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Final Exam Material Flashcards

1
Q

3 main causes for dizziness

A
  1. otologic
  2. neurologic
  3. general medical
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2
Q

Otologic

A
  • BPPV
  • vestibular neuritis
  • superior canal dehiscence
  • meniere’s
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3
Q

Neurologic

A
  • vertibrobasilar insufficiency
  • stroke
  • migraine
  • low CSF
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4
Q

General medical

A
  • B12
  • orthostatic hypotension
  • hypoglycemia
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5
Q

Balance control

A

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

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

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6
Q

Vestibular system

A
  • semicircular canals (post, ant, lateral)
  • otolith organs
  • nerve
  • cochlea
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7
Q

Semicircular Canals

A
  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)
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8
Q

Peripheral vestibular dysfunction-causes

A
  • vestibular apparatus
  • vestibular portion of CN VIII
  • some cerebellopontine angle tumors
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9
Q

Central vestibular dysfunction-causes

A
  • vestibular nuclei
  • central pathways
  • also cerebellopontine angle tumors
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10
Q

Peripheral vestibular dysfunction categories

A
  • unilateral vs. bilateral
  • reduced vs. absent function
  • acute (BPPV) vs. Chronic (meniere’s)
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11
Q

Examples of peripheral diagnoses

A
  • 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)
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12
Q

Benign Paroxysmal Positional Vertigo (BPPV)

A
  • 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
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13
Q

BPPV epidemiology

A

Women>men

-spontaneous remissions common, but recurrences can occur

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14
Q

BPPV-cupulolithiasis

A
  • otoconial material gets stuck in canal

- disrupts cupula’s response to gravity

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15
Q

BPPV-canalithiasis

A
  • 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
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16
Q

BPPV prognosis

A
  • 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)
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17
Q

Vestibular Neuritis

A
  • 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
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18
Q

Vestibular Neuritis epidemiology and S/S

A

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
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19
Q

Vestibular neuritis management

A
  • vestibular suppressants (anavert/meclazine)
  • bedrest x 24-72 hrs
  • gradual return to functioning
  • total recovery in about 6 weeks
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20
Q

Vestibular neuritis and vestibular rehab

A
  • significantly speeds recovery
  • slowly increases ambulation
  • general conditioning
  • gaze stabilization exercises
  • facilitate central compensation
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21
Q

Meniere’s disease etiology

A
  • 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
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22
Q

Meniere’s disease S/S

A
  • 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
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23
Q

Meniere’s management

A
  • meds for vertigo (anavert/meclazine)
  • diuretics
  • middle ear injections (gentamicin, steroids, surgery)
  • no cure
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24
Q

Examples of central vestibular diagnoses

A
  • TBI
  • CVA
  • MS
  • Tumors
  • Meningitis
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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
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

Neuro II (6 decks)

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