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1

3 main causes for dizziness

1. otologic
2. neurologic
3. general medical

2

Otologic

-BPPV
-vestibular neuritis
-superior canal dehiscence
-meniere's

3

Neurologic

-vertibrobasilar insufficiency
-stroke
-migraine
-low CSF

4

General medical

-B12
-orthostatic hypotension
-hypoglycemia

5

Balance control

input (visual, rotation, gravity, pressure)
brain
output (ocular reflex, postural control)

A discrepancy bw any of these 3 systems can cause nausea and vertigo

6

Vestibular system

-semicircular canals (post, ant, lateral)
-otolith organs
-nerve
-cochlea

7

Semicircular Canals

1. Ampulla (bulbous bony opening that houses cupula)
2. Cupula (sensor/sail that houses hair cells. Directly connected to vestibular nerve)
3. Canals (orthogonal...ant, post, lateral/horizontal)

8

Peripheral vestibular dysfunction-causes

-vestibular apparatus
-vestibular portion of CN VIII
-some cerebellopontine angle tumors

9

Central vestibular dysfunction-causes

-vestibular nuclei
-central pathways
-also cerebellopontine angle tumors

10

Peripheral vestibular dysfunction categories

-unilateral vs. bilateral
-reduced vs. absent function
-acute (BPPV) vs. Chronic (meniere's)

11

Examples of peripheral diagnoses

-acoustic neuroma/other tumors
-meniere's disease
-gentamicin otolithic ablation
-local trauma
-guillan barre or MS at CN VIII root entry
-BPPV
-infection: labyrinthitis, vestibular neuritis
-perilymphatic fistula (breakage in membrane bw middle and inner ear)

12

Benign Paroxysmal Positional Vertigo (BPPV)

-most common cause of vertigo
-brief episodes of vertigo precipitated by rapid change of head posture (30sec-2mins)
-ex. every time they roll over in bed it happens

13

BPPV epidemiology

Women>men
-spontaneous remissions common, but recurrences can occur

14

BPPV-cupulolithiasis

-otoconial material gets stuck in canal
-disrupts cupula's response to gravity

15

BPPV-canalithiasis

-otoconial debris gets into a semicircular canal
-post/ant>lateral
-creates a suction moment which acts on the cupula and fluid can't continue through the canal

16

BPPV prognosis

-tends to be self limiting (6-12 mos)
-vestibular rehab can speed up recovery SIGNIFICANTLY
-antivertiginous drugs ineffective (anavert/meclazine)
-elderly respond more slowly
-if symptoms persist, MRi indicated (acoustic neuroma, cerebellar or 4th ventricle tumor)

17

Vestibular Neuritis

-second most common cause of vertigo
-swelling in vestibular area
-probable viral etiology
*similar to bell's palsy
*sometimes epidemic occurences
*upper respiratory or GI infections
-concurrent or preceded by 2 weeks

18

Vestibular Neuritis epidemiology and S/S

Primary ages: 30-60 (women-40, men-60)
-acute onset of prolonged severe rotational vertigo which increases with movement of the head (hits you all at once)
-associated with horizontal-rotatory nystagmus, postural imbalance, and nausea/vomiting
-could be unilateral or bilateral

19

Vestibular neuritis management

-vestibular suppressants (anavert/meclazine)
-bedrest x 24-72 hrs
-gradual return to functioning
-total recovery in about 6 weeks

20

Vestibular neuritis and vestibular rehab

-significantly speeds recovery
-slowly increases ambulation
-general conditioning
-gaze stabilization exercises
-facilitate central compensation

21

Meniere's disease etiology

-hereditary or sporadic
-damage to hair cell inside cupula (changes amt of vestibular info being sent to CNS from vestibular nerve)
-distension of endolymphatic system with hair cell damage

22

Meniere's disease S/S

-vestibular and AUDITORY involvement (complaints of hearing lost in 1 or both ears, sense of fullness in ears)
-vertigo usually lasts hours (preceded by ear pressure/fullness)
-change in tinnitus (ringing)
-change in hearing function

23

Meniere's management

-meds for vertigo (anavert/meclazine)
-diuretics
-middle ear injections (gentamicin, steroids, surgery)
-no cure

24

Examples of central vestibular diagnoses

-TBI
-CVA
-MS
-Tumors
-Meningitis

25

Sensation testing for vertigo issues

-could be a neuropathy issues
-part of balance
-is info coming in from the periphery accurate?
-possible rule out a central diagnosis

26

Symptom: dysequilibrium/imbalance

Central: moderate to severe

Peripheral: moderate

27

Symptom: nausea/vomiting

Central: mild-moderate

Peripheral: severe

28

Symptom: oscillopsia

Central: severe

Peripheral: mild

29

Symptom: tinnitus

Central: rare

Peripheral: may occur

30

Symptom: hearing loss

Central: rare

Peripheral: common

31

Symptom: neurologic

Central: common

Peripheral: rare

32

Symptom: nystagmus

Central: pure vertical, unchanged with fixation, no fatigability, no latency

Peripheral: mixed torsional, dampens with fixation, fatigues, latency post-maneuver

33

Duration and disease

Seconds-BPPV, TIA
Minutes-TIA, migraine
Hours-Meniere's, migraine
Days-vestibular neuritis, trauma, labyrinthine infarct

34

Nystagmus

-named by the fast phase
-composed of slow and fast movements
-involuntary movement of the eyes

35

Spontaneous nystagmus

-stationary head tests
-have pt look straight ahead
-normal=no movement
-vertical=central pathology
-horizontal=peripheral hypofunction
*L=R hypofunction
*R=L hypofunction
-repeat with fixation removed

36

Gaze holding nystagmus

-have pt follow finger 30 degrees in all directions
-nystagmus=suggests central pathology

37

Eye ROM/smooth pursuit

-use object or finger
-check vertical, horizontal
-look for smooth coordinated movement
-ask if pt has double vision (if yes, refer to neurologist)
-vertical eye movement -abnormal=central pathology

38

Convergence

-begin 2 ft away
-ask pt to focus on finger or object
-bring toward face--pupils should adduct
-may be absent in pts with PMH of cataract surgery
-abnormal test suggests central pathology

39

Saccades

-have person quickly move vision between 2 targets (finger, nose, 2 fingers)
-test horizontal and vertical
-look for correction after over or undershooting
-abnormal test suggests central pathology

40

Dynamic visual acuity

-check C-spine before doing this
-same as for static but with head motion
-tilt head 20-30 degrees
-grasp from behind and move side to side-2 complete mvts per second
-record lowest line read and compare to state
->2 line different=VOR problem
-abnormal test is peripheral or central

41

VOR

-vestibular ocular reflex

42

VOR cancellation

-pt should be able to override the vestibular ocular reflex
-abnormal test=central pathology

43

Head thrust test

-test named by direction of head mvt
-peripheral vestibular hypofunction
-+rht=R hypofunction
-+LHT=L hypofunction
-+BHT=B hypofunction

44

Head shaking test

-use room light or goggles
-pt closes eyes
-shake head 20x side to side
-have pt open eyes
-vertical nystagmus=central
-horizontal nystagmus=peripheral hypofunction
*L=R hypofunction
*R=L hypofunction

45

Dizziness can mean...

-vertigo
-motion sickness
-lightheadedness
-dysequilibrium
-compilation of one or more above

46

Vertigo

-illusion of motion
-two types-
*subjective (you feel the motion)
*objective (you see the motion)
-commonly associated with inner ear disorder

47

Motion sickness

-mismatch bw visual and vestibular systems
-commonly occurs with
*cars
*boats
*airplanes
*trains

48

Lightheadedness

-pre-syncope
-may indicate CV origin

49

Dysequilibrium

-feeling of unsteadiness
-vestibular ataxia (mismatch bw vestibular system and communication to the brain stem)

50

What diagnoses benefit most from vestibular rehab

-BPPV
-Vestibular neuritis/labrynthitis
-dysequilibrium with age
-meniere's disease (stable, surgical, less than 1 attack per month)
-central vestibular (brainstem, cerebellar)
-central (MS, PD, stroke)

51

Goals for vestibular rehab

-to optimize function
-decrease dizziness
-improve balance and the ability to walk
-decrease fear and anxiety
-prevent falls
-increase gait speed
-improve the patient's ability to perform daily activities

52

Treating BPPV

-canalithiasis
*CRT
*Brandt-Daroff Exercises
-cupulolithiasis
*liberatory maneuver
-habituation exercises
-general conditioning

53

Treating vesitbular hypofunction

-vertiginous position adaptation training
*used to assist restoring gaze stability
*trains the VOR to work with CNS oculomotors
-habituation training
*helps desensitize the patient to positions/movements
*gaze stabilization exercises
-static/dynamic balance training
-substitution or compensation (if 1 system is working, develop the other 2)

54

Adaptation

-aka habituation activities
-ocular stabilization exercises
-brandt/daroff exercises (also working to resolve the problem of canlithiasis in BPPV)
-vertiginous positions
-general conditioning

55

Substitution or compensation

-working toward dependence on another sensory system and/or assistive device
-use of visual cues
-use of somatosensory cues

56

Vestibular examination progression

1. Central
*rule out
*if undiagnosed, unexplained, or new onset, refer out
2. Peripheral
*vertebrobasilar artery insufficiency
*vestibular
3. Cervical
*whiplash or cervical vertigo

57

Cervicogenic Dizziness

-diagnosis of exclusion
-consider cervical origin
*trauma
*pain
*chronic posturing

58

Cervicogenic Dizzinss Evaluation

-history of acute cervial/head trauma
*R/O upper cervical hypermobility
*onset: immediate vs. delayed
*stage, irritability, nature, symptom severity

-observation
*willingness to move
*motor control (ataxia, UMN signs)
*mental state
*gait (balance and fall risk)
*other signs of trauma

59

Differentiating capital vs. cervical involvement- HEAD STILL, NECK MOVES

-rotate body underneath head, stabilize head in space
-positive reproduction of symptoms-neck is positive, head is unknown (cannot r/o vestibular)
-negative reproduction of symptoms-neck involvement is not suspected, head is uknown

60

Differentiating capital vs. cervical involvement-NECK STILL, HEAD AND NECK MOVE EN BLOC

-rotate head and neck together
-positive reproduction of symptoms--head is positive, suspect vestibular involvement, neck is unknown
-negative reproduction of symptoms--head/vestibular not suspected, neck is unknown

61

Cervicogenic Intervention

-manual intervention to the cervical spine
*treat jt restrictions
*passive physiologic intervertebral movement
*segmental mobility testing and accessory mobilization
-treat soft tissue restrictions
-balance and postural training
-vestibulo-ocular reflex (VOR) exercises

62

Four square step test-populations

-geriatric
-vestibular
-transtibial amputees
-stroke

63

Four square step test-cut offs and test

-tests dynamic balance and ability to change direction
-older adults/geriatric=>15 at risk for multiple falls
-vetibluar=>12 sec
-tt amputees=>24 sec
-acute stroke=failed attempt or >15 sec
-MCID not established

64

Balance evaluation systems test (BESTest)-population

-balance
-cerebellar infarct
-parkinson's
-peripheral neuropathy
-vestibular

65

BESTest-categories

-grouped into 6 systems
-biomechanical constraints
-stability limits, anticipatory postural adjustments, postural responses, stability in gait

66

BESTest-scoring

-score of 108 points total, calculated into a percentage score (0-100%)
-MCID not established
-69% differentiates fallers from non-fallers (greater than 69 is no risk for falls, and vice versa)

67

Motion sensitivity test-population

-community dwelling individuals with complaints of motion provoked dizziness during routine ADLs
-geriatrics
-TBI
-vestibular

68

Motion sensitivity test

-different head/body movements
-duration of dizziness is recorded with stop watch (1 pt for 5-10sec, 2 for 11-30, 3 for >30)
-subject asked to rate dizziness on 0-5 scale

69

Motion sensitivity test-scoring

-no MCID
-0-10% mild
-11-30% moderate
31-100% severe

70

Bucket test-pt population

-unilateral vestibular hypofunction
-BPPV
-cervicogenic headache

71

Bucket test scoring

-unilateral vestibular weakness and BPPV-1.3 degrees on normal side for those<50

72

Dizziness handicap inventory-pt population

-vestibular
-BPPV
-individuals with dizziness
-MS
-brain injury
-geriatrics

73

Dizziness handicap inventory-test

-25 items
-self report questionnaire
-three domains: functional, emotional, physical
-max score of 100

74

Dizziness handicap inventory-scoring

-higher score=greater perceived handicap due to dizziness
-MCID=vestibular=18 pts
-mild-0-30
-mod-31-60
-severe 61-100

75

Activities-specific balance confidence scale (ABC)-pt population

-elderly
-Ms
-parkinson's
-stroke
-unilateral TT amputation
-vestibular

76

ABC-test

-16 item self report
-balance confidence with different activities
-items rated from 0-100

77

ABC-scoring

0=no confidence
100=complete confidence
-<67% indicates risk for falling, can accurately classify people who fall 84% of the time

78

TBI and dizziness

-15-78% of head traumas cause dizziness
-32-61% of patients with TBI have abnormal vestibular testing
-88% show at least one vestibular deficit
-61% recieved diagnosis of BPPV

79

Causes of TBI dizziness

-lesions of peripheral vestibular system
-BPPV
-perilymphatic fistula
-labyrinthine conussion
-lesions of central vestibular system
-brainstem concussion/post-concussive syndrome
-cerebellar contusion

80

Why concerned about TBI and dizziness?

-dizziness may be the underlying cause of the TBI
-dizziness may complicate rehab
-dizziness may mimic cognitive impairments
-cognitive impairments due to TBI may complicate vestibular rehab

81

Strategies for dizziness in a TBI patient

-reduce confusion
-improve motivation
-encourage consistency of performance
-improve attention
-improve problem solving
-encourage declarative as well as procedural learning
-seek moderate level of arousal
-provide increased supervision
-progress may be slower