Is there a solely peripheral problem?
Is there a peripheral and central involvement?
Is there a central involvement alone?
Is there an impact on posture control, gait and balance?
Is there an impact on gaze stabilization, how is gaze fixation?
Is there an aphysiologic behavior?
We are able to answer nearby all these potential questions by using a highly sophisticated and logistical linked technology after a careful anamnestic history taking, of course.
Quite often we see patients with several, coupled damages in the vestibular system:
-BPPV and vestibular insufficience: unilateral (“ Lindsay-Hemenway” ) or bilateral.
-Meniere or endolymphatic hydrops with vestibular migraine.
-unilateral, partial or total peripheral vestibular loss with central involvements (ex Wallenberg…)
-Basal ganglion disorders or spinocerebellar disorders with peripheral vestibular disorders like uni- or bilateral labyrinthine insufficience.
-peripheral disorders with aphysiologic behaviors ( chronic subjective dizziness )
Our first approach to asset a patient without a valid diagnosis will be :
CDP (SOT , evt HS-SOT ) with MCT and ADT ; evt LOS ; evt LFP
SACCADES , SMOOTH PURSUIT testing
VOR and OKN ( evt OKAN )
-extend of damage : side and site ( ex VPPB ) ,partial or total ( ex Vestibular neuritis ) , systems involved (ex Meniere , superior canal dehiscence , acoustic neuroma ) , uni - or bilateral chronic vestibular insufficience
-we use alone or in combination:
-audiometric battery , Bekesy audiometry , Reflex decay , ECoG , AEP , OAE , DPOAE
- VHIT , SHA , SRT , Calorics
-c-vemp , o-vemp , SVV
-DVA , DFT
-once the exact diagnosis and impact on postural control established, elaboration of an adequate PT program.
- Sometimes medical treatment.
- Quantification of gait (LFP), postural control and balance (CDP-LOS, MCT, ADT, LFP)
- Quantification of Fall risks (LFP-Tinetti score)
- Mapping or functional imaging of the presumed sites of lesions sites of lesions by oculomotor testing:
Saccades -horizontal (PPRF , NPH )
-vertical ( MRF , riMLF , nC )
Smooth pursuit (ex SCA)
Gaze fixation nystagmus ( ex MS)
Upbeat nystagmus ( Pontomedullar brainstem )
Downbeat nystagmus ( Vestibular cerebellum )
Skew torsion (Mesencephalic brainstem )
Torsionel nystagmus ( Mesodiencephalic brainstem )
- Referral to neurologist, Medical imaging (MRI , CT scan )
-Orthoptic referral to rule out vergence disorders , heterophoria , heterotropia ( Orthoptic division MINSAN )
- Elaboration of an adequate PT program.
- Quantification of medication efficience concerning postural and gait control ( PD , PSP , MSA , CBD , DLB , Alzheimer disease , Vascular , Large fibre peripheral neuropathy , spinocerebellar atrophy , leucoaraiosis , NPH , disuse disequilibrium…)
-Quantification of medication impact on oculomotor disorders (vestibular migraine)
- in a large majority of cases we are able to state what is wrong , where it is wrong and how is the impact on the different systems involved (proprioceptive , visual ,vestibular and motor control)
-by this way we are able to elaborate an appropriate strategy of treatment ( PT and/or medical) with an almost positive outcome.
We believe that vertigo , dizziness and balance disorders should be analysed as an entity in itself, so it needs to to be explored and treated in an holoistic integrative, evidence based way.
A figured case :
Owning a car, we will need a repair shop and a mechanic as well.
Our car will be the peripheral vestibular system.
Our repair shop will be the brain , brainstem and cerebellum
Our mechanic will be a correct diagnose ,mapping and quantification of lesions , elaboration of a treatment program, quantitative control of the outcome by treatment.
If now the car is broken, we must see in our repair shop what can and what has to be done .
If our car and our repair shop are both broken, the mechanic should provide help, at least in short term thinking .
If now the mechanic is broken too … ‘ Good night’.
Dr med Jean Bausch
AEP : auditory evoked potentials
ADT: adaptation test (CDP )
BPPV : benign peripheral paroxysmal vertigo
CBD : corticobasal degeneration
CDP : computerized dynamic posturography ( SMART EQUITEST /Neurocom )
c-VEMP : colic vestibular evoked myogenic potentials
DFT: dynamic fixation test
DLb : dementia with lewy bodies
DPOAE : distortion products by optoacoustic emissions
DVA: dynamic visual acuity
HS-SOT : head shake sensory organization test ( CDP )
LFP: long force plate ( NEUROCOM /R )
LOS: limits of stability ( CDP )
MCT : motor control test (CDP )
MLF : medial longitudinal fasciculus
MS : multiple sclerosis
MSA: multiple system atrophy
MRF: mesencephalic reticular formation
nC : nucleus of cajal
NpH : normal pressure hydrocephalus
NPH : nucleus prepositus hypoglossi
OAE: Oto-acoustic emissions
OKAN: optokinetic afternystagmus
OKN: optokinetic nystagmus
o-VEMP: ocular vestibular evoked myogenic potentials
PD: Parkinson disease
PSP: Progressive supranuclear Palsy
PT : Physiotherapy
PPRF: parapontin reticular formation
SCA : spinocerebellar atrophy
SHA: slow harmonic acceleration
RST: rotational step test
riMLF : rostral interstitial nucleus of the MLF
SVV: subjective visual vertical
VHIT : video head impulse test
VNS : videonystagmoscopie
VNG : Videonystagmographie
VOG : videooculography
VOR: vestibulo-ocular reflex