Vestibular Physiotherapy in Neuro Rehab: Screening and Assessment
Vestibular Physiotherapy in Neuro Rehab: Screening and Assessment
Vestibular symptoms are common in clients with neurological conditions but often remain under-recognised. Dizziness, imbalance, blurred vision, and motion sensitivity can significantly impact function and safety for people living with neurological conditions. For allied health professionals working in neuro rehab, having the skills to screen for vestibular dysfunction is crucial. Early recognition allows for more targeted interventions, improved outcomes, falls prevention and timely referral to a specialist vestibular physio.
In this blog, we’ll cover:
- An overview of the vestibular system
- Key screening questions for vestibular dysfunction
- Formal vestibular assessment tools used in clinical practice
The Vestibular System
The vestibular system is central to balance, spatial orientation, postural control, and gaze stability. It works closely with the visual system and proprioceptive input to provide the brain with accurate sensory information about movement and body position.
When functioning normally, these systems align to maintain stability and clear vision during movement. When disrupted, clients may experience dizziness, nausea, blurred vision, nystagmus, motion sensitivity, or postural instability and falls.
A useful analogy is reading in the back of a moving car: the eyes and body sense stillness, but the vestibular system detects acceleration. This sensory mismatch explains motion sickness and mirrors many vestibular symptoms seen in neuro rehab.
Peripheral vs Central Vestibular Dysfunction
- Peripheral conditions: e.g. Benign Paroxysmal Positional Vertigo (BPPV), unilateral hypofunction, vestibular neuritis. Common symptoms include spinning vertigo, short-lived dizziness, or position-induced nystagmus.
- Central conditions: Seen in clients with brainstem/cerebellar lesions, multiple sclerosis, concussion, vestibular migraine, or degenerative conditions. Symptoms are often imbalance, blurred vision, “spaciness,” or motion sensitivity rather than true vertigo.
Vestibular Screening
Screening for vestibular dysfunction should be part of a comprehensive neuro assessment. Subjective questioning provides important diagnostic clues and guides onward referral decisions.
Key questions to ask include:
- Symptom description: Is the dizziness spinning, light-headedness, imbalance, or “rocking”?
- Onset and duration: Seconds (suggesting BPPV) vs constant (possible central causes)
- Aggravating/relieving factors: Are symptoms triggered by head movements, busy visual environments, exercise or stress? Do they improve with rest or visual fixation?
- Associated symptoms: Hearing loss, tinnitus, migraine history, nausea, palpitations, sweating, or red flags (the “5 D’s and 3 N’s”: diplopia, dysarthria, dysphagia, dysmetria, drop attacks; numbness, nystagmus, nausea/vomiting).
- Medical history: Stroke risk factors, recent infections, migraine, medications, cardiovascular disease, or mental health history.
These questions can help differentiate between vestibular dysfunction, other neurological conditions, and medical factors. If vestibular involvement is suspected, referral to a vestibular physio is recommended for further in-depth assessment and targeted intervention.
Referral to a Vestibular Physio
While neuro physios can and should perform basic vestibular screening, referral is recommended, especially when:
- Suspected acute BPPV or acute hypofunction (urgent review within a week)
- Suspected chronic hypofunction
- Suspected central vestibular dysfunction
- Severe motion sensitivity limiting participation/ADLs
- Balance deficits that aren’t responding to conventional balance rehab
- The client has complex, persistent, or unclear vestibular symptoms
Vestibular Objective Assessment
Specific vestibular assessment tools can identify impairments and guide targeted treatment. These assessments are predominantly looking for any signs of nystagmus or impaired vestibulo-ocular reflex (VOR).
- Nystagmus: rapid, repetitive, uncontrolled eye movement (vertical, horizontal, or torsiona)l. Its direction, intensity, and duration help differentiate peripheral vs central vestibular disorders (e.g. right-beat nystagmus may suggest left-sided involvement).
- VOR: an involuntary reflex that stabilises vision by moving the eyes opposite to head movement, allowing for a clear and steady view of the world. It relies on the semicircular canals and otolith organs detecting head movements and sending signals to the brain stem via the vestibular nerve and then to the eye muscles, resulting in compensatory eye movements and gaze stabilisation. Problems with the VOR can cause dizziness, blurred vision, and balance impairments.
Key vestibular tests include:
- Range of movement: following a target with eyes only (horizontal and vertical). Analyse any limited ROM or end range nystagmus
- Smooth pursuit: Track a moving object. Analyse smoothness of eye movement and ability to keep target in focus – any saccadic or cogwheel pursuit?)
- Saccades: Quick eye movements between two targets. Analyse speed/accuracy.
- Convergence: Eyes moving inward to focus on a near target as it’s brought closer to nose. Analyse distance at which double image reported or one eye deviates outwards
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- Rapid, passive head turn while client focuses on a stationary target. Analyse ability to maintain visual fixation – corrective saccades indicate impaired VOR.
- Client to focus on therapist’s nose – therapist to cover one eye then quickly switch to cover the other eye. Analyse any abnormal movements of uncovered eye e.g. vertical movement of the uncovered eye could suggest CNS involvement.
- Grasp clients head with both hands, tilt head down 30 degrees, client to maintain eye contact with therapist nose, slowly move patient’s head 30degrees to left and right while therapist moves in same direction to stay in front of patient. Analyse if eyes stay fixed on target – saccadic corrections indicate VOR impairment.
- Passive horizontal oscillation of the head for 20 secs. Post-movement nystagmus suggests unilateral peripheral vestibular hypofunction.
- Self-reported tool performing 10 different head and/or body movements to identify provocative movements and help guide habituation training.
- Gold standard for assessing posterior canal BPPV. Looks for vertigo and positional nystagmus. Remember: not all nystagmus is BPPV, central causes must also be considered.
- Assesses horizontal canal BPPV. Analyse if nystagmus and vertigo occur on both sides. Eye movement patterns help distinguish peripheral vs central causes.
Clinical Impact and Treatment Pathways
Recognition of vestibular dysfunction is essential, to ensure neuro rehab interventions are specific and targeted to optimise functional outcome.
The goals of vestibular rehab will be guided by the assessment findings, but may include improving gaze stability, postural stability, motion sensitivity, visual sensitivity, dizziness and ultimately improving activity participation and quality of life.
Reflection Questions for Clinicians
- Do confident do you feel in recognising when a client’s dizziness or reduced balance may be vestibular in origin?
- How confident are you in differentiating between peripheral and central vestibular presentations?
- What screening questions could you add to your standard neuro assessment to better identify vestibular symptoms?
- Do you have clear referral pathways to ensure clients with suspected vestibular dysfunction receive specialist assessment?
Responses