ataxia or
unsteadiness, and limited cervical motion. Head movements typically aggravate the symptoms. Other disease
processes, such as cerebellar and spinal ataxia, bilateral
vestibular loss, benign paroxysmal positioning vertigo
(BPPV), and chronic unilateral vestibular loss, can also
manifest similar signs and symptoms. These otologic and
neurologic causes of dizziness may also cause restricted
cervical motion and neck pain owing to muscular guarding of the neck to limit head movements.
475
Consequently, the presence of disequilibrium or

lightheadedness, cervical pain, ataxia or unsteadiness,
and limited cervical motion is not consistently indicative
of a cervical cause of the dizziness, and the clinical decision making process should first rule in or rule out otologic and neurologic causes of the symptoms. If the
symptoms are due to an otologic or neurologic cause, this
fact should become apparent with a comprehensive clinical examination, vestibular function tests, or radiological
evaluation. If there are no apparent neurologic or otologic causes for the symptoms, one should conduct a more
detailed evaluation of the upper quarter. This evaluation
should include assessment of active and passive cervical
range of motion, tests for instability in the upper cervical
spine, neurologic examination of the upper extremities
(strength, sensation, and reflexes), palpation of the cervical spine musculature, and segmental mobility testing of
the cervical spine. A detailed description of these examination procedures is beyond the scope of this chapter;
two specific test maneuvers, however, are addressed here.
Some authorities recommend testing for VBI during
the cervical screening examination before treatment of
the cervical spine is initiated. We should emphasize one
point regarding VBI testing in the clinic. Studies to date
have shown that the clinical tests for vertebral artery
compression do not have adequate sensitivity to rule
out the disorder (see Richter and Reinking54 and Childs
and colleagues55 for in depth reviews of this issue).
Therefore, a negative test result does not rule out the possibility of vertebral artery compromise.
Despite its lack of utility as a screening test, local
statutes and practice patterns may dictate the performance
of VBI testing. Testing for VBI often consists of the vertebral artery compression test (cervical extension and
rotation), typically performed in the supine position. It
should be noted that this test position is similar to the
final position in the Dix-Hallpike test used to assess for
BPPV.56 There are differences in the two tests, at least in
patients with normal cervical range of motion. The test
for VBI involves full extension and rotation, whereas the
Dix-Hallpike test involves 45 degrees of rotation and 10
to 20 degrees of cervical extension. In patients with limited cervical range, however, the Dix-Hallpike test may
involve movements at the limits of extension and rotation.
If a patient with complaints of cervical pain and dizziness experiences symptoms of dizziness with either the
Dix-Hallpike test or the vertebral artery compression test,
differentiating between BPPV and VBI can be problematic. As discussed previously, it is unlikely that VBI
would produce isolated symptoms of dizziness or the
characteristic patterns of nystagmus one sees in patients
with BPPV. However, given the nature and severity of the
deficits that can result from VBI, one would like to be
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able to differentiate between these two entities. This differentiation can be made if one remembers the following
two facts: (1) BPPV is brought about by changes in head
position relative to gravity, regardless of the position of
the cervical spine, and (2) VBI due to cervical motion is
brought on by the position of the cervical spine, regardless of head position relative to gravity.
Consequently, one can test for BPPV by positioning
an individuals head (relative to gravity) in a position
identical to that for the Dix-Hallpike test without extending the neck, by having the person lie supine on a table
that is in the modified Trendelenburg position (foot of the
table elevated relative to the head). Another method is to
perform the side-lying test for BPPV.57 If cervical rotation must be avoided as well, the individual can lie down
in a partial side-lying position. Because the neck is maintained in a neutral position with these test modifications,
symptoms brought on with the tests would not be attributed to VBI. In an analogous fashion, one can position
the individuals cervical spine in a position identical to
the Dix-Hallpike position without changing the orientation of the head relative to gravity. The patient sits, forward flexes at the hips, and at the same time extends and
rotates the neck. This sequence of movements places the
cervical spine in a position identical to that obtained in
the Dix-Hallpike and vertebral artery compression tests,
but the patients head position remains unchanged relative to gravity. Maintaining the vertical orientation of the
patients head prevents the occurrence of the signs and
symptoms of BPPV (which are provoked by changes in
head position relative to gravity). Therefore, any symptoms associated with this position change may be attributed to vertebral artery compression and VBI.
Another method of testing for VBI, which is recommended by the Australian Physiotherapy Association,
involves having the patient actively assuming the following positions in a sequential manner: extension, rotation,
and quadrant position (rotation and extension).58 Each
position is maintained for 10 seconds while the examiner
monitors the patients status. If results of these positions
are negative (no dizziness, nausea, tinnitus, headache,
blurred vision, slurred speech, slowed responses, or facial
or tongue paresthesia), the examiner repeats the positions
by using passive movements with overpressure. This testing method, when done in sitting, avoids the severe position changes of the head relative to gravity and may help
differentiate between BPPV and VBI. In particular, if this
test is performed in the seated position first and no signs
or symptoms are noted, subsequent Dix-Hallpike test
findings can be attributed to BPPV.
When patients complain of dizziness associated
with head movements on a fixed trunk, one cannot dif-
ferentiate, from that statement, whether the symptoms

are attributable to a vestibular disorder, cervicogenic
dizziness, or a combination of the two. To differentiate
between a cervical cause of the dizziness and a vestibular
cause of the dizziness, one must isolate the two systems.
One method is to perform a clinical variation of the neck
torsion nystagmus test,5961 whereby one looks not for
nystagmus but for provocation of symptoms, as individuals without cervical disorder can have nystagmus with
this test. To test the cervical spine in isolation, one must
move the patients body under a stable head. For example, the patient rotates the trunk in one direction while the
examiner stabilizes the head in space (Fig. 29.2A and B).
Symptom provocation (dizziness) with this test would
indicate a cervical component to the disorder. To test the
vestibular system in isolation, the head and body must
move together (en bloc). To test for horizontal rotation,
for example, the head and trunk move as a unit, as in a
standing pivot or with the patient sitting in a chair or on
a stool that will rotate (Fig. 29.2C). The examiner must
stabilize the head in relationship to the trunk with this
test. Provocation of symptoms by this test suggests a
vestibular component to the disorder. It is important to
perform the complete sequence in order to determine
whether the symptoms originate from the cervical spine,
the vestibular system, or both. A similar approach can be
utilized to differentiate between vestibular and cervical
causes of dizziness induced by vertical head movements
(cervical flexion-extension).
Another method of assessing whether or not the
symptoms originate from the cervical spine is a trial of
manual cervical traction. The theory behind this examination technique is that unloading the cervical spine may
alter the cervical somatosensory inputs to the CNS.
While unloading of the cervical spine can be performed
in various ways, application of traction while the patient
is sitting causes minimal disturbance of the vestibular
system. A reduction in symptoms during the traction
would suggest a cervical component to the disorder. The
test can be modified by placing the patient in a symptom
provoking position before applying the manual traction
to test for alleviation of the symptoms. This examination
technique has not yet been validated in the literature, but
we have found it clinically useful.
Management
Treatment in cases of supposed cervicogenic dizziness is
directed to the clinical findings and the patients symptoms. Treatment of the cervical spine should address
restricted mobility (due to joint restrictions or muscle
tightness), hypermobility, increased muscle tone, trigger
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477
Figure 29.2 (A) The patient complains of symptoms of dizziness with head rotation to the left.
(B) To assess the cervical contribution to her symptoms, her head is stabilized in space, and she
turns her body to the right. (C) To assess the vestibular contribution to her symptoms, she is rotated
en bloc to the left. In this example, the patient is sitting on a stool that rotates. The same examination procedure could be performed with the patient standing.
points, poor cervical posture, and impaired cervical

kinesthesia. Detailed descriptions of the treatment
approaches for upper quarter dysfunction are
beyond the scope of this chapter; the therapeutic
treatments may include cervical spine mobilization,

range-of-motion exercises, cervical strengthening exercises, cervical proprioception exercises, soft tissue mobilization, and therapeutic agents.
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Owing to the apparent role of the upper cervical

spine in the generation of cervicogenic dizziness, treatment may need to be focused on this area. Numerous
techniques are available to increase joint mobility in the
upper cervical spine. The treatment techniques described
here are examples of those that have been well tolerated
by patients, are relatively easy to perform, and appear to
be effective in improving cervical mobility and reducing
pain. In addition, the patients may note a reduction in
dizziness. The first technique is occipito-atlas distraction,
which can be performed in various manners. In one technique, the patient lies supine, and the patients head is
supported by the therapist. The therapist positions their
hands such that the superior nuchal line of the patients
skull is resting on the therapists fingertips (Fig. 29.3A).
The therapist can simply allow the patients head to rest
on the fingertips or can apply gentle traction to the upper
cervical spine by either flexing the metacarpal phalangeal
B
Figure 29.3 Methods of cervical traction: (A) The patient
rests the head on the therapists fingertips, and the therapist
can lean away from the patient, providing traction. (B) A variation of this technique has the therapist supporting the patients
occipital region in the palms and fingers. By leaning away from
the patient, the therapist can apply traction to the upper cervical
spine.
joints or leaning away from the patient. A second method

of performing the traction is for the therapist to cup
the patients occipital region in the palm and fingers
(Fig. 29.3B). The therapist applies traction by leaning
away from the patient.
The second technique is designed to increase rotation between C1 and C2 (Fig. 29.4). The patient lies
supine. The therapist prepositions the patients lower cervical spine into flexion. This position can be combined
with lateral flexion (not shown). While maintaining the
cervical flexion, the therapist then passively rotates the
patients head in the direction of restricted mobility to the
end of passive, pain-free motion. If the prepositioning of
the lower cervical spine is maintained, this cervical rotation occurs only in the upper cervical spine. At end range,
the patient attempts to gently rotate in the opposite direction. This motion is blocked by the therapists hand. After
1015 seconds, the patient relaxes, and the therapist
gently rotates the patients neck in the direction of
the restricted motion. This treatment technique is analogous to the hold-relax stretching techniques often used to
stretch limb musculature. The force generated by the
patient during the active, resisted rotation in this technique is minimal. Telling the patient to look in the direction of the rotation is often sufficient to generate the
appropriate level of force.
As with most mobilization techniques, it is important to follow up with active exercises to maintain the
increased range. Any findings of imbalance or motion
sensitivity can be treated with head movement exercises,
positioning or habituation exercises, and balance exercises described elsewhere in this book. In addition, retraining of cervical kinesthesia should be initiated. Exercises
such as those described by Revel and coworkers42 have
been shown to be effective. The basic components of this
exercise approach are as follows:
Figure 29.4 Mobilization of C1C2 to increase cervical

rotation to the left.
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479
Slow passive supine head movement with eyes

fixed on a target.
Follow a moving target using alternatively slow
pursuit and saccades, with free eye and head
movement.
Sitting and standing exercises with restricted
peripheral vision:
Active head movements following a slowmoving target.
Active head movements to maintain gaze on a
fixed target while the trunk is passively moved.
Fixating on a target and memorizing the head
position; then closing the eyes, performing maximal rotation, returning to the starting position,
and opening the eyes (angle reproduction).
The exercises performed while peripheral vision is
restricted utilize glasses in which all but foveal vision is
blocked (Fig. 29.5A). Since any eye movement while the
patient is wearing these glasses results in blocked vision,
the only way for the patient to visually follow a moving
target is to move the head. Head position is driven therefore by visual input and must be carefully controlled by
the patient in order to accomplish the task. In order to
maintain gaze on a fixed target while the trunk is rotated,
head motion must be disassociated from trunk motion
(Fig. 29.5B).
Finally, the patient can practice angle repositioning
while using the foveal glasses (Fig. 29.6). The patient
must reproduce the starting position without visual cues.
If an error in head positioning has occurred, the patient
will not be looking at the target upon opening the eyes.
Errors in performance will be apparent to the observer,
because the foveal glasses force the patient to shift the
head position in order to reacquire the target. The patient
will receive kinesthetic feedback about the amplitude and
direction of the error that can be incorporated into subsequent trials, leading to improved performance. As with
the progression of motion sensitivity and habituation
exercises, the variables that can be manipulated with
these exercises include speed, amplitude, and direction of
movement, as well as repetitions and sets.
There is evidence that treatment of cervical dysfunctions can lead to decreased symptoms of dizziness
and improvements in postural stability.62 In one of the
few randomized, controlled trials on this issue, Karlberg
and colleagues63 reported on the improvements in cervical pain and mobility as well as postural control in a controlled study of individuals undergoing physical therapy
for cervical pain and dizziness. In this study, the type of
treatment for the cervical dysfunction was not controlled
owing to the variety of symptoms and physical findings.
Prior to treatment, the patients displayed significantly
Figure 29.5. Cervical kinesthesia training exercises. (A)

Foveal glasses. (B) Eyes maintain gaze on a fixed target (indicated by straight arrow) while the trunk is rotated to the right.
The foveal glasses necessitate disassociation of head and trunk
movements. Similar exercises can be performed with hip and
trunk flexion and extension in the sitting position.
higher body sway velocities than healthy controls when

the gastrocnemius muscles or posterior cervical musculature were vibrated. After treatment, which was restricted
to treatment for the cervical dysfunction, there was a
marked improvement in the vibration-induced sway
velocity. The investigators reported that after treatment,
the sway velocity during vibration of the gastrocnemius
muscles returned to normal levels. They noted, however,
that the patients continued to display increased sway
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Figure 29.6 Cervical repositioning using foveal glasses. (A) Gaze is fixed on a target, and head
position is memorized. (B) The patient closes the eyes and fully rotates the neck in one direction
while the eyes remain closed. (C) The patient attempts to return the head to the starting position
while the eyes remain closed. (D) The patient opens the eyes and, if necessary, adjusts the head
position more to reacquire the target. Because of the foveal glasses, the only way for the patient to
look at the target is to move the head. The patient receives kinesthetic feedback as to direction and
amplitude of error, which is incorporated into subsequent trials.
velocities when tested with vibration applied to the posterior cervical musculature. This study and other nonrandomized controlled trials in the literature suggest that
treatment of the identified cervical dysfunction in individuals with suspected cervicogenic dizziness may lead
to resolution of the dizziness as well as the cervical signs
and symptoms.
Summary
The existence of a cervical cause of dizziness continues
to be a topic of debate. Although individuals with cervi-
cal symptoms may have complaints of imbalance and

lightheadedness, no clear clinical test can be used to
unequivocally identify the cervical spine as the cause of
the symptoms. There is some anatomical and physiological evidence to suggest that the cervical spine could
influence balance and perceptions of stability, but how
this influence could actually lead to symptoms of dizziness remains unclear. As stated in the introductory comments, the debate over a cervical cause of dizziness may
be academic from a physical therapy standpoint. If
patients present with cervical dysfunction and imbalance,
we should treat them for both conditions.
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481
CASE STUDY
Case Report
History
JB is a 63-year-old male referred by his family physician to a neurologist in the vestibular clinic. JB was
evaluated by the neurologist and referred to physical
therapy for treatment of possible cervicogenic dizziness. JB is initially seen in physical therapy on
11/18/96.
JB states that he has been bothered by episodic
bouts of dizziness that started approximately 1 year
ago. He states that the afternoon prior to the onset of
his symptoms, he had been lifting sheets of plywood
out of his pickup truck. The next morning he awoke
with mild discomfort and stiffness in his neck and a
strong sense of imbalance, with a tendency to lose his
balance to the left. He denied having vertigo or aural
symptoms in association with the onset of these
symptoms. He states that since the initial episode, he
has been bothered by a chronic sense of lightheadedness and disequilibrium. He states that his symptoms
are exacerbated by head motion and exertion and after
sitting in one position for a prolonged period (e.g.,
driving or reading). Associated with the increased
symptoms of disequilibrium are cervical and shoulder
symptoms. He describes these symptoms as mild to
moderate pain and stiffness in the cervical spine and
upper trapezius muscles. He does note some difficulty walking in the dark and on uneven surfaces. He
denies having oscillopsia, positioning vertigo,
migraine headaches, increased symptoms in busy
visual environments, extremity numbness or weakness, and incoordination.
JB states that he underwent magnetic resonance
imaging and carotid ultrasound in the past, results of
which were normal. Electronystagmography and
caloric test showed no evidence of unilateral hypofunction or oculomotor abnormalities. Audiograms
showed bilateral, mild, high-frequency sensorineural
hearing loss. His medical history is unremarkable. He
is taking no medications. He is a retired engineer.
JBs oculomotor findings are normal. There is no

spontaneous or gaze-evoked nystagmus in room light
or with use of Frenzel lenses. Extraocular movements
are normal. His saccadic and smooth pursuit eye
movements are normal. VOR cancellation and VOR

gains to both slow and rapid head rotations are normal. With Frenzel lenses, there was no head shakinginduced nystagmus. Dix-Hallpike test results are
negative bilaterally. Tragal compression, Valsalva
maneuver, or hyperventilation does not induce nystagmus and vertigo. There is a one-line difference
between static and dynamic visual acuity scores.
Balance Examination
JBs Romberg test result with eyes open is normal.

With eyes closed, he performed the test for 30 seconds, but he exhibited excessive sway. Results of
Romberg testing on 4-inch thick foam with eyes open
are also normal. With eyes closed, his performance
was again characterized by increased sway. Sharpened Romberg test result with eyes open is normal;
Sharpened Romberg test with eyes closed is positive
since JB could perform the test for a maximum of 20
seconds. Evaluation of unrestricted gait shows normal velocity and no ataxia, but JB exhibits minimal
head or trunk rotation. When asked to rotate his head
while walking, he develops a mild amount of ataxia
(4 deviations from a 12-inch-wide 10-yard-long path)
and notes a provocation of disequilibrium and cervical discomfort.
Upper Quarter Examination
JBs posture is characterized by a forward head.

Cervical flexion and extension are mildly limited, but
there is no pain or symptom provocation at end range.
Cervical rotation is 75 degrees to the right and 60
degrees to the left. JB notes a provocation of his cervical symptoms and disequilibrium at the limits of his
cervical rotation to the left. Trunk rotation to the right
under a stable head reproduces his symptoms, but en
bloc rotation does not. Palpation of the cervical spine
reveals increased muscle tone and tenderness in the
left suboccipital musculature, the left upper trapezius
muscle, and a trigger point in the left sternocleidomastoid muscle. Segmental evaluation shows restricted rotation to the left at C1C2. No other segmental
restrictions are noted. Manual muscle testing of the
upper extremities finds normal, symmetrical strength.
Light touch is normal in the upper extremities. Deep
tendon reflexes are also normal. Manual traction of
the cervical spine in the sitting position decreases his
symptoms.
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C A S E S T U D Y (continued)
Impressions
There is no evidence of unilateral or bilateral vestibular hypofunction on examination. In addition, there
are no signs or history suggestive of BPPV. His history of exertion-induced symptoms may be suggestive of a perilymphatic fistula. However, there are no
physical findings consistent with a fistula; specifically, there was no induction of nystagmus or vertigo
with tragal compression or Valsalva maneuver. JBs
balance examination shows a mild disturbance in
static postural stability (increased sway on Romberg
test with eyes closed and positive Sharpened
Romberg test result with eyes closed). He demonstrates the ability to use vestibular cues to maintain
upright stance. He has mild dynamic postural instability with head rotation while ambulating. The findings of JBs upper quarter examination are consistent
with a musculoskeletal dysfunction in the upper cervical spine. The positive result with trunk under head
rotation and negative result with en bloc rotation are
consistent with a cervical cause of dizziness. The
decreased symptoms during cervical traction are also
suggestive of cervicogenic dizziness. Although cervicogenic dizziness is a controversial entity, this
patient presents with cervical signs and symptoms
that may be related to his symptoms of imbalance
(specifically, the temporal correlation between the
disequilibrium and cervical symptoms).
Treatment (11/18/96)
Because JBs symptoms are believed to be cervical in
nature, the initial treatment focuses on his cervical
problems. Treatment consists of soft tissue mobilization of the sub-occipital musculature, the left upper
trapezius muscle, and the left sternocleidomastoid
muscle. This is followed by mobilization of C1
C2 using a muscle energy technique (contract-relax)
with active resisted isometric cervical rotation to the
left at JBs end range. Following treatment, JBs rotation is symmetrical and symptom free. He is instructed in a home program to correct the forward head
posture (dorsal glide of the head performed in prone),
active resisted cervical rotation also performed in
prone, and self-massage of the sub-occipital musculature.
Return Clinic Visit (12/1/96)

Upon return to the clinic, JB notes a mild decrease in
his symptoms of disequilibrium and cervical discomfort. On examination, results of Romberg tests with
eyes closed on both a firm surface and the 4 thick
foam are normal. Results of Sharpened Romberg test
with eyes closed and ambulation with head rotation
are unchanged. Cervical range of motion shows 70
degrees of rotation to the left and 75 degrees to the
right. Palpation demonstrates increased muscle tone
in the left sub-occipital musculature and left sternocleidomastoid muscle, as well as a mild limitation in
rotation to left at C1C2.
Treatment consists of soft tissue mobilization of
the sub-occipital musculature and left sternocleidomastoid muscle, spray and stretch of the left sternocleidomastoid muscle, and mobilization of C1C2.
After treatment, JB has symmetrical and pain-free
cervical rotation. He is instructed to continue with his
home exercise program.
Return Clinic Visit (12/8/96)
JB returns to the clinic for reassessment and further
treatment. He has had no symptoms of disequilibrium
or cervical discomfort in the preceding week. His balance examination shows normal static balance
(Sharpened Romberg with eyes closed) and no head
rotationinduced symptoms or ataxia while walking.
He continues to demonstrate a 5-degree restriction in
cervical rotation to the left. He is treated with joint
mobilization of C1C2: distraction, muscle energy
techniques, and grade 3 oscillations to increase rotation to the left. He is instructed to continue with his
home exercise program for an additional 46 weeks.
Since he has been symptom free for an entire week,
we believe that further outpatient physical therapy is
not indicated at this time. He is instructed to call in 1
month to inform us of his progress, or earlier if he
becomes symptomatic.
Telephone Call (2/2/97)
JB phones to say he is doing well (no disequilibrium
and no cervical symptoms). He stopped performing
the home exercises 3 weeks ago, and he has noted no
ill effects from stopping them. He will return to the
clinic as needed.
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Chapter 29
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37. Alund M, Ledin T, Odkvist L, Larsson SE: Dynamic posturography among patients with common neck disorders:
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38. Karlberg M, Johansson R, Magnusson M, Fransson PA:
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39. Karlberg M, Persson L, Magnusson M: Impaired postural
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40. Treleaven J, Jull G, Lowchoy N: Standing balance in persistent whiplash: a comparison between subjects with and
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49. de Jong JMBV, Bles W: Cervical dizziness and ataxia. In:
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does evidence on the diagnostic accuracy of the vertebral
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Fitz-Ritson D: Assessment of cervicogenic vertigo. J
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APPENDIX A
Questionnaire for History and Examination
02/13/07
QUESTIONNAIRE
PHYSICIAN NAME, MD
NAME:__________________________ AGE:_______________ DATE: ____________________
PRESENT OCCUPATION:________________________________________________________
Name and address of physician(s) you wish our report to be sent:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please answer these questions to the best of your ability. PLEASE BRING QUESTIONNAIRE
WITH YOU DO NOT MAIL IT BACK. Please give necessary details for yes answers. We realize that this form is long, but when it is filled out carefully, it allows us to devote more time to
your specific problem, rather than asking you related questions during your visit. If you need
to CHANGE or CANCEL an appointment, please contact our office.
Describe your major problem or the reason why you are seeing us.
Please describe in detail the circumstances and date in which the problem began and what were your
initial symptoms and problems. Was there any stress or anxiety around the onset of the problem?
If you have spells, please describe a typical spell in as much detail as possible and describe the frequency and duration of the spells.
What do you personally think your problem is due to?
1. Please check the symptoms which characterize your problem and grade their severity
from 2 (marked), 1 (moderate) to 0 (none). Put 0 if you do not have these symptoms.
a. Sensation of imbalance
( ) Trouble with walking
( ) Poor balance
( ) Falls
b. Sense of movement of the environment or of ones own body
( ) Rotation (spinning, tumbling or cartwheeling)
( ) Linear movement or pulling
( ) Tilt
c. Sensations not associated with movement of the environment
( ) Lightheadedness or impending faint
( ) Floating
( ) Swimming
( ) Giddiness
( ) Rocking
( ) Spinning inside of head
( ) Fear or avoidance of being in public places
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Appendix A QUESTIONNAIRE FOR HISTORY AND EXAMINATION
d. Associated symptoms
( ) Sweating
( ) Nausea
( ) Vomiting
( ) Queasiness
e. Impaired vision
( ) Double vision
( ) Blurred vision
( ) Flashes of light
( ) Jumping of vision when walking or riding in a car
2. To what extent is your dizziness or imbalance brought on by:
(Check one answer for each question.
None
Some
Severely
Turning over in bed, bending over or looking up

Standing up
Rapid head movements
Walking in a dark room
Walking on uneven surfaces
Loud noises
Cough, sneeze, strain, laugh, blowing up balloons
Movement of objects in the environment
Moving your eyes while your head is still
Wide open spaces
Tunnels, bridges, supermarkets
Menstrual periods
3. Other questions concerning dizziness

Can you bring on your dizziness voluntarily? If answered yes,
please describe.
Do or did you have moderate-severe motion (car or boat) sickness.
If yes, when did it start?
Do or did you avoid situations in which you were tumbled or spun
(amusement rides, merry-go-rounds)? When did you begin?
Has anyone observed jerking of your eyes with dizzy spells?
YES
NO
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4. Have you ever had: (If yes, please give details.)
YES
NO
YES
NO
Infections of ears
Difficulty with your hearing
Pain, fullness, popping or pressure in ear
Pain, pins/needles, numbness, twitching, or weakness of face
Crossed eyes or lazy eye.
Ringing in ears (called tinnitus)
If you answered yes to tinnitus, please answer the following questions.
State the frequency and duration of the tinnitus during the past 6 months
Please circle the correct answers. The tinnitus is primarily
in the left, right or both ears. It is steady, pulsating.
It is high, low pitched.
5. REVIEW OF SYSTEMS (If yes, give details.)
Within the last 6 months have you noted:
Significant loss in strength
Significant loss of energy
10 lb. or more weight change (if yes, up__or down
Significant memory loss (amnesia)
Significant change in hand writing
Pins and needles, numbness in arms or legs
Muscle or joint aches (If yes, which muscles or joints__________________)
Urinary incontinence (leakage of urine)
Problems with sleeping
Shortness of breath
Trouble chewing_____ or swallowing________ or speaking_________
Incoordination
Palpitations (irregular or fast beating) of the heart
Headaches
If you answered yes to headaches, please answer the following:
Approximate age they began _________;
Number per month ______; Pain intensity (110 with
10 the most severe) _____
Since the onset of headaches have you had at least 5 headaches that:
Lasted at least 4 hours
Started on one side of the head, if yes usually which side?
Were throbbing or pulsatile in quality?
Were severe enough to interfere with your schedule?
Were aggravated by routine physical activity?
Were associated with nausea and/or vomiting?
Were aggravated by bright lights or loud noises?
487
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6. PAST MEDICAL HISTORY (If yes, give details.)

Have you had any injuries due to trauma? (If yes, please describe the injury and when it
occurred.)
Have you had any surgery? (If yes, please describe the surgery and when it occurred.)
Have you been exposed to any of the following?

(If yes please, describe the exposure and when it occurred.)
YES
NO
YES
NO
YES
NO
Child abuse
Intravenous antibiotics
Loud noises (guns, machinery, loud music)
Drug therapy for cancer (if yes, what type)
Have you had any of the following infections? (If yes, give details.)
Syphilis or venereal disease
Lyme disease
Meningitis
Other infections
Has your past or present health been affected by: (If yes, give details.)
Heart problems
Diabetes
Thyroid disorders
Treatment by a psychiatrist_______ or counselor__________
Depression______, anxiety_______, severe stress______, phobias_______
High cholesterol
High______ or low_________ blood pressure
Pain in back of jaw (TMJ), grinding
Loss of consciousness (faints)
Seizures or convulsions
Arthritis
Neck pain
List all major illnesses, injuries, and surgeries not described above
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7. SOCIAL HISTORY
YES
NO
Do or did you use alcohol? How much?

Do or did you ever smoke:
If so how many packs/day?
What age did you start?
If you quit at what age?
How many cups of caffeinated drink per day (coffee, tea, soda)?
8. FAMILY HISTORY
Which family members (dad, mother, children) have or had:
Headaches
Menieres syndrome
Hearing loss
Vertigo or dizzines
Balance problems or tremor
Diabetes
Cancer or brain tumors
Stroke
Heart disease
High blood pressure
Psychiatric disorders
Other neurologic diseases
If your parents are alive, what are their ages?

If your parents have died, at what age and from what cause?
9. ALLERGIES TO MEDICATIONS and please note if drug causes rash or difficulty
breathing.
10. MEDICATIONS
What are your current medications, include hormones, birth control pills, special diet, etc. (Name
and Amount/Day)?
1.
5.
2.
6.
3.
7.
4.
8.
489
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11. HAVE YOU HAD:
Yes
Result
When
Hearing test
Evaluation by a neurologist
Evaluation by an ear doctor
Evaluation by an eye doctor
Caloric test (water or air in ear)
MRI (was dye also given by injection?)
12. MULTIDIMENSIONAL DIZZINESS INVENTORY: SECTION A

In the last 6 months, what percentage of the time has dizziness interfered with your activities?
Mark Line: ---------------------- ------------------- -------------------- ----------------- ----------------0%
20%
40%
60%
80%
100%
Instructions. Please answer the following questions about your dizziness and how it affects your
life. Read each question and then circle a number on the scale under that question to indicate
how that question applies to you.
1. Rate the level of your dizziness at the present moment.
2.
3.
4.
5.
1
2
3
4
5
none
slight
moderate
quite a bit
extreme
Since the time your dizziness began, how much has your dizziness changed your ability to
work? (___Check here, if you have retired for reasons other than your dizziness.)
1
2
3
4
5
not at all
slightly
moderately
quite a bit
extremely
How much has your dizziness changed your ability to do household chores?
1
2
3
4
5
not at all
slightly
moderately
quite a bit
very much
Does your dizziness significantly restrict your participation in social activities such as going
out to dinner, going to movies, dancing or to parties?
1
2
3
4
5
not at all
slightly
moderately
quite a bit
very much so
To what extent does dizziness prevent you from driving your car?
1
2
3
4
5
not at all
slightly
moderately
markedly
severely
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491
MULTIDIMENSIONAL DIZZINESS INVENTORY: SECTION B

This scale consists of a number of words that describe different feelings and emotions. Read each item and then
mark the appropriate answer in the space next to that word. Indicate to what extent you generally feel this way, that
is, how you feel on the average. Use the following scale to record your answers.
1
very slightly
or not at all
_____interested
_____distressed
_____excited
_____upset
_____strong
_____guilty
_____scared
2
a little
3
moderately
_____irritable
_____alert
_____ashamed
_____inspired
_____nervous
_____determined
_____attentive
4
quite a bit
5
extremely
_____jittery
_____active
_____afraid
_____hostile
_____enthusiastic
_____proud
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Index
An f following a page number indicates a figure; a t indicates a table, and a b indicates a box.
A
Acetazolamide, nystagmus treatment, 185
Acoustic immittance measurement, immittance audiometry, 166
tympanogram types, 165166
Acoustic neuroma(s), complications of surgery, 208
early postoperative course, 323
fundamental skills disabilities, 402f, 402404
middle cranial fossa approach, 206, 206f
radiosurgery, 208
suboccipital craniectomy, 207f, 207208
surgical removal, 205208
translabyrinthine approach, 206207, 207f
vestibular-evoked myogenic potential application, 154
vestibular rehabilitation, 313
Acoustic reflex, 166
Activities of Daily Living Assessment for Vestibular Patients, 399
Activity Specific Balance Scale (ABC), 113, 277, 383, 387b, 461
Adaptation, vestibular, exercises enhancing, 314315
guidelines for development, 314315
vonluntary motor control, 315
Adaptive control, compensation mechanisms, 20b, 2324, 24b
loss of bilateral labyrinthine function, 2324
loss of unilateral labyrinthine function, 23
neurophysiologic substrate of vestibulo-ocular reflex adaptation,
2627
psychological factors role, 25
recalibration, substitution, and alternative strategies, 1924
VOR adaptation, 2426
Afferent neurons, vestibular, 1011
Aging, changes in mean frequency of postural sway, 69
normal vestibular function, 376383
postural disturbances, 61t
vestibular dysfunction, 6869
Air-bone gap, 164
Air conduction threshold, audiogram, 163
Alexanders law, peripheral spontaneous nystagmus, 179
Alports syndrome, causing bilateral labyrinthine deficiency, 104
Aminoglycoside ototoxicity, 171172
Aminopyridines, downbeat nystagmus management, 420
upbeat nystagmus management, 423
Ampulla, 3
Angular accelerations, 92
Angular velocity, 45f
Ankle strategy, postural control, 42, 43f, 56
restabilizing actions, 67
Anticholinergic agents, nystagmus treatment, 184185
Anxiety, avoidance behaviors, 462, 463
hypersensitivity to visual motion, 462
migraine asssociation, 192
primary, nonvestibular dizziness, 462464
vestibular and balance rehabilitation therapy, 463464
Arnold-Chiari malformation, 64, 418, 420
Ascending tract of Deiters, 10

Aspirin toxicity, 172
Ataxia, cerebellar, case study, 402, 402f, 402t
cervical proprioceptors, 67, 474
paroxysmal and familial, 64
spinocerebellar, 437438
Audiogram, pure-tone interpretation, 164165
recording hearing thresholds, 163
types, 163, 164f
Auditory brainstem response, basic morphology, 167, 167f
clinical applications of testing, 166167
Auditory canal, external, irrigation, 126f
Auditory disorders, assessment and management, 162176
history and physical examination, 162
Aural rehabilitation, assistive listening devices, 170
Autoimmune vestibulopathy, therapy, 104
Automatic postural responses, tests, 136137
triggering, 4142
B
Baclofen, downbeat nystagmus treatment, 420
nystagmus treatment, 184
upbeat nystagmus treatment, 422f, 423
Balance, Activities-Specific Balance Confidence Scale (ABC), 113
aphysiological problems, 138140, 140f
Berg Balance Scale, 291293, 383, 384386b
bilateral vestibular loss, 338339, 343, 343f
cervical spine lesions, 472474
cervicogenic dizziness, 472474
Dynamic Gait Index, 290, 292293b, 451, 461
exercises to improve, 324, 325f
Modified Fast Evaluation of Mobility, Balance, and Fear, 387,
388389b
progression, 326
Balance assessment, altering sensory cues, 286
balance coding, 288, 288t
elderly persons, 390
Fukudas stepping test, 122128, 288289, 289f
functional balance test, 286, 286f
measures of sway, 285286
modified Clinical Test for Sensory Interaction in Balance (CTSIB),
286, 286f
self-initiated movements, 286289, 287f
sitting balance, 284285
standing reach test, 287, 287f
static balance, 285
Bar-B-que roll treatment, horizontal canalithiasis, 248, 250f
Barany maneuver, benign paroxysmal positional vertigo diagnosis,
236f, 236237
Basil ganglia, disorders, 65
Basilar migraine, 191
Bechterews phenomenon, 22
493
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Benign paroxysmal positional vertigo (BPPV), 1314

age distribution, 234t
Brandt-Daroff habituation exercises, posterior canal cupulolithiasis,
246248, 247f, 251, 253
canal involvement, 234235, 235t
canalithiasis theory, 99, 234, 235f
case studies, 257258
cervicogenic dizziness, 476
characteristics and history, 233235
clinical application of vestibular-evoked myogenic potential,
153154
cupulolithiasis theory, 99, 245248
diagnosis, 235237
differential diagnosis, 262t
disability in, 399400
Dix-Hallpike maneuver, 236f, 236t, 236237
evaluation, 98
fluid mechanics, 14f
frequency of complaints, 234t
liberatory maneuver, posterior canal, 245246
low-amplitude, secondary nystagmus, 99
management, 211, 233260
mechanism, 233234
nystagmus in, 118
nystagmus in horizontal canal, 237, 238f
physiology, 13f, 1314
positional component, 63
roll test, 237, 238f
self-limiting disorder, 99
semicircular canal involvement, 234235, 248251, 249f
side-lying test, 237, 237f
test series, 237
theory explaining typical features, 99
traumatic brain injury, 445
treatment, 211, 238239, 239t, 245248
treatment algorithm, 251252, 252f
treatment contradictions, 255256
vertigo in, 63, 283
vestibular disorders, 231
vestibulospinal distortion, 63
Benign recurrent vertigo, due to migraine, 191192
Berg Balance Scale, assessing balance, 291293
falling risks in elderly, 383, 384386b
postural control, 448451, 449451b
Betahistine, Mnires disease, 102
Bilateral vestibular disorders, 103104
Bilateral vestibular loss, 23, 338359
assessment, 140, 141f, 339344
balance, 338339
balance and gait, 343f, 343344
comorbidities, 341
compensatory strategies, 345
dizziness, 339
dynamic visual acuity, 341342, 342f, 342t
etiology, 339
exercise facilitating recovery, 345346
fall history, 339341
gaze stability, 344, 344b, 347b
history, 339
oscillopsia, 339
postural stability, 344345, 348b
primary complaints, 338339
progression of exercises, 347, 350t
recovery level, 346
recovery mechanisms, 344345
somatosensory system, 342343
subjective complaints, 341
test results, 339, 340341b
treatment, 346351
treatment and prognosis guidelines, 347351
vestibular function, 341
visual system, 341
Body hearing aid, 169
Bone conduction, audiogram, 163
Bony labyrinth, peripheral sensory apparatus, 3, 4f
Brain, traumatic injury. See Traumatic brain injury
Brainstem, 9f, 910
diagnosis of lesions, 409, 410f
lesions in upbeat nystagmus, 420421, 422f
skew deviation in infarctions, 411, 413t
Brainstem-evoked acoustic response, Mnires disease, 101
Brainstem-evoked response audiometry, 174
Brandt-Daroff habituation exercises, benign paroxysmal positional
vertigo management, 246248, 247f, 251, 253
C
Calcium channel receptor, migraine and, 193
Caloric testing, 119t, 125127, 127f
Canalith repositioning treatment, benign paroxysmal positional vertigo
management, 239240, 240f
home treatment handouts, 243, 244f
modifications, 240243, 241t, 243f
posterior and anterior canal canalithiasis, 251, 251f
treatment recommendations, 245
vertigo treatment, 447
Canalithiasis, benign paroxysmal positional vertigo, 13, 234235,
235t
horizontal canal, 248249, 250f
posterior canal, 239
Carbadopa-levodopa, 438
Carbamazepine, upbeat nystagmus management, 423
Cawthorne-Cooksey exercises, guidelines for developing, 316317
treatment approach, 313
vestibular hypofunction, 316, 316b
Center of body mass, controlling, 3637, 37f, 4046, 42f, 43f, 45f
Central nervous system, information from vestibular system, 32
processing signals for head orientation, 2
Central processing, vestibular input, 810
vestibular system, 2
Central vestibular lesions, postural reactions, 6364
traumatic head injury, 446
Cerebellar ataxia, case study, 402, 402f, 402t
Cerebellar flocculus, gain of vestibulo-ocular reflex, 10
Cerebellar nodulus, duration of vestibulo-ocular reflex responses, 10
Cerebellar vermal lesions, 122
Cerebellar vermis, vestibular stimulation, 10
Cerebellopontine angle tumors, 174
Cerebellum, central processing of input, 10
lesions of anterior-superior vermis, 10
vestibular adaptation role, 65, 92
Cerebral palsy, postural reactions, 66
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Cervical reflexes, cervico-ocular reflex, 12
cervicocollic reflex, 12
cervicospinal reflex, 1213
Cervical spine lesions, cervicogenic dizziness, 469475
oculomotor findings, 469472
Cervical vertigo. See Cervicogenic dizziness
Cervico-ocular reflex, complementing vestibulo-ocular reflex,
267268
potentiation of, improving gaze stability, 344
vestibular hypofunction, 268, 268f, 311, 311f
Cervicogenic dizziness, balance findings, 472474
benign paroxysmal positional vertigo, 476
case study, 481482
cervical anatomy and physiology, 469
cervical kinesthesia training exercises, 479f, 479480, 480f
cervical proprioception alterations, 468f, 468475
cervical spine lesions, 469475
etiologies, 467475
examination, 475476, 477f
management, 467484
mobilization techniques, 477479, 478f
occipito-atlas distraction, 478, 478f
oculomotor findings, 469472
posterior cervical sympathetic syndrome, 467
proprioception, 474475
smooth pursuit neck torsion test, 471472
treatment, 476480, 478f, 479f, 480f
vertebrobasilar insufficiency, 467468, 475476
whiplash associated disorders, 469, 471, 474
Chemical labyrinthetomy, Mnires disease, 209211
Chemotherapeutic agents, ototoxicity, 172
Children, balance, 363
central vestibular and postural control deficits, 370371
evaluation, 365370
Learning Accomplishment Profile, 361f
musculoskeletal system, 368
peripheral disorder treatment, 370
postural and oculomotor control development, 363365, 364f
posturography testing, 369
sensory organization testing, 369370
sensory screening, 368
treatment, 370371
vestibular defects incidence, 360363, 361f, 362f
vestibular dysfunction symptoms, 365, 366t
vestibular function assessment, 365, 366367t
vestibular hypofunction, 360375
vision screening, 368369, 369f
Chronic vestibular insufficiency, 8487
Cilia, otolithic membrane, 144
Clinical examination, oculomotor and vestibulo-ocular testing,
278281
Clinical Test for Sensory Interaction in Balance, rehabiliation assessment, 286, 286f
sensory cues for orientation, 452
Clonazepam, nystagmus treatment, 184, 420
Cochlear implants, profoundly hearing impaired, 172174, 173f
Commissural connections, 90
Compensation process, aging and vestibular dysfunction, 67,
6869
Compensation strategies, vestibulo-ocular hypofunction, 265271
Complete vestibular loss. See Bilateral vestibular loss
495
Computerized dynamic posturography, 134142, 135f, 136t, 137f,

138t, 139t, 140f, 141f, 141t
Concussion, brain injury, 445446
Conductive hearing loss, 164
Contest dependency, repair of peripheral vestibular lesions, 17
Controlling center of body mass, 4046
Conversion, somatoform disorder, 220
Coordination, vestibular hypofunction, 282
Coping strategies, vestibular hypofunction, 319
Cortical astasia, subjective visual vertical tilts, 417
Corticosteroids, sensorineural hearing loss, 170171
Craniectomy, suboccipital, acoustic neuroma removal, 207f, 207208
Crista ampullaris, hair cells, 4
Cupula, 4
Cupulolithiasis, benign paroxysmal positional vertigo, 13, 118,
233234
treatment options and indications, 249250, 250f
Cutoff behavior, 8
D
Decompensation, 77, 87
Deficiency, 5960
DeGangi-Berk Test of Sensory Integrations, assessment of dysfunction in children, 365, 368f
Dementia, outcome measures, 437t
Depression, elderly persons, 382383
symptoms, 221b
Diet, migraine management, 195196t
Diplopia, vertical, 111
Disability, assessments, 277t, 398399
long-term, 277
Disablement, evaluation, 398399
World Health Organization system, 399
Disequilibrium, 110
association with aging, 433434
treatment, 458466
Distortion, 60
Dix-Hallpike maneuver, benign paroxysmal positional vertigo, 236f,
236t, 236237, 476, 477f
clinical examination, 282283, 284f
Dizziness, anxiety, 219, 463
assessment, 126, 216218, 387390
bilateral vestibular loss, 339
case studies, 222225, 438
cervical proprioceptors, 67
cervicogenic. See Cervicogenic dizziness
chronic pupillary changes, 219
circumstance, 111
clinical examination, 218t, 218219, 278, 279b, 280b
diagnostic elements, 108109
disability, 112, 215, 218, 218t
disability scale, 113b
Dizziness Handicap Inventory (DHI), 216218, 217t, 377, 398399,
461
dynamic visual acuity, 13f, 132
extreme rotation, 263
factitious disorders, 221
fall inventory, 113
general anxiety disorder, 219
head extension, 263
history, 108113, 109t
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Dizziness (Continued)
mal de dbarquement syndrome, 110
malingering, 221
management, 221222, 222b, 222t
management goals, 112113
migraine, 189, 460462
Million Behavioral Medicine Diagnostic (MBMD), 216
mood disorders, 219220
Motion Sensitivity Quotient Test, 317, 318t
nonvestibular, 294295, 433443, 458466
obsesssive compulsive disorder, 219
panic attacks with and without agoraphobia, 219
physical examination, 113123
physical findings for diagnosis, 114t
physical therapy, 112113
positional, with nystagmus, 263
positive and negative affective scale, 216, 216b
problem-oriented approach, 321
psychiatric disorders, 464
psychogenic stance and gait disorders, 218t, 218219
psychological conditions association, 111
psychological problems in, 214226, 222t
somatoform disorders, 220
symptoms, 108111, 110t
terms describing, 108110
trauma-induced, 446, 446t
Dizziness Handicap Inventory (DHI), 216218, 217t, 377, 398399,
461
Dopamine D2 receptor, and migraine, 192193
Downbeat nystagmus, 64, 262, 419b
description, 418
etiology, 418, 419420
lesion of paramedian craniocervical junction, 64
management, 420
Driving, disability, 399, 400, 401t, 403, 406
Driving Habits Questionnaire, 399
Drop attacks, basilar insufficiency, 64
Dynamic disturbances, correction after unilateral labyrinthectomy,
2021
Dynamic Gait Index, quantifying gait dysfunction, 290, 292293b,
451, 461
Dynamic posture platform, 57f
Dynamic posturography. See Posturography, dynamic
Dynamic visual acuity (DVA), assessing vestibular function, 118, 121f
assessment, 130133
complete vestibular loss, 341342, 342f, 342t
quantified, 130133, 131f
E
Elderly persons, Activity-Specific Balance Scale (ABC), 383, 387b
attention in postural control, 382
balance assessment questionnaires, 383387
balance tests, 390
Berg Balance Scale, 383
cerebellar atrophy, 382
depression, 382383
disuse equilibrium, 433434, 434f
dizziness assessment, 387390
fear of falling, 382, 433434, 434f
home assessment, 390
home safety checklist for fall hazards, 379381b
Modified Falls Efficiency Scale, 383

Modified Fast Evaluation of Mobiity, Balance, and Fear Baseline
questionnaire, 387, 388389b
musculoskeletal deficits, 381382
postural hypotension, 382
risk factors, management following identification, 390391
risk of falling, 383
semicircular canal function, 376377
somatosensory changes, 378381
treatment duration, 390
utricular and saccular function, 377378
Vestibular Activities of Daily Living, 383397
vestibular function, 376378
vestibular function tests, 378
visual deficits, 378
white matter disease, 382
Electrocochleography, 168f, 168169
clinical applications, 168
Mnires syndrome, 101
Electromyographic responses, 55
latencies and amplitudes, 41
measurement of postural reactions, 137f
vestibular deficit during horizontal translations, 62
Electronystagmography (ENG), 125
Endolymphatic hydrops. See Mnires syndrome
Endolymphatic sac surgery, Mnires syndrome, 209
Epilepsy, vestibular. See Vestibular epilepsy
Equilibrium, delayed reactions, 65
Ewalds second law, cutoff behavior explanation, 8
head-shaking nystagmus, 22
Exercises, adaptation, 314315, 315f
adjustments for severe dizziness, 349b
benign paroxysmal positional vertigo, 246248, 247f
Cawthorne-Cooksey, 313, 316, 316b
cervical kinesthesia training, 48f, 479f, 479480
facilitating recovery, 312, 322b, 345346
gait, 324325, 326
gaze stability, 324, 325b, 448
gaze stability suggested progression, 325b
habituation, 317
home program for nonvestibular dizziness, 434
in oscillopsia, 183
postural instability, 452453
treatment, 323326, 324f, 325f
postural stability, 312, 324325, 325f
response to, 314, 315f
substitution approach, 315317
vestibular system enhancement, 349f
Eye-head coordination, after traumatic brain injury, 447448
Eye movements, maneuver-induced, 118119, 121t
nicotine and, 180
saccadic, 122, 122t
smooth pursuit, 134, 270, 344
vestibulo-ocular reflex generation, 2
Eyeball torts, 147
F
Factitious disorder, psychological, 221
Falls, central vestibular without vertigo, 427
fear in elderly, 382, 433434
history of bilateral vestibular loss, 339341
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history of dizziness, 113
history of vestibular hypofunction, 277278
Modified Falls Efficacy Scale, 383
risks in elderly, 383
Tinetti Fall Risk Assessment, 438, 439f
Filtering, separating tilt from linear acceleration, 16
Forced prolonged position, horizontal canal benign paroxysmal positional vertigo, 249
Fractures, brain injury, 446
Fukudas stepping test, assessing balance and gait, 122123
self-initiated movements, 288289, 289f
Functional deficits, posturography testing, 139t
Functional history, physical therapy evaluation, 278, 278b
G
GABA (gamma-aminobutyric acid), 180
downregulation, 9192
Gabapentin, nystagmus treatment, 183184, 184f
Gain, 14
Gait, bilateral vestibular loss, 338, 344
exercises to improve, 324325, 326
Gait evaluation, assessment, 289293
Berg Balance Scale, 291293
dizziness, 218t, 218219
Dynamic Gait Index, 290, 292293b
negotiating obstacle course, 290291, 291f
red flags, 293294
Gait stability, head movement requirements during, 274
Gaze stability, complete vestibular loss, 344, 344b
exercises to improve, 324, 325b, 347b
Gentamicin, Mnires syndrome, 102, 405
ototoxicity, 48
unilateral peripheral vestibular dysfunction, 78
Geriatric Depression Screening Scale, 383
H
Habituation, exercises, 317
Hair cells, peripheral sensory apparatus, 4, 5f
polarization vector, 146
Hallpike-Dix test, 118, 121f
Head acceleration, graph, 47, 47f
Head heaves, 84
Head movement, and position, vestibular hypofunction, 274
Visual Analogue Scale, 112, 112f
Head rotation, effects on canals, 5f
running, 178, 179f
Head-shaking nystagmus, development, 23
test, 117118, 120t
Head stabilization, postural compensation, 68
responses, 4647
Head thrust, in vestibulo-ocular hypofunction, 268269, 269f
Head-thrust test, 119t
unilateral vestibular loss, 117
Hearing aids, 169170
traditional, 169170
types, 169, 169f
Hearing impairment, sensorineural, in children, 360, 361f, 361362,
362f
Hearing loss, causes, 175
classification, 165t
497
conductive, 164
evaluation, 170
laboratory testing, 170
labyrinthitis, 171
Lyme disease, 171
pure tone average, 165
Ramsay Hunt syndrome, 171
Rocky Mountain spotted fever, 171
sensorineural, 170171
surgical management, 172175
syphilis, 171
types, 164165
Hip strategy, controlling cneter of mass, 44
postural control, 42
Home, assessment, 390
Home Safety Checklist, 378, 379371b
modifications, 390
Hydrocephalus, normal-pressure, description, 434, 441f
management, 437
outcome scores, 436437, 437t, 440t
symptoms, 434436
Hypertropia, 280
I
Image-shifting device, nystagmus, 185f, 185186
Imbalance, case study, 440, 440t, 441, 441f
nonvestibular, 433443
outcome measurements, 435436, 437t
persistent, benign paroxysmal positional vertigo, 254255
Internal auditory canal, signals from vestibular nerve, 8
International Classification of Functioning, Disability, and Health
Model of Disablement, 228
K
Kalman filter, 15f, 1516
Kinesthesia, training exercises, 479f, 479480, 480f
Kinocilium, otolith structure, 144145
L
Labyrinth nerve, 125f
Labyrinthectomy, Mnires syndrome, 209, 210f
unilateral, compensation after, 2023
Labyrinthine deficits, modifications to postural stability, 61
unilateral and bilateral, 6162
Labyrinthine dysfunction, bilateral loss, 2324
Labyrinthine hypofunction, 263
Labyrinthine inputs, deficient, 6061
Labyrinthitis, hearing loss due to, 171
serous, 171
suppurative, 171
Labyrinths, bony and membranous, 34, 4f
Lateropulsion, after unilateral vestibular deafferentation, 81
Wallenbergs syndrome, 428
Learning Accomplishment Profile (LAP), sensorineural hearing
impairment, 361f
Lermoyez phenomenon, 101
Leukoaraiosis, case study, 441, 441f
description, 434
etiology, 434
management, 437
Liberatory maneuver, benign paroxysmal positional vertigo, 245246,
251, 252253
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Lightheadedness, 110
Linear accelerations, 92
Lyme disease, hearing loss, 171
M
Macula(ae), 4
Mal de dbarquement syndrome, 110
case study, 202
cause, 202
disability scores, 459
land-sickness and, 202
nonvestibular dizziness, 459460
post-therapy symptom score, 460
treatment, 203204, 459
treatment outcome parameters, 460, 460t
Malingering, psychological disorder, 221
Medial longitudinal fasciculus nystagmus, 10
Medical Outcomes Study Short-Form Health Survey Questionnaire,
399
Medications, downbeat nystagmus, 420
psychological problems, 222, 222t
vestibular neurons and, 88
Memantine, nystagmus treatment, 184
Membranous labyrinth, peripheral sensory apparatus, 34, 4f
Mnires Disease Outcomes Questionnaire, 399
Mnires syndrome, chemical labyrinthectomy, 209211
clinical synptoms, 6263, 101
diagnosis, 63, 101
diagnostic tests, 101
disabilities, 404406, 432f
disorder of inner ear function, 101
endolymphatic sac procedures, 209
hearing loss, 6263
labyrinthectomy, 209, 210f
labyrinthine function, 79
medical therapy, 102, 208209, 405
migraine vs., 197, 197t, 199
psychological support, 102
psychosocial consequences, 405, 406
sacculotomy to relieve pressure build-up, 102
treatment, 102
vertigo due to, 182
vestibular deficiency, 6263, 100
vestibular-evoked myogenic potential application, 152153
vestibular nerve section treatment, 102
vestibular neurectomy, 209
Middle cranial fossa approach, acoustic neuroma, 206, 206f
Migraine, abortive medical therapy, 196
Activities-Specific Balance Confidence Scale, 461
with aura, 189, 191, 193
basilar, 191
case example, 188189
childhood periodic syndromes, 192
classification and criteria for diagnosis, 189192, 190b
diet, 195196t
disorders associated with, 192, 460
Dizziness Handicap Inventory, 461
Dynamic Gait Index, 461
incidence, 188
management, 193196
medications, 193196
neuro-otological disorders, 191b
nonvestibular dizziness, 460462
outcome measures, 461
pathophysiology, 192193
peripheral vestibular lesion and, 461
prophylactic medical therapy, 194196
recurrent vertigo, 191192
schedule to treat, 194b
serotonin receptor drugs, 197t
symptoms, 188189, 189t
Timed Up and Go test, 461
vestibular and balance rehabilitation therapy, 461, 462
vestibular treatment, 193194
vs. Mnires syndrome, 197t, 199
without aura, 191
Million Behavioral Medicine Diagnostic (MBMD), dizziness, 216
Mixed-type hearing loss, 164, 164f
Mobilization techniques, cervicogenic dizziness, 477479, 478f
Modified Falls Efficacy Scale, 383
Modified Fast Evaluation of Mobility, Balance, and Fear Baseline,
387, 388389b
Mood disorders, dizziness, 219220
Motion, sensing and perceiving, 3334
sensors, 33
Motion Sensitivity Test, assessing dizziness, 317, 318t
Motion sickness, disorders associated with migraine, 192
dizziness, 110111
problems in vestibular processing, 1617
Motor control, voluntary, adaptation and, 315
Motor coordination, development, 45f, 4546
Motor cortex lesions, postural reactions, 65
Multiple sclerosis, manifestations of paroxysmal vestibular
syndromes, 427
vestibular-evoked myogenic potentials, 154
N
Nausea, dizziness, 111
Neck movements, postural instability, 324, 324f
Neck reflexes, tonic, assessment, 368f
Neocerebellum, lesions, 65
Neural integrator, 10
Neurectomy, vestibular, 148, 148f
Neuroma, acoustic. See Acoustic neuroma
Neuropeptides, vestibular adaptation, 2627
Nonvestibular dizziness, 433443
assessment and treatment development considerations, 464465
conditions other than vestibular disorders, 459464
definition, 458459
mal de dbarquement category, 459460, 461t
migraine category, 460462
posttherapy symptom score, 460
primary anxiety and panic category, 462464
therapy outcomes, 460t
Noradrenergic system, migraine and, 193, 193t
Nylen-Barany maneuver, benign paroxysmal positional vertigo diagnosis, 236f, 236237
Nystagmus, central positional, without vertigo, 261262
central vestibular, 115116, 116f
clinical examination of visual-ocular motor function, 279280
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downbeat, 64, 262, 418420
drugs, 183185, 184b
fixation blocked, 115t
jerk-waveform see-saw, 417
neuropharmacology, 180
optical devices, 185f, 185186
optokinetic, cervical spine lesions, 469470
pathogenesis, 179, 183
peripheral vestibular, 79, 79f, 115f
peripheral vs. vestibular, 115t
recovery, 22
spontaneous, 113115
surgery, 186
torsional, 417
treatments, 178187
upbeat, 262, 418, 420423
vestibular, 129, 129f
in vestibular neuritis, 100
visual consequences, 183, 184b
voluntary, 219
O
Obsessive-compulsive disorder, dizziness, 219
Obstacle course, gait evaluation, 290, 291f, 325
gait treatment, 325
Occipito-atlas distraction, cervical traction, 478, 478f
Ocular counterrolling, as otolithic dynamic response, 8384
response to otolithic stimulation, 147
Ocular tilt reaction, causes, 415
diagnostic rules in roll, 414f, 414415
dyfunction in roll plane, 410
natural course and management, 415417, 416f
paroxysmal, 415
patient with, 415, 416f
in spontaneous nystagmus, 116, 118f
triad of responses, 64
types of disorders, 417
in unilateral vestibular deafferentation, 7981
Ocular torsion, 80, 80f
Oculomotor testing, cervical spine lesions, 469472
Optical devices, treatment of nystagmus, 185186, 186f
Optokinetic after nystagmus response, possible effects, 470471
Optokinetic systems, cervical spine lesions, 470
Orientation, body to vertical, 3440
perception of, 34
postural alignment, 3436
postural goals, 40, 40f
sensory information, 3640
Orthostatic hypotension, 263
Oscillopsia, 87, 111, 178
downbeat nystagmus, 418
etiology, 182f
illusory movements, 183
pathogenesis, 182183
treatment, 183
Otoacoustic emissions, 167168
Otoconia, 377
calcium carbonate crystals, 4
otolith structure, 145
Otolith function tests, 144158
peripheral vestibular lesions, 147149
499
Otolithic membranes, containing calcium carbonate crystals, 4

Otoliths, central projections, 146147
function, 145f, 146
function of otolithic input, 147
linear acceleration and static tilt, 7f
motion sensors, 17
organs, 4
primary otolithic afferents, 146
push-pull arrangement of sensors, 7
responding to acceleration, 7
structure, 144146, 145f
Otoscopic examination, 160
Ototopical medications, 172
Overload, compensation, 16
P
Panic attacks, nonvestibular dizziness, 462464
symptoms, 221b
with and without agoraphobia, 219
Parkinsons disease, 437438
equilibrium reactions, 65
treatment, 438
Paroxysmal and famial ataxia, broad-based gait, 64
Paroxysmal central vertigo, central vestibular falls without vertigo,
427
lateropulsion in Wallenbergs syndrome, 428
manifestations in multiple sclerosis, 427
thalamic astasia, 427428
Peabody Development Motor Scales, 365, 366t
Perilymphatic fistula, 102103, 211212, 212f, 446
diagnosis, 103, 175
medical treatment, 103
physical examination, 103
symptoms, 102103, 174175
vertigo and nystagmus, 263
vertigo of unknown origin, 103
Peripheral disorders, children with, 370
Peripheral neuropathy, large-fiber, 437438
Peripheral sensory apparatus, bony labyrinth, 3, 4f
hair cells, 4, 5f
membranous labyrinth, 34, 4f
vascular supply, 45, 6f, 9f
vestibular system, 78
Peripheral vestibular deficit, dizziness, 215
Peripheral vestibular disorders, migraine and, 461
nystagmus, 113115
postural reactions, 5963
Peripheral vestibular lesions, otolith function testing, 147149
Pharmacological toxicity, 171172
Physical deconditioning, bilateral vestibular, 339
problem, 326f, 326327
Physical therapy, mal de dbarquement syndrome, 202204
Physical therapy diagnosis, clinical examination, 229230
diagnosis-driven treatment, 229t
diagnostic flowchart, 230231, 231f
functional assessment of vestibular dysfunction, 232t
identification of modifiers, 231232, 232t
patient history, 229
vs. medical diagnosis, 228
Physical therapy intervention, gait and balance outcome tests, 434
Pitch, head tilt, 7, 7f
31Herdman(p2)-Index
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Pitch plane, topographic diagnosis of vestibular syndromes, 409, 410f

Platform perturbations, testing automatic postural responses, 4142,
42f
Polarization vector, functional, 146
otolithic receptor hair cells, 146
Position, sensing and perceiving, 3334
Position testing, 118119
Positional and movement testing, clinical evaluation, 282283
Positive and negative affective scale, dizziness assessment, 216, 216b
Posterior cervical sympathetic syndrome, cervicogenic dizziness, 467
Posttherapy symptom scale, 277t
Postural abnormalities, 5475
labyrinthine deficits, 6162
Postural alignment, vestibular deficits, 3436
Postural control, 135
attention in elderly persons, 382
balancing body, 32
Berg Balance Scale, 448451, 449451b
case studies, 48, 49
Clinical Test for Sensory Interaction in Balance tests, 286, 286f
roles of vestibular system, 32f, 3253, 47, 49t
treatment in deficits in children, 370371
vestibular information for, 39f, 40, 40f
Postural dysfunction, pathology of sensory-motor centers, 6466
Postural examination, clinical evaluation, 282
Postural hypotension, elderly persons, 382
Postural instability, clinical evaluation, 274
clinical tests, 56t
vestibular hypofunction, 274, 323326
Postural reactions, benign paroxysmal peripheral positional vertigo,
63
central vestibular lesions, 6364
changes with aging, 6869
deficient labyrinthine inputs, 6061
indications of vestibulospinal distortion, 63
indicators of vestibular deficiency, 6163
Mnires syndrome, 63
peripheral vestibular disorders, 5963
unilateral and bilateral labyrinthine deficit, 6162
Postural responses, automatic, 4146
central control, 68
orienting body to vertical, 3536, 36f
stimulating vestibular system electrically, 35
vestibular contributions, 5657
Postural stability, complete vestibular loss, 344345
control underlying, 448452
exercises to improve, 312313, 322b, 348b
impairments limiting, 452453, 453f
mechanisms for recovery, 6669
modifications following loss of sensory inputs, 66, 66b
sensory substitution, 6667
Postural strategies, selection, 4245
Postural sway, frequency changes in elderly, 69
Posturography, advantages and disadvantages, 56t
assessment of dysfunction in children, 369, 370
dynamic, 134142, 135f, 136t, 137f, 138t, 139t, 140f, 141f, 141t,
219, 219b, 220f
identifying vestibulospinal deficiency, 61
mean, benign paroxysmal positional vertigo, 254, 254f
Pressure testing, 119
Progressive supranuclear palsy, 437438
Prone extension test, children, 365, 368f

Proprioception, cervicogenic dizziness, 474475
Psychiatric factors, vestibular hypofunction, 319
Psychological disorders, anxiety, 219
dizziness, 111, 214226, 222t
malingering, 221
medication, 222, 222t
Psychological factors, vestibular hypofunction, 319
Pure tone average, degree of hearing loss, 165
Q
Quick Bar-B-que roll, cupulolithiasis benign paroxysmal positional
vertigo, 249250
Quick phases, 79, 79f
Quiet stance, tests, 58
R
Radiography, hearing loss, 170
Radiosurgery, acoustic neuromas, 208
Range of motion/strength, clinical egaluation, 282
Recalibration, 1924
Redlich-Oberstein zone, 410
Rehabilitation. See also Vestibular rehabilitation
nonvestibular dizzinss, 458
vestibular disorders, 89, 446b, 446447
Repair, central lesions, 1718
Repositioning maneuvers, benign paroxysmal positional vertigo, 252,
253t
Reticulospinal tract, receiving sensory input, 11
Retinal slip, visual image movement across retina, 311
Retropulsion test, 123
Rinne test, 162163, 163f
Rocky Mountain spotted fever, hearing loss, 171
Roll plane, signs and symptoms, 414f, 414415
topographic diagnosis of vestibular syndromes, 409, 410f
Romberg test, advantages and disadvantages, 56t
balance evaluation, 285
self-localizaion, 58
test of vestibular function, 122123
Rotary chair testing, 127130, 129f, 130f, 131f
S
Saccadic eye movements, 122, 122t, 134
deficits, 122t
substitution strategy, vestibulo-ocular hypofunction, 265, 266f
Saccadic system, modifications in vestibulo-ocular hypofunction, 267
Saccula, 3
Saccular function, elderly persons, 377378
Saccular sac, 145
Scarpas ganglion, 78
Scopolamine, nystagmus treatment, 184
Sedatives, common vestibular, 181t
Self-initiated movements, evaluation, 286289, 287f, 289f
Self-motion, perception of, 34
in sensation, 34
sensing and perceiving, 3334
Semicircular canals, 57, 6f
coplanar pairing, 6
dehiscence, 174, 263
effects on head rotation, 5f
31Herdman(p2)-Index
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function in elderly persons, 376377
motion sensors, 33
Semont maneuver, modified, horizontal canal cupulolithiasis, 250,
250f
Sensor ambiguity, vestibular processing problems, 16
Sensorimotor integration, 15f, 1516
Sensorineural hearing impairment, motor and balance deficits in
young children, 360, 361f, 361362, 362f
Sensorineural hearing loss, 164, 164f, 170171
Sensory apparatus, peripheral, 35
Sensory cues, altering, 5758
Sensory evaluation, clinical, 281282
Sensory input, vestibular system, 2
Sensory-motor centers, postural dysfunction with, 6466
Sensory organization, children, 369370
Sensory organization test, 37, 135, 135t
Sensory orientation, surface dependent pattern, 39
visually dependent pattern, 39
Sensory redundancy, coplanar pairing, 6
Sensory substitution, postural stability recovery, 66
Serotonin 5HT, migraine and, 193, 197t
Shearing force, 7
Sinemat, 438
Singleton test, gait evaluation, 290
Sitting balance, assessment, 284285
Skew deviation, 80, 80f, 116, 118f, 280
brainstem and thalamic infarctions, 410, 413t
Smooth pursuit, eye movements, 134
neck torsion test, 471472
oculomotor and vestibulo-ocular testing, 279
vestibulo-ocular hypofunction, 270
Somatization, 220
Somatosensory input, substitution in vestibular hypofunction,
311312
Somatosensory system, altering sensory clues, 345
complete vestibular loss, 342343
position and motion of body, 33, 54
reflexes, 13
Space motion sickness, 17
Spasm of convergence, dizziness, 219
Spatial hemineglect, impairing focal attention toward space, 426
Speech audiometry, speech reception threshold measurement, 165
word recognition testing, 165
Speech detection threshold, 165
Speech reception threshold, speech audiometry, 165
Speech recognition score, 165
Spinocerebellar ataxia, 437438
Spontaneous nystagmus, 113115
Stability, postural control, 448, 448f
Stability limits, boundaries of sway, 36
Stabilizing head, postural control, 4647
Stabilometry, advantages and disadvantages, 56t
clinical tool, 58
Standing reach test, self-initiated movements, 287, 287f
Stapes, hypermobile, 263
Static balance, assessment, 285
Stepping tests, advantages and disadvantages, 46t
turning on vertical axis, 59
Stereocilia, otolith structure, 168
Strength, clinical evaluation, 282
Striola, separating direction of hair cell polarization, 7
Subjective visual vertical, test, 134
501
Suboccipital craniectomy, acoustic neuroma removal, 207f, 207208

Substitution, 1924
exercises, 315317
Summation potential, electrocochleography, 168
Sway, in mal de dbarquement syndrome, 202203
measures of, 135, 285286
in Mnires syndrome, 63
postural, healthy subjects, 39f
postural differences, 44, 69
Sway-referencing stimulation, 37, 38f
Syphilis, hearing loss, 171
T
Test of Sensory Functions in Infants, assessment of dysfunction in
children, 365, 368f
Thalamic astasia, 427
subjective visual vertical tilts, 417
Thalamic hemiataxia, 427428
Three-Minute Walk Test, 451
Tiltboards, advantages and disadvantages, 56t
lateral or anterior-posterior tilts, 59
Time constant, 14
Timed Up and Go Test, gait assesssment, 293
migraine, 461
modified, 436
Tinetti Fall Risk Assessment, 438, 439f
Torsional nystagmus, locations of lesions, 417
vestibular dysfunction in roll, 417
Tragus movement, 119
Translabyrinthine approach, acoustic neuroma removal,
206207, 207f
Traumatic brain injury, case study, 454455, 455f
central vestibular lesions, 446
concussion, 445446
fractures, 445446
impairments limiting postural stability, 452453, 453f
postural control underlying stability, 448449
time course for recovery, 453454
vertigo, 447
vestibular pathology, 444445
vestibular rehabilitation, 446b, 446447
weakness following, 452
Trunk muscle activations, stabilizing head, 4647
Tullio phenomenon, 119
perilymph fistula, 102103
Tumarkins otolithic crisis, Mnires disease, 101
Tympanometry, types of tympanograms, 165166
U
Unilateral vestibular deafferentation (uVD), 76, 7984. See also
Unilateral vestibular loss
dynamic symptoms, 8184, 82f
factors affecting, 8489
ocular tilt reaction in, 7981
ocular torsional position before and after, 149, 150f
otolithic dynamic responses in, 8384
recovery after, neural evidence, 8992, 91f
sensory components, 84
static symptoms, 79, 79f
symptoms and extent of recovery, 8586t
unilateral vestibular loss, 76
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Unilateral vestibular loss, causes, 7779

gentamicin injection, 78
neural activity patterns, 7677
vestibular compensation, 7697
Upbeat nystagmus, 421b
description, 420421
etiology, 421
management, 421423, 422f
Ushers syndrome, causing bilateral labyrinthine deficiency, 104
Utricle, 3
otolith structure, 116, 118f
Utricular function, elderly persons, 397398
test, 134
Utricular sac, 145
V
Vascular loops, elongated or tortuous vessels, 212
retrolabyrinthine exposure of vascular compression, 212f, 212213
Vascular supply, central processing of vestibular input, 9f,
910
peripheral sensory apparatus, 45, 6f, 9f
Velocity storage, 180
Vertebral artery compression, vertigo and nystagmus, 261
Vertebral-basilar arterial system, peripheral and central vestibular,
9f, 910
Vertebrobasilar insufficiency, cervicogenic dizziness, 467468,
475476
Vertical diplopia, 111
Vertigo, acute, 180182
after traumatic brain injury, 447
alcohol, 104
benign paroxysmal positional, 98, 182, 211, 283
benign recurrent, 191192
central positional, with nystagmus, 261
central syndromes, 410, 412413t
cervical. See Cervicogenic dizziness
disabling positional, 103
in dizziness, 111
epileptic auras, 427
maneuver-induced, 118119
Mnires disease and endolymphatic hydrops, 101, 182
migraine as cause, 188
neuropharmacology, 180
paroxysmal central, 427428
pathophysiology, 178180
perilymphatic fistula, 103
peripheral positional, with nystagmus, 262263
positional, case study, 264
posttraumatic, 211
recurrent, treatment, 182
treatment, 180182
vestibular neuritis, 99100
Vestibular Activities of Daily Living Scale, 383387
Vestibular adaptation, 1931
compensatory mechanisms, 20b
recovery mechanism, 310311
spatial localization in, 25
Vestibular afferent neurons, firing patterns, 12
Vestibular and balance rehabilitation therapy, 458, 459, 461, 462,

463464
Vestibular compensation, 7697. See also Unilateral vestibular loss
models, 92
Vestibular cortex, activation during vestibular stimulation, 424
functions, 424, 425f
locations, 424
multimodal sensorimotor function and dysfunction, 424426
spatial hemineglect, 426
static cortical spatial disorientation, 426
vestibular epilepsy, 426427
Vestibular defects, posturography testing, 139t
Vestibular deficits, bilateral, compensatory mechanisms,
2324, 24b
EMG responses in, 62
incidence in children, 370371
Vestibular disorders, 9899
benign paroxysmal positional vertigo, 9899
bilateral, 103104
central. See Vestibular system, central
clinical examination, 229230
compensatory processes, 6769
diagnostic flowchart, 230f, 230231
frontal roll plane, 410417
horizontal yaw plane, 423424
mechanism of injury, 445
Mnires syndrome and endolymphatic hydrops, 101
perilymphatic fistula, 102103
plane-specific, 411f
postural disturbances, 5475, 61t
rehabilitation, 89
sagittal pitch plane, 417418
signs and symptoms in roll, 414f, 414415
treatment, 178187, 229t
vestibular neuritis, 423
Vestibular Disorders Activities of Daily Living Scale, 399, 400
Vestibular epilepsy, 426427
auras, 427
cortical vertigo syndrome, 426
management, 427
seizures, 426
Vestibular-evoked myogenic potentials (VEMPs), 55, 56t
acoustic neuroma, 154
benign paroxysmal positioning vertigo, 153154
case study, 154155
clinical applications, 133, 152154
method, 133, 151152
multiple sclerosis, 154
physiological background, 150151, 151f
results, 133f
stimulation of saccule, 151
superior semicircular dehiscence, 152
test of saccular function, 133
testing otolith function, 150154
Vestibular function, effect of aging, 376378
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INDEX
models, 92
tests, 125143
Vestibular hypofunction. See also Vestibulo-ocular hypofunction
activities vs. limitations, 274
adaptation treatment, 314315
assessment form, 303306
assessment of outcome, 275276
assessment to treatment transition, 294295
balance assessment, 284289
Cawthorne-Cooksey exercises, 313, 316b, 316317
cellular recovery, 309
cervical range of motion, 274
in children, 360375
clinical examination, 278, 279b, 280b
coordination assessment, 282
disability scale, 277t
dynamic component, recovery, 310
in elderly, 376397
evaluation form, 300302
exacerbation of symptoms, 353
exercise facilitating recovery, 312313
exercises to improve gaze stability, 324, 325b
exercises to improve postural stability, 322t, 323, 324
fall history, 277278
functional history, 278, 278b
gait evaluation, 289293, 291f
head movement and position perception, 274
health condition, 273b
improvement determination, 295
medical history, 276
medications, 320
Motion Sensitivity Test, 317, 318t
oculomotor and vestibulo-ocular testing, 278281
outcome, factors affecting, 317320
participation vs. restriction, 275
physical comorbidities, 319
physical deconditioning, 274, 326f, 326327
physical therapy assessment, 272299
positional and movement testing, 282284, 283t, 284f
postural examination, 282
postural instability, 274, 322326
psychiatric and psychological factors, 319
range of motion and strength, 282
recovery after rehabilitation, 320
recovery expectations, 317320
recovery mechanisms, 309312
recovery of postural stability, 323326
return to driving, 327
self-initiated movements, 286289, 287f, 288t
sensory cues alteration, 286, 286f
sensory evaluation, 281282
subjective history, 276277
substitution treatment, 311312
symptoms, 272, 273b
tonic firing rate, reestablishment, 309310
treatment, 309337
treatment approaches, 314317
treatment goals, 278, 313317
503
vestibular adaptation, 310311, 314

vestivulo-ocular function and dysfunction, 272274
Vestibular inputs, responses controlled by, 77, 77f
Vestibular loss, bilateral. See Bilateral vestibular loss
pattern, 38, 38f
unilateral, test results, 285t
Vestibular nerve, 125f
peripheral system, 78
treatment of Mnires syndrome, 102
Vestibular neurectomy, 148, 148f
Vestibular neuritis, cause of vertigo, 99100
initial treatment, 100
irritative nystagmus, 100
peripheral vestibular loss, 113, 114f
symptoms and signs, 100
Vestibular nuclear complex, 9, 9f
Vestibular paroxysmia, 103
Vestibular processing, higher-level problems, 1416
velocity storage, 1415
Vestibular reflexes, vestibulo-ocular reflex, 1112
vestibulocollic reflex, 12
vestibulospinal reflex, 12
Vestibular rehabilitation, assessment, 446b, 446447
brain injury and vestibular dysfunction, 444457
vertigo, 313
vestibular system pathology, 443444
Vestibular schwannoma. See Acoustic neuroma
Vestibular system, anatomy, 218, 3f
in automatic postural responses, 47
central, syndromes, 410, 412413t
vascular lesions, 409432
cervical reflexes, 1213
higher-level problems, 1618
motor output of neurons, 1011
organization, 2f
orienting body to vertical, 3436, 36f
overload compensation, 16
physiology, 218
in postural control, 32f, 3253
purpose, 23
selecting sensory information, 3640
sensing and perceiving position and motion, 16
sensor and motor system, 33
somatosensory reflexes, 1314
vestibular reflexes, 1112
visual reflexes, 13
Vestibulo-ocular cancellation, oculomotor and vestibulo-ocular testing,
120
Vestibulo-ocular hypofunction, compensatory strategies, 265271
enhanced smooth pursuit, 270
head movement prediction, 268269, 269f
saccade substitution, 265, 266f
Vestibulo-ocular reflex (VOR), abnormal, 265
adaptation studies, 20, 2426
bedside tests, 118t
cervico-ocular reflex and, 267268
context specificity of VOR gain adaptation, 26
critical period for adaptation, 2122
deficient, saccade substitution, 265, 266f
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INDEX
Vestibulo-ocular reflex (VOR) (Continued)

diagnosis of disorders, 409, 410f
error signals driving adaptation, 20
experiments in primates, 23
generating eye movements, 2
inadequate, 82, 82f
inadequate compensatory slow phases, substitution of
saccades, 22
neurophysiologic substrate adaptation, 2627
normal, 265
output for, 10
plasticity, 89
regular afferent neurons, 12
restoration of spontaneous activity in deafferenated nuclei, 21
restoration of static and dynamic balance after unilateral
labyrinthectomy, 2021
spontaneous nystagmus, 116118
translational, 266
Vestibulo-ocular system, adaptation exercises, 314
Vestibulo-ocular testing, clinical examination, 278281
Vestibulocerebellum, lesions, 65
Vestibulopathy, acute unilateral (idiopathic). See Vestibular neuritis
autoimmune, 104
chronic, disability, 400
Vestibulospinal deficiency, indicators, 6163
Vestibulospinal distortion, benign paroxysmal peripheral positional
vertigo, 63
Vestibulospinal reflex, elderly persons, 376377
generating body movements, 2
output for, 1011, 11f
Vestibulospinal system, clinical tests, advantages and limitations, 55
examination, 5559
Vestibulospinal tract, lateral, 11, 11f

medial, 11
Virtual reality environments, 59
Virtual reality technology, 59, 60f
Vision screening, children, 368, 369, 369f
Visual acuity, clinical vestibular test, 118, 121f
Visual defects, elderly persons, 378
Visual deficits, modifications to postural stability, 36, 36f
Visual signals, detecting and reducing motion relative to surroundings,
3738, 39f
Visual system, body movement determinations, 33, 34f
reflexes, 13
signaling head position and movement, 33
Visual tracking, 120122, 134
Vomiting, dizziness, 111
W
Waardenburgs syndrome, causing bilateral labyrinthine deficiency, 104
Walk While Talk Test, 436
Walking, exercise in vestibular hypofunction, 327
self-selected speed, 451
Wallenbergs syndrome, infarction of dorsolateral medulla, 64
lateropulsion, 428
ocular tilt reaction, 423
Weber tuning fork test, 162, 163f
Whiplash-associated disorders, 469, 471, 474
White matter disease, 382
Work, return following acoustic neuroma resection, 402403
return in Mnires syndrome, 405406
Y
Yaw plane, topographic diagnosis of vestibular syndromes,
409, 410f

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00Herdman(p2)-FM

Steven L. Wolf, PT, PhD, FAPTA, Editor-in-Chief

For more information on each title

Susan J. Herdman, PT, PhD, FAPTA

I would like to dedicate this edition of

tion on quantification of vestibular function tests and

impression that the content of this book could have

Steven L. Wolf, Ph.D., PT, FAPTA, FAHA

tem such as disuse disequilibrium and central disorders.

HEALTH CONDITION DISORDER OR DISEASE

Normal Function and Structure

explore the extent of recovery that can be achieved. Some

Susan J. Herdman, PT, PhD, FAPTA

Neil T. Shepard, PhD

Ronald J. Tusa, MD, PhD, NCS, ATC

Gail F. Metzger, BS, MS, OTR/L

1 Anatomy and Physiology of the Normal

3 Role of the Vestibular System in

5 Vestibular Compensation: Clinical

6 Vestibular System Disorders

7 History and Clinical

12 Migraine, Mnires and Motion

13 Therapy for Mal de

11 Pharmacological and Optical

Medical Assessment and

Medical and Surgical

Ian S. Curthoys, PhD and

Emily A. Keshner, PT, EdD

Sharon Polensek, MD, PhD

Fay B. Horak, PT, PhD

9 Otolith Function Tests

Ronald J. Tusa, MD, PhD

8 Vestibular Function Tests

14 Surgical Management of Vestibular

15 Psychological Problems and

Rehabilitation Assessment and

Susan J. Herdman, PT, PhD, FAPTA

17 Physical Therapy Management of

Susan J. Herdman, PT, PhD, FAPTA

23 Management of the Elderly Person

16 Physical Therapy Diagnosis for

25 Assessment and Management

Ronald J. Tusa, MD, PhD

Susan L. Whitney, PT, PhD, NCS, ATC

Appendix 19A Evaluation

20 Interventions for the Patient

Susan J. Herdman, PT, PhD, FAPTA

22 Management of the Pediatric Patient

28 Non-vestibular Dizziness and

21 Assessment and Interventions

27 Assessment and Management

Susan J. Herdman, PT, PhD, FAPTA

26 Non-vestibular Dizziness and

19 Physical Therapy Assessment of

Appendix A Questionnaire for

1 Anatomy and Physiology of the

Purpose of the Vestibular System

3 Role of the Vestibular System in

Sensing and Perceiving Position and Motion