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 WHAT WE BELIEVE IN MATTER OF VERTIGO, DIZZINESS, GAIT AND POSTURAL CONTROL : A SHORT INTRODUCTION

 

We approach the patient in a holoistic integrated way.

 

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 :

         VNS,VNG,VOG

          CDP (SOT , evt HS-SOT ) with MCT and ADT ;  evt LOS ; evt LFP

           SACCADES  , SMOOTH PURSUIT testing

           VOR and OKN ( evt OKAN )

 

The disorder is peripheral:

 

-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.

 

The disorder is central:

 

 - 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)

 

The disorder is peripheral and central:

 

- 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 

 

Abreviations:

 

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

ECoG: electrocochleography

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

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