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Introduction
1. Cardiopulmonary system
2. Pulmonary system
3. Neuromuscular system
3.1 Central nervous system
3.2 Anatomy and function of spinal cord
3.3 Peripheral nervous system
3.4 Stroke deficits and recovery
3.5 Traumatic brain injury
3.6 Spinal cord injury
3.7 Neurodegenerative disorders and epilepsy
3.8 Peripheral nervous system conditions
3.9 Other neurological conditions
3.10 Interventions for neurological conditions
3.11 Vestibular system
3.11.1 Anatomy, examination, and disorder classification
3.11.2 Peripheral disorders and intervention strategies
4. Pediatrics
5. Musculoskeletal system
6. Other system
7. Non systems
Wrapping up
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3.11.2 Peripheral disorders and intervention strategies
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3. Neuromuscular system
3.11. Vestibular system
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Peripheral disorders and intervention strategies

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Differential diagnosis of peripheral vestibular dysfunction with intervention strategies

Benign paroxysmal positional vertigo (BPPV)

Peripheral vestibular disorders
Peripheral vestibular disorders
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An endolymph disorder causing brief, intense vertigo due to a change in head position - the otoconia within the semicircular canals become dislodged.

Confirmation of BPPV

  • Confirmed by performing the Dix-Hallpike test - before completing the test, the therapist must perform a vertebral artery test and ensure appropriate cervical range of motion is present
    • Patient positioned in long sitting, with the head turned 45 degrees toward the affected side
    • Patient is quickly lowered to supine with the head remaining at 45 degrees and hanging over the edge of the mat, while the therapist observes for nystagmus
      • Nystagmus will resolve within 30-60 seconds
      • A positive test occurs when the patient experiences nystagmus and vertigo with a head position change
    • Repeat the test on the contralateral side
Dix-Hallpike maneuver showing the patient lying supine with the head turned 45 degrees and extended off the table to assess BPPV.
Dix Hallpike
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Understanding what nystagmus means in relation to BPPV

  • Ageotropic (apogeotropic)
    • Fast beating phase of the nystagmus is moving away from the ground (towards the upper ear) - this indicates lateral canal BPPV
  • Geotropic
    • Fast beating phase of nystagmus is moving towards the ground (towards the lower ear) - this also indicates lateral canal BPPV
  • Torsional (rotary), upbeating
    • Indicates posterior canal BPPV

Differentiation of BPPV and canals impacted

Lateral canal BPPV

  • Can manifest as ageotropic or geotropic horizontal nystagmus
  • Treatment is with the log roll maneuver or barbeque roll maneuver to move the otoconia into position (performed as a home exercise program)
  • Log roll maneuver: the patient rolls sequentially from supine through a head turn toward the affected ear, a head turn away from the affected ear, and a prone position, ending back in supine toward the affected side, guiding the otoconia out of the lateral canal.
  • Barbeque roll maneuver: the patient rolls in 90-degree increments from side-lying on the affected side, through supine, to side-lying on the unaffected side, to prone, pausing at each position, and finishes by returning slowly to sitting.

Posterior canal BPPV (most common BPPV)

  • Typically presents with torsional (rotary), upbeating nystagmus
  • The Epley maneuver is performed to reposition the otoconia: the patient moves from sitting to supine with the head turned toward the affected side, then rotates the head and body through a series of positions to guide the otoconia out of the posterior canal, finishing in sitting.

Anterior canal BPPV (least common BPPV)

  • Typically presents with vertical downbeat nystagmus
  • The Yacovino maneuver is performed to reposition the otoconia: the patient moves from sitting to supine with the head extended below horizontal, then to a chin-to-chest position, and back to sitting, guiding the otoconia out of the anterior canal.
Epley maneuver illustrating the sequential head and body positions used to reposition displaced otoconia in the inner ear.
Epley maneuver
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Meniere’s disease

Definitions
Meniere’s disease
A chronic inner ear disorder with common symptoms of fullness in the ear, ringing in the ear, loss of hearing, and vertigo due to abnormal fluid buildup in the ear.

Episodes of vertigo can last from minutes to days. Due to the chronicity of the disease, management focuses on reducing the frequency of attacks and managing symptoms.

Management of symptoms

  • Low sodium diet - reduces fluid levels
  • Regular exercise - improves balance and reduces stress
  • Management of stress - stress can exacerbate an episode of vertigo
  • Diuretics - reduce fluid within the ear
  • Surgery - drains excess fluid or removes the damaged portion of the inner ear

Physical therapy management of individuals with Meniere’s disease is symptom-based, and episodes of care are short. The focus will primarily be to assist with any balance deficits or muscle weakness, provide an individualized home exercise program, and reinforce patient education.

Vestibular neuritis

Definitions
Vestibular neuritis
Inflammation of the vestibular nerve, which can be caused by viral infection, autoimmune disorders, or bacterial infections.

Symptoms include sudden onset of severe vertigo (spinning sensation), nausea and vomiting, dizziness and lightheadedness, difficulty walking, and nystagmus. Symptoms are typically sudden and improve with medical intervention over a few days.

Treatment options

  • Antibiotics for the management of infection
  • Corticosteroid medication for the management of inflammation
  • Anti-nausea medication for persistent nausea and vomiting

Acute vertigo typically subsides within days, but vestibular rehabilitation (gaze stabilization, habituation, and balance training) is recommended to address the lingering imbalance and dizziness from unilateral vestibular hypofunction. If any balance or coordination deficits continue, then physical therapy interventions will be prescribed at that time.

Labyrinthitis

Definitions
Labyrinthitis
Inflammation of the inner ear caused by viral infections, bacterial infections, autoimmune disorders, or head trauma.

Symptoms include vertigo, nausea and vomiting, balance problems, hearing loss, tinnitus (ringing in the ears), and ear pain. Most symptoms resolve within a few weeks, but some permanent hearing loss may be present.

Treatment interventions

  • Antihistamines - for treatment of vertigo symptoms
  • Anti-nausea drugs - for treatment of nausea and vomiting
  • Corticosteroids - for treatment of inflammation
  • Antibiotics - for treatment of infection

Benign paroxysmal positional vertigo (BPPV)

  • Endolymph disorder; dislodged otoconia in semicircular canals cause brief, intense vertigo with position change
  • Confirmed via Dix-Hallpike test
    • Check vertebral artery test and cervical ROM first
    • Head turned 45° toward affected side, quickly lowered to supine, hanging over mat edge
    • Positive test: nystagmus/vertigo elicited, resolves in 30-60 seconds
    • Repeat on contralateral side

Nystagmus patterns in BPPV

  • Ageotropic (apogeotropic): fast phase away from ground → lateral canal BPPV
  • Geotropic: fast phase toward ground → lateral canal BPPV
  • Torsional (rotary), upbeating → posterior canal BPPV

Differentiation of BPPV by canal

  • Lateral canal BPPV
    • Ageotropic or geotropic horizontal nystagmus
    • Treated with log roll or barbeque roll maneuver (home exercise program)
  • Posterior canal BPPV (most common)
    • Torsional, upbeating nystagmus
    • Treated with Epley maneuver
  • Anterior canal BPPV (least common)
    • Vertical downbeat nystagmus
    • Treated with Yacovino maneuver

Meniere’s disease

  • Chronic inner ear disorder: ear fullness, tinnitus, hearing loss, vertigo from abnormal fluid buildup
  • Episodes last minutes to days; management focuses on reducing attack frequency and symptoms
  • Management: low sodium diet, regular exercise, stress management, diuretics, surgery (drain fluid/remove damaged inner ear portion)
  • PT role: symptom-based, short episodes of care; address balance/weakness, home exercise program, patient education

Vestibular neuritis

  • Inflammation of vestibular nerve (viral, autoimmune, or bacterial cause)
  • Symptoms: sudden severe vertigo, nausea/vomiting, dizziness, gait difficulty, nystagmus
  • Treatment: antibiotics, corticosteroids, anti-nausea medication
  • Acute vertigo resolves in days; vestibular rehab (gaze stabilization, habituation, balance training) recommended for lingering unilateral hypofunction

Labyrinthitis

  • Inflammation of inner ear (viral, bacterial, autoimmune, or trauma-related)
  • Symptoms: vertigo, nausea/vomiting, balance issues, hearing loss, tinnitus, ear pain
  • Most symptoms resolve in weeks; permanent hearing loss possible
  • Treatment: antihistamines (vertigo), anti-nausea drugs, corticosteroids (inflammation), antibiotics (infection)

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Peripheral disorders and intervention strategies

Differential diagnosis of peripheral vestibular dysfunction with intervention strategies

Benign paroxysmal positional vertigo (BPPV)

An endolymph disorder causing brief, intense vertigo due to a change in head position - the otoconia within the semicircular canals become dislodged.

Confirmation of BPPV

  • Confirmed by performing the Dix-Hallpike test - before completing the test, the therapist must perform a vertebral artery test and ensure appropriate cervical range of motion is present
    • Patient positioned in long sitting, with the head turned 45 degrees toward the affected side
    • Patient is quickly lowered to supine with the head remaining at 45 degrees and hanging over the edge of the mat, while the therapist observes for nystagmus
      • Nystagmus will resolve within 30-60 seconds
      • A positive test occurs when the patient experiences nystagmus and vertigo with a head position change
    • Repeat the test on the contralateral side

Understanding what nystagmus means in relation to BPPV

  • Ageotropic (apogeotropic)
    • Fast beating phase of the nystagmus is moving away from the ground (towards the upper ear) - this indicates lateral canal BPPV
  • Geotropic
    • Fast beating phase of nystagmus is moving towards the ground (towards the lower ear) - this also indicates lateral canal BPPV
  • Torsional (rotary), upbeating
    • Indicates posterior canal BPPV

Differentiation of BPPV and canals impacted

Lateral canal BPPV

  • Can manifest as ageotropic or geotropic horizontal nystagmus
  • Treatment is with the log roll maneuver or barbeque roll maneuver to move the otoconia into position (performed as a home exercise program)
  • Log roll maneuver: the patient rolls sequentially from supine through a head turn toward the affected ear, a head turn away from the affected ear, and a prone position, ending back in supine toward the affected side, guiding the otoconia out of the lateral canal.
  • Barbeque roll maneuver: the patient rolls in 90-degree increments from side-lying on the affected side, through supine, to side-lying on the unaffected side, to prone, pausing at each position, and finishes by returning slowly to sitting.

Posterior canal BPPV (most common BPPV)

  • Typically presents with torsional (rotary), upbeating nystagmus
  • The Epley maneuver is performed to reposition the otoconia: the patient moves from sitting to supine with the head turned toward the affected side, then rotates the head and body through a series of positions to guide the otoconia out of the posterior canal, finishing in sitting.

Anterior canal BPPV (least common BPPV)

  • Typically presents with vertical downbeat nystagmus
  • The Yacovino maneuver is performed to reposition the otoconia: the patient moves from sitting to supine with the head extended below horizontal, then to a chin-to-chest position, and back to sitting, guiding the otoconia out of the anterior canal.

Meniere’s disease

Definitions
Meniere’s disease
A chronic inner ear disorder with common symptoms of fullness in the ear, ringing in the ear, loss of hearing, and vertigo due to abnormal fluid buildup in the ear.

Episodes of vertigo can last from minutes to days. Due to the chronicity of the disease, management focuses on reducing the frequency of attacks and managing symptoms.

Management of symptoms

  • Low sodium diet - reduces fluid levels
  • Regular exercise - improves balance and reduces stress
  • Management of stress - stress can exacerbate an episode of vertigo
  • Diuretics - reduce fluid within the ear
  • Surgery - drains excess fluid or removes the damaged portion of the inner ear

Physical therapy management of individuals with Meniere’s disease is symptom-based, and episodes of care are short. The focus will primarily be to assist with any balance deficits or muscle weakness, provide an individualized home exercise program, and reinforce patient education.

Vestibular neuritis

Definitions
Vestibular neuritis
Inflammation of the vestibular nerve, which can be caused by viral infection, autoimmune disorders, or bacterial infections.

Symptoms include sudden onset of severe vertigo (spinning sensation), nausea and vomiting, dizziness and lightheadedness, difficulty walking, and nystagmus. Symptoms are typically sudden and improve with medical intervention over a few days.

Treatment options

  • Antibiotics for the management of infection
  • Corticosteroid medication for the management of inflammation
  • Anti-nausea medication for persistent nausea and vomiting

Acute vertigo typically subsides within days, but vestibular rehabilitation (gaze stabilization, habituation, and balance training) is recommended to address the lingering imbalance and dizziness from unilateral vestibular hypofunction. If any balance or coordination deficits continue, then physical therapy interventions will be prescribed at that time.

Labyrinthitis

Definitions
Labyrinthitis
Inflammation of the inner ear caused by viral infections, bacterial infections, autoimmune disorders, or head trauma.

Symptoms include vertigo, nausea and vomiting, balance problems, hearing loss, tinnitus (ringing in the ears), and ear pain. Most symptoms resolve within a few weeks, but some permanent hearing loss may be present.

Treatment interventions

  • Antihistamines - for treatment of vertigo symptoms
  • Anti-nausea drugs - for treatment of nausea and vomiting
  • Corticosteroids - for treatment of inflammation
  • Antibiotics - for treatment of infection
Key points

Benign paroxysmal positional vertigo (BPPV)

  • Endolymph disorder; dislodged otoconia in semicircular canals cause brief, intense vertigo with position change
  • Confirmed via Dix-Hallpike test
    • Check vertebral artery test and cervical ROM first
    • Head turned 45° toward affected side, quickly lowered to supine, hanging over mat edge
    • Positive test: nystagmus/vertigo elicited, resolves in 30-60 seconds
    • Repeat on contralateral side

Nystagmus patterns in BPPV

  • Ageotropic (apogeotropic): fast phase away from ground → lateral canal BPPV
  • Geotropic: fast phase toward ground → lateral canal BPPV
  • Torsional (rotary), upbeating → posterior canal BPPV

Differentiation of BPPV by canal

  • Lateral canal BPPV
    • Ageotropic or geotropic horizontal nystagmus
    • Treated with log roll or barbeque roll maneuver (home exercise program)
  • Posterior canal BPPV (most common)
    • Torsional, upbeating nystagmus
    • Treated with Epley maneuver
  • Anterior canal BPPV (least common)
    • Vertical downbeat nystagmus
    • Treated with Yacovino maneuver

Meniere’s disease

  • Chronic inner ear disorder: ear fullness, tinnitus, hearing loss, vertigo from abnormal fluid buildup
  • Episodes last minutes to days; management focuses on reducing attack frequency and symptoms
  • Management: low sodium diet, regular exercise, stress management, diuretics, surgery (drain fluid/remove damaged inner ear portion)
  • PT role: symptom-based, short episodes of care; address balance/weakness, home exercise program, patient education

Vestibular neuritis

  • Inflammation of vestibular nerve (viral, autoimmune, or bacterial cause)
  • Symptoms: sudden severe vertigo, nausea/vomiting, dizziness, gait difficulty, nystagmus
  • Treatment: antibiotics, corticosteroids, anti-nausea medication
  • Acute vertigo resolves in days; vestibular rehab (gaze stabilization, habituation, balance training) recommended for lingering unilateral hypofunction

Labyrinthitis

  • Inflammation of inner ear (viral, bacterial, autoimmune, or trauma-related)
  • Symptoms: vertigo, nausea/vomiting, balance issues, hearing loss, tinnitus, ear pain
  • Most symptoms resolve in weeks; permanent hearing loss possible
  • Treatment: antihistamines (vertigo), anti-nausea drugs, corticosteroids (inflammation), antibiotics (infection)

More from Vestibular system

  • Anatomy, examination, and disorder classification