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Specialized Knowledge and Skills in Adult Vestibular Rehabilitation for Occupational Therapy Practice
03/11/20

Introduction

People with impairments of the vestibular system often have subtle problems that have profound ramifications for their ability to engage in daily life tasks and activities at home and to participate in society outside the home. Vestibular impairment often restricts an individual’s ability to participate in everyday occupations, affecting not only that individual but also significant others, including family members, friends, coworkers, and caregivers. Occupational therapy facilitates increased independence in daily life tasks and participation in work and social occupations. For these reasons, occupational therapy is an appropriate intervention for clients needing vestibular rehabilitation to decrease symptoms and increase independence in all aspects of their lives. Thus, vestibular rehabilitation is within the scope of practice for occupational therapists and occupational therapy assistants1 who have specialized knowledge and skills in this area. This document provides an understanding of the essential knowledge and skills needed by practitioners working with individuals with vestibular impairments and will be of interest to payers, practitioners, or consumers who wish to know more about occupational therapy practice using vestibular rehabilitation techniques.

People with vestibular disorders may present with symptoms including vertigo, oscillopsia, nausea, disequilibrium, spatial disorientation, visual motion sensitivity, decreased dynamic visual acuity, decreased concentration, and decreased skill in dual task performance. Spatial orientation deficits and disequilibrium may be manifested as head and body tilt while sitting or standing, perception of tilt while sitting or standing, veering or drifting to the side while walking or steering a vehicle, or a sense of not knowing which way is up. These problems may result in fear of falling. These symptoms may affect occupational performance and can result in social withdrawal and depression. For example, visual motion sensitivity may cause disequilibrium, vertigo, nausea and disorientation, leading to slower or more awkward performance of self-care skills, decreased participation in social activities, and decreased ability to perform home management tasks outside of the home, such as grocery shopping. Vertigo, disequilibrium, and other symptoms may interfere with job skills as they cause difficulty standing, reaching, walking, turning the head to scan the environment, or making social gestures with the head such as nodding.

Definition

The term vestibular rehabilitation refers to intervention to decrease symptoms and increase independence, safety, and participation in people with specific disorders of the peripheral vestibular apparatus, the central vestibular pathways, and age-related disequilibrium. Interventions include, but are not limited to, exercise and activity programs to reduce vertigo and oscillopsia, repositioning interventions for positional vertigo, exercises and activities to improve standing and walking balance during activities, and safety training at home and at work. A client receiving occupational therapy including vestibular rehabilitation techniques may also receive occupational therapy using other interventions. For example, a client with a head injury may also receive perceptual, motor, or life skills training. Vestibular rehabilitation is used to treat the sequelae of specific medical conditions, and provides an alternative or adjunct to pharmacologic and surgical intervention by the physician. Clients who receive vestibular rehabilitation have specific medical conditions that can be demonstrated with objective diagnostic tests or otherwise medically determined. Most people who are referred for vestibular rehabilitation are adults. They have a wide variety of health conditions including, but not limited to, benign paroxysmal positional vertigo (BPPV); acute, chronic, and recurrent labyrinthitis; vestibular neuronitis; some autoimmune disorders; postconcussion vertigo; postoperative vertigo; Ménierè’s disease; bilateral vestibular weakness or total vestibular loss due to ototoxicity; presbystasis or disequilibrium of aging; some cases of strokes, some cases of multiple sclerosis, some cases of Parkinson’s disease, some Parkinsonian syndromes, and some cases of migraine.

Although the focus of this document is on adult vestibular rehabilitation, we note that the same or similar vestibular impairments may occur in children. The literature has few papers on the efficacy of vestibular rehabilitation in children. These disorders are difficult to diagnose because children may not be able to describe their symptoms and because, for technical reasons, young children cannot always be tested with standard objective diagnostic tests. Vestibular disorders that occur in childhood that may respond to vestibular rehabilitation include childhood paroxysmal vertigo, which may be related to migraine; BPPV; labyrinthitis; vestibular neuronitis; bilateral impairment due to ototoxicity; some autoimmune disorders; and congenital malformations of the inner ear. In pediatric vestibular rehabilitation, treatment activities must be age appropriate.

Knowledge and Skills for Entry-Level and Advanced Practitioners

Clients with vestibular disorders have a complex combination of physiological and psychological problems. The effects of vestibular impairments are subtle and pervasive. Many people with these problems are not able to describe the sensations they have or the motions that elicit vertigo or disequilibrium. Therefore, rehabilitation of most individuals with vestibular impairments requires skills beyond entry-level competence. The specialized nature of this intervention requires specific, advanced-level knowledge. Intervention may require specific techniques that focus directly on the vestibular impairment. Advanced skills build on earlier competencies in knowledge, performance, critical reasoning, interpersonal abilities, and ethical reasoning and additional competencies developed during independent study of the literature, continuing education coursework, and additional practice. An in-depth understanding of the structure and function of the vestibular system, visual/vestibular/proprioceptive interactions, and the principles of motor control is essential when providing vestibular rehabilitation. Occupational therapy entry-level education provides a foundation in functional anatomy, neuroscience, and motor control that assists the practitioner in understanding the types of complex problems experienced by clients with vestibular impairments. Practitioners need further training, however, to address the subtle problems of clients with these disorders. Advancedlevel skills are necessary for evaluation of the deficits and specific manipulations that alter vestibular function. This knowledge and these skills are not provided to occupational therapists at the entry level. Appendix 1 outlines the basic science knowledge necessary for advanced practice. Occupational therapists use knowledge of vestibular system anatomy and physiology when determining underlying problems that affect occupational performance. An individual’s central nervous system uses information about head movement to help control four classes of behavior: (a) postural reflexes for control of balance, (b) vestibulo-ocular reflexes to stabilize gaze so the individual can see clearly, (c) coding of spatial coordinates for object orientation and navigation, and (d) some autonomic responses to prepare for “fight-or-flight” behavior. Appendix 2 outlines the applied science knowledge necessary for advanced practice.

The occupational therapist must be highly skilled at evaluating the consequences of subtle vestibular deficits, such as balance disturbances due to head movements while sitting, standing, walking, reaching, and performing transfers between positions.

Understanding the potential impact of vestibular impairment on participation in healthy occupations requires knowledge of the effect of vestibular impairment on the life of the person. See Appendices 3–8 for specific examples of how vestibular impairments impact performance in occupation (AOTA, 2002). Refined skills in activity analysis are essential for evaluation of and intervention planning for these clients. The occupational therapist uses knowledge of body structure and function in conjunction with observation and activity analysis when evaluating subtle decrements in performance during typical daily activities. At the entry level, occupational therapists and occupational therapy assistants are familiar with the location of the vestibular labyrinth and know that the symptoms of vestibular disorders include vertigo, poor balance, and fear of falling. Their use of the occupational profile helps to determine which tasks elicit those symptoms. They are able to determine if clients would benefit from adaptive safety equipment; to recommend equipment appropriate for the home; and to educate clients about other safety concerns, such as appropriate clothing and shoes.

They also are able to evaluate many activities of daily living directly to determine if training is needed and provide training when necessary. Appendix 9 outlines the essential evaluation skills for the advanced practitioner. Appendix 10 outlines specific information on intervention using vestibular rehabilitation methods. Occupation therapy practitioners who do vestibular rehabilitation may seek reimbursement through Medicare and other third-party payers. Examples of possible Current Procedural Technology (CPT) codes include, but are not limited to, codes for neuromuscular reeducation of movement, balance, coordination, and/or posture for sitting and/ or standing activities (97112); manual therapy (97140); and therapeutic activities to improve functional performance (97530) (American Medical Association, 2006).

The occupational therapist assumes the ultimate responsibility for the delivery of occupational therapy services, including evaluation of the person and development of the intervention plan. The advanced occupational therapist may delegate certain selected interventions to an entry-level occupational therapist or to an occupational therapy assistant who has demonstrated service competency in those interventions. All practitioners should know when and how to refer clients to other health professionals when needed, including but not limited to: specialty physicians, certified driving rehabilitation specialists, psychologists, physical therapists, audiologists, and social workers.

Brief Review of the Research Literature

Vestibular rehabilitation in occupational therapy practice is supported by the literature, although considerable research remains to be done. This section is not an exhaustive review of the research but gives an overview of the research on vestibular impairment and vestibular rehabilitation that is relevant to occupational therapy. Suggested readings not cited here are listed in the “Additional Reading” list.

In the first paper describing the use of exercises for vertigo, Cawthorne (1944) indicated that some patients with postconcussion vertigo are rendered “helpless and immobile,” preceding later work by occupational therapists and their collaborators showing that patients with disorders that cause vertigo have significantly reduced independence in activities of daily living (Cohen, 1992; Cohen, Ewell, & Jenkins, 1995; Cohen & Jerabek, 1999; Cohen & Kimball, 2000; Cohen, Kimball, & Adams, 2000; Cohen, Wells, Kimball, & Owsley, 2003; Farber, 1989; Morris, 1991).

In Cooksey’s first paper describing vestibular rehabilitation exercises (Cooksey, 1945), he mentioned the need for teamwork by rehabilitation staff, including occupational therapists. Cooksey specifically noted the role of occupational therapy in the early resumption of purposeful activity. In his 1946 paper, Cooksey indicated that purposeful activity should be incorporated into the daily exercise program for these patients. Structured, purposeful activity is an effective treatment modality for reducing vertigo, improving balance, and increasing independence in activities of daily living (Cohen, Kane-Wineland, Miller, & Hatfield, 1995; Cohen, Miller, Kane-Wineland, & Hatfield, 1995). Vertigo habituation exercises are also effective in decreasing symptoms, improving spatial orientation skills, and increasing independence and ability to perform purposeful activity that involves repetitive head movements (Cohen & Kimball, 2002, 2003, 2004b, 2004c). Thus, exercises and purposeful activities may be components of a successful rehabilitation program for many patients with vertigo. For a critical review of more recent studies on vertigo habituation treatments and other issues, see Cohen’s 2006 review paper.

A series of studies has shown that patients with vestibular disorders also have high rates of anxiety and other psychosocial problems (Eagger, Luxon, Davies, Coelho, & Ron, 1992; Yardley & Hallam, 1996; Yardley, Luxon, & Haacke, 1994; Yardley & Putman, 1992). Many of these kinds of problems might be appropriate for intervention by occupational therapists, combining our understanding of physical and psychosocial disorders. Patients with benign paroxysmal positional vertigo are best treated with passive maneuvers of the head that are thought to reposition otoconial particles that have become displaced from one compartment to another. Occupational therapists and their collaborators have been in the forefront of investigators showing that these repositioning maneuvers are effective treatments (Cohen & Jerabek, 1999; Cohen and Kimball, 2004a, 2005; Macias, Lambert, Massingale, Ellensohn, & Fritz, 2000; Steenerson & Cronin, 1996; Steenerson, Cronin, & Marback, 2005).

Appendixes

The following Appendixes outline the basic knowledge needed to understand and treat vestibular disorders, the effects of vestibular disorders on occupational performance, and the types of interventions occupational therapists use. The appendices are not exhaustive. Further knowledge of specific conditions may be needed in some circumstances, particularly when clients have more than one diagnosis or health condition. Also, by the nature of growth in clinical skills, the division between entry-level and advanced knowledge is somewhat fluid as the practitioner learns more and advances in clinical knowledge and skill. Furthermore, the knowledge base listed here is not absolute. Research in basic and applied science continues to expand the available knowledge base. Therefore, practitioners continue to read the literature, attend continuing education courses, and otherwise engage in activities to maintain and improve their knowledge and understanding of intervention in this area, to support their evidence-based practice. Vestibular disorders decrease the ability to be independent in many activities of daily living. In general, tasks that require rapid or repeated head movements, tasks that require good postural control especially while standing or walking, and tasks that require good spatial orientation may be affected. Clients who have fallen or who are at risk for falls may severely restrict their movements and may actually increase their risk of falling as a result.

These people often cease participation in exercise programs for strengthening, cardiovascular conditioning, weight loss, or bone health. In a few rare instances, avoiding motions or positions that elicit vertigo may even mean delaying necessary surgical The American Journal of Occupational Therapy 671 Downloaded from http://ajot.aota.org on 02/12/2020 Terms of use: http://AOTA.org/terms procedures due to potential discomfort during postoperative bed rest. Clients with vestibular impairments often require more time to complete routine self-care skills. They may need to adapt the environment for safety or change the way in which they perform some tasks (e.g., to sit rather than stand or to hold an object for safety while standing). They may need to reduce the amount of extraneous stimulation in the environment during task performance since divided attention becomes more difficult, so they may require reduced noise, less visual clutter, or fewer tasks requiring simultaneous attention. Therefore, they may become less efficient when performing tasks.

Many clients deliberately constrain their lives, becoming less active within and outside the home. So, they may abandon activities that they consider to be nonessential and reduce their participation in essential tasks. Many people stop driving or drive only within their neighborhoods and avoid highway driving. They may even change jobs to reduce travel or to avoid other job-related requirements that elicit vertigo or disequilibrium.

Many people with vestibular disorders stop socializing or attending worship services because they are embarrassed by their ataxic gaits and do not want to give the appearance of intoxication. Some clients, who have vertigo when they bow during required prayers or who are unable to kneel while praying, may feel spiritually bereft. These problems can affect relationships with family, friends, and coworkers. Even the most understanding spouses may become upset when intimate sexual activity is interrupted by vertigo, quiet time together while taking a walk is made unpleasant due to repeated stumbling or drifting back and forth, and the affected individual may no longer be able to participate in shared sports or other exercise activities.

See Appendixes 3–8 for further examples. Specific evaluation and intervention skills are used in vestibular rehabilitation. The occupational therapy practitioner who works in this specialty must be familiar with the evaluation skills in Appendix 9 and the intervention skills in Appendix 10.

 

Appendix 1. Basic Science Knowledge for Vestibular Rehabilitation

Detailed knowledge of the structure of the ear and vestibular labyrinth, including semicircular canals, otoliths, and vestibular nerve Detailed knowledge of the physiology of the vestibular labyrinth, including basic understanding of the inertial mechanisms of the semicircular canals and otoliths Understanding of central vestibular projections, including vestibular nuclei, vestibulocerebellar projections, vestibulospinal projections, vestibulo-ocular projections, and vestibulocortical projections Understanding of multisensory interactions, including visual, vestibular, haptic, and proprioceptive Understanding of vestibulo-autonomic interactions Manifestations of the vestibular influence on postural control (e.g., vestibulopostural responses) Manifestations of vestibuloocular control (e.g., vestibuloocular reflex) Understanding of other eye movements and oculomotor responses: saccades, smooth pursuit, optokinetic responses, fixation/ suppression, and interaction of vestibulo-ocular reflex with other eye movements Manifestations of vestibular influence on spatial orientation: vertical orientation and path integration Manifestations of vestibulo-autonomic responses.

Appendix 2. Applied Science Knowledge for Vestibular Rehabilitation

Familiarity with symptoms of vestibular disorders: vertigo and oscillopsia, balance deficits, path integration impairments, autonomic signs, cognitive problems, psychosocial problems, hearing loss, and auditory/perceptual illusions on rare occasions Familiarity with principles of objective diagnostic tests: low-frequency sinusoidal tests of the vestibuloocular reflex, bithermal caloric tests, vestibular-evoked myogenic potentials, Dix-Hallpike and side-lying tests, and computerized dynamic posturography. Advanced practitioners should be familiar with the standard techniques for recording eye movements, including electrooculography/electronystagmography, and infrared videooculography. Advanced practitioners should also be familiar with related oculomotor tests and auditory screening tests. Familiarity with peripheral vestibular disorders: Labyrinthitis/vestibular neuronitis; acute, self-limiting, recurrent, and chronic benign paroxysmal positional vertigo, Ménierè’s disease, perilymph fistula, acoustic neuroma, Tullio’s phenomenon, ototoxicity, and other causes of bilateral vestibular impairment Familiarity with central vestibular disorders: presbystasis, cerebellopontine angle tumor, Arnold Chiari malformation, medulloblastoma, migraine, multiple sclerosis, Parkinson’s disease and the Parkinsonian syndromes, lateral medullary syndrome and other cerebrovascular accidents, traumatic brain injury, and vertebrobasilar insufficiency Familiarity with systemic disorders: diabetes, autoimmune disorders, especially those causing connective tissue disorders Understanding of relevant physician subspecialties: otology/neurotology and otoneurology Understanding of cognitive strategies and problems in dual- and multitask performance

Appendix 3. Examples of Impact on Activities of Daily Living

Eating: leaning across a table to pass something

Bathing: bending to reach the legs, feet, perineal area, closing eyes to wash hair

Toileting: bending to wipe, bending to pull garments up or down, maintaining balance while standing to urinate (males), twisting to reach toilet paper if behind toilet

Transferring: sit-to-stand transfers from toilet, other seats

Grooming and hygiene: bending the head forward to groom hair or brush teeth

Taking medication: bending the head back to swallow medication

Sexual activity: being in the superior position and weight shifting or moving the head rapidly; stability on water bed or other positioning furniture

Sleep: head movements during sleep, changing sleeping positions, or maintaining the head in certain positions during sleep will elicit vertigo and cause waking, possibly nausea, and disequilibrium while groggy

Instrumental Activities of Daily Living Meal preparation, cleaning, other home management skills: Bending down, looking into high or low cabinets or shelves, and tasks that require repetitive head movements may all elicit symptoms. Task performance may be compromised or the task may be abandoned altogether.

Gardening, yard work: Tasks may be performed less efficiently or abandoned; falls may occur on uneven ground. Vehicle care: Car washing and changing oil and filters may be difficult or impossible. Child, elder, and pet care: tasks that involve picking up and carrying loads, bending rapidly, performing or assisting in transfers, diaper changing, cleaning up messes on floor

Community mobility: Driving will be more difficult, especially under conditions of reduced visibility, and may be abandoned or performed only for limited errands.

Shopping: Navigating stores, carrying packages, bending to pick up items, scanning shelves for items will be more difficult and may be abandoned.

Safety: ascending/descending fire escapes and stairs, dim areas with only emergency lighting

Play, leisure, social participation, religious activities: Visual motion sensitivity, difficulty kneeling, navigating in crowds, vertigo elicited by repetitive head movements or bending the head down; activities and rituals may be severely restricted or abandoned.

Appendix 4. Examples of Performance Skills Affected by Vestibular Impairments

Posture: Standing balance is impaired in most people with vestibular impairments. People may tilt the head and/or body off the vertical. They may have difficulty attaining and maintaining upright standing. This skill is particularly difficult when visual cues are absent or decreased. Static head and trunk posture while seated are sometimes impaired; dynamic sitting balance may also be impaired.

Mobility: Mobility skills are manifested as veering toward one side while walking, ataxic gait, and falling or stumbling, particularly on uneven surfaces. Load compensation skills are impaired. Clients may need to use light touch to improve orientation and stability.

Coordination: Dual-task performance skill is decreased.

Energy: Routine tasks take more energy than usual, and endurance is decreased.

Work, either paid employment or volunteer jobs: Symptoms elicited by a wide range of tasks will cause reduced efficiency and sometimes total inability to perform some jobs, depending on task demands.

Appendix 5. Examples of Performance Patterns Affected by Vestibular Impairments

Habits: Skill components of habits may be disrupted, and performance efficiency may be reduced, increasing the cognitive load and increasing the difficulty of performing habitual skills that were previously easy to perform (e.g., basic activities of daily living may have to be performed with modifications).

Routines: Due to effects on performance skills, routines are less efficient and may need to be changed or abandoned altogether (e.g., hair washing may require supervision for safety and may take too long in the morning before work, so the client’s morning and evening routines may be changed).

Roles: Some roles may be reduced or even abandoned, with consequent detrimental economic and psychosocial effects (e.g., clients with Ménierè’s disease may have to leave their jobs).

Appendix 6. Examples of Context Affected by Vestibular Impairments

Physical: The physical environment may require modifications for safety (e.g., installing bathroom grab bars), or the home environment may require significant change (e.g., removing throw rugs, changing lighting patterns).

Social: Misunderstanding of symptoms and problems by family, friends, and significant others may lead to hard feelings, reduced participation in socialization, changes in preferred social environments. These problems may occur due to decreased self-confidence, fear of falling, and a history of falls.

Spiritual: Falls, vertigo, decreased concentration, and decreased ability in dual task performance, which all lead to decreased performance in vocational and vocational activities and decreased participation in the community, can cause decreased sense of self-worth, self-doubt, and decreased joy in life.

Virtual: Visual motion sensitivity may lead to avoidance of virtual environments.

Appendix 7. Examples of Activity Demands Affected by Vestibular Impairments

Timing: Tasks may take longer than before. Space demands: Lighting, flooring, and support surfaces may have to be changed.

Social demands: Reduced social interaction per task may be required due to reduced tolerance for auditory and visual noise.

Required bodily functions: Reduced function of vestibulo-ocular reflex, vestibulospinal reflex, and reduced spatial orientation skills all affect functional performance.

Appendix 8. Examples of Client Factors Affected by Vestibular Impairments

Mental functions: reduced attention skills, reduced ability for dual task performance

Sensory functions: reduced vestibular function, sometimes reduced auditory function Neuromuscular functions: reduced postural control, reduced dynamic visual acuity, impaired gait

Vestibular labyrinth: In some instances, structural abnormalities in the physical labyrinth may be present, but these features cannot be observed; they may only be inferred.

Appendix 9. Occupational Therapy Evaluation Skills for Vestibular Rehabilitation

Detailed occupational and health histories relevant to symptoms Objective clinical tests involving the vestibuloocular reflex head thrusts, Dix-Hallpike and sidelying maneuvers, and other tests of positional vertigo in lateral and anterior canals Tests of path integration skill Oculomotor tests: saccades, pursuit, optokinetic nystagmus, vergence, visual/vestibuloocular reflex interaction, evaluation of spontaneous nystagmus Standardized and nonstandardized tests of standing and walking balance, including Clinical Test of Sensory Organization on Balance, Functional Reach, Berg Balance Scale, Get Up and Go/ Timed Up and Go, Dynamic Gait Index, expert observation of other gait and balance skills including stair climbing, subtle gait deficits, and weight shifting deficits Qualitative self-evaluations of ADL independence: Activities-Specific Balance Confidence scale, Dizziness Handicap Inventory, and Vestibular Disorders Activities of Daily Living scale Tests of dynamic visual acuity and oscillopsia Measures to evaluate vertigo: head shaking, repetitive activities Cognitive and psychosocial assessments: qualitative assessments and self-report on scales Evaluation of independence in activities of daily living, including subtle changes and problems Home, work, and driving safety

Appendix 10. Occupational Therapy Intervention Skills for Vestibular Rehabilitation

Repositioning treatments for benign paroxysmal positional vertigo, including canalith repositioning, liberatory maneuvers, log-rolling maneuvers, Brandt Daroff exercises, other repositioning exercises and activities Vertigo habituation exercises and activity programs Gaze stabilization exercises and activities, including eye–head coordination tasks

Balance therapy: exercises and activities for “static” standing, weight shifting, and balance control; exercises and activities for “dynamic” balance control during translation through space, leading to independence in dual task performance and safety during obstacle avoidance tasks Home and work safety, including environmental modifications for lighting, flooring, modification of work area Training in mobility skills on the bed; transfers to and from the floor, in the home, and in the external environment for falls prevention (e.g., use of a ladder, elevator, escalator, stairs, opening door, transfers to and from automobile, and functional mobility through visually challenging environments and environments with challenging support surfaces) Knowledge of community and online resources for patient information Patient education about condition, symptoms Specific to Ménierè’s disease patients: in coordination with nursing, work on meal-planning skills if dietary restriction is recommended by the physician In coordination with audiology, for patients with hearing loss recommend communication and functional devices for telephone, alarm clock, and other devices for which sound is important; recommendations for modification of work and other tasks, as needed, for hearing loss Recommendation of assistive devices for balance and safety during standing, walking, carrying objects, and other activities of daily living Task modification to reduce cognitive load during dual- and multitask performance; dual-task performance training

Glossary

Benign paroxysmal positional vertigo
A common disorder of the vestibular system characterized by vertigo elicited by head movements in the pitch plane and characterized by a positive response on the Dix–Hallpike maneuver.
Disequilibrium
Poor balance.
Labyrinthitis
Inflammation or disease of the vestibular labyrinth of the inner ear.
Ménière’s disease
A disorder of the inner ear affecting both the auditory and vestibular systems. It is characterized by sensorineural hearing loss on at least one occasion, two or more spontaneous episodes of vertigo lasting at least 20 minutes, and tinnitus or aural fullness in the affected ear. Nystagmus is present during an attack (Committee on Hearing and Equilibrium, American Academy of Otolaryngology—Head and Neck Surgery, 1995).
Neurotologist
An otolaryngologist who specializes in ear and inner-ear disorders, including vestibular disorders.
Nystagmus
A stereotyped combination of repetitive slow- and fast-phase eye movements. The slow phase, usually difficult to observe with the naked eye, represents compensatory vestibulo-ocular or optokinetic responses; the fast phase represents rapid saccades that reset the position of the globe in the eye socket.
Optokinetic responses
Conjugate eye movements used to follow a full-field moving visual stimulus (i.e., when the entire visual scene moves around the person).
Oscillopsia
The illusion of object motion during head movement.
Otolaryngologist
A physician who specializes in ear, nose, and throat disorders.
Otoneurologist
A neurologist who specializes in vestibular and auditory disorders.
Presbystasis
Disequilibrium of aging. This diagnosis excludes known causes of balance problems, such as central neurologic conditions, peripheral vestibular impairments, or peripheral neuropathies that affect the lower extremities (e.g., diabetic neuropathies).
Pursuit
Also known as smooth pursuit. Conjugate eye movements are used to follow a discreet moving visual stimulus.
Saccades
Conjugate eye movements in which the eyes move for one of three reasons: (1) as the quick phase of nystagmus, to reset the position of the globe in the eye socket, (2) for gaze error correction (i.e., to catch up with a visual stimulus that is moving too fast for pursuit movements), and (3) volitional movements to look around a stationary visual environment. Saccades are the only volitional eye movements that we are able to generate. (You are using saccades to read this page.)
Spatial orientation
Awareness of one’s position relative to gravity and the environment.
Vergence
Disconjugate eye movements used to make the eyes move toward or away from each other, in order to focus on an object.
Vertigo
The illusion of self-motion (e.g., spinning or falling).
Vestibular rehabilitation
The use of activities and exercise to treat vertigo, balance problems, functional limitations, and disability caused by impairments in the vestibular system.
Vestibular system
The sensory system with receptors in the vestibular labyrinth of the inner ear. It detects head motion and contributes to control of posture, eye movements, and spatial orientation. The brain pathways include the vestibular portion of Cranial Nerve VIII; the vestibular nuclei; the parts of the cerebellum that receive and process vestibular signals; the projections from the vestibular nuclei that descend in the spinal cord via the vestibulospinal tracts; the projections from the vestibular nuclei that ascend in the medial longitudinal fasciculus to Cranial Nerves III, IV, and VI to control the vestibulo-ocular reflex; and the smaller projections that ascend from the vestibular nuclei to the thalamus and related nuclei with further small projections to the vestibular cortex.
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