1. Dix Hallpike if negative, 2. roll test if negative, 3. side lying test

Lab 1: BPPV exam Flashcards by Rebecca Nam

Of vestibular PT issues, what percent is BPPV?

21%

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what is the second most common complaint in Dr. offices?

Dizziness
70% will have dizziness in USA population at sometime in their lives

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when does peripheral spontaneous nystagmus occur? Fixation/nonfixation

fixation in room light DECREASES nystagmus
*Frenzels: cannot fixate, so nystagmus appears

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oculomotor issues indicate:

central involvement
CN issues (3, 4, 6)

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oculomotor issues to screen:

ocular alignment: vertical skew deviation
vertical skew deviation (alternate cover test)
smooth pursuits
saccades
vergence
ocular ROM
GEN
spontaneous nystagmus

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What are the HINTS exam components and when to perform?

When: constant ongoing vertigo w/ spontaneous nystagmus, diagnose vestibular neuritis and rule OUT stroke

components:
Head impulse test
nystagmus
test of skew

used to determine peripheral: vestibular neuritis OR CENTRAL (stroke)

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results of HINTS for peripheral vertigo:

+ HIT: loss of eye fixation with head impulse, positive HIT
- N: no nystagmus or horizontal/unidirectional
- TS: no skew

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central vertigo HINTS exam results:

HIT: intact VOR
+ nystagmus: vertical, rotatory, horizontal bidirectional
+ TS: positive skew

stroke!

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CONTRAS for cervical position provocation testing

hx of neck surgery
recent neck trauma
severe RA
AO or OA instability
cervical myelopathy
cervical radiculopathy
carotid sinus syncope
chiari malformation
vascular dissection syndromes

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5Ds and 3 Ns

dizziness, drop attacks, dysarthria, dysphagia, diplopia

nausea, numbness/tingling in face, nystagmus

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order of comprehensive vestibular clinical exam

subjective/systems review
self report measure: DHI, ABC
gaze stability: oculomotor, VOR
balance
position provocation testing

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canalithiasis symptoms

latent onset of vertigo/nystagmus
gradually intense, then subside: episodic
lasts few seconds to less than 1 minute

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cupulolithiasis (adhere to cupula)

immediate symptoms
-intensity remains
-constant as long as canal is provoked or varies depending on side of involvement
-lasts as long as head is held in provoking position

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For BPV testing, which side do you test first?

less affected side

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Before BPV testing, what are 3 things to do:

ask contras
in sitting check AROM c-spine, asking about 5Ds, 3Ns, then active rotation + extension.
clear alar, transverse, and VBAI

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BPV test sequence

Dix Hallpike
if negative,
roll test
if negative,
side lying test

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ewald’s 1st law

vertical canal (posterior/anterior) BPPV:

*eye movements are in plane of canal being stimulated

ASCC and PSCC

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posterior canal BPPV

corrective fast phase is UPBEAT and TORSION towards down ear
*side of torsion: R or L
*whether it stays or goes, cupula or canal

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R posterior canal nystagmus

upbeat, right torsional

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R anterior canal nystagmus

downbeat, right torsional

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R or L horizontal canal observed nystagmus

horizontal ageotropic and geotropic
head roll test

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+ posterior canal test results:

+ DHT: upbeat, same side torsional

reversal phase: downbeat, opposite torsional
return to sit: downbeat, opposite torsional

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right anterior canal + test:

+ DHT: downbeat, R torsion
reversal phase: upbeat, L torsion
return to sit: upbeat, L torsion

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+ roll test: if geotropic nystagmus,

beating towards same side GROUND
(beat down with right side being worse = HSC BPV canalithiasis)

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apogeotropic nystagmus

beating UP/away from ground cupulolithiasis = side involved has LESS nystagmus

illusion of movement (spinning, rocking, swaying, falling)

vertigo

sense of being off-balance (unsteady, wobbly, drunk, tilted)

Disequilibrium

foggy-headed, heavy-headed, light- headed, motion-sickness

gaze-instability

Light-headed, pre-syncope, tunnel vision

Cardiovascular: decreased blood flow to the brain

floating, swimming, rocking

anxiety symptoms

diplopia, oscillopsia (vision jumping)

oscillopsia: visual, but also bilateral hypofunction both: visual

motion sickness is caused by a

visual-vestibular mismatch

What is the cause? Aggs: Positional: lying down, sitting up or turning over in bed, bending forward Eases: Holding still, time

BPPV

What is the cause? Aggs: Head movement, visual- vestibular mismatch Eases: Holding still, closing eyes

gaze-instability (vestibular hypofunction!)

What is the cause? Aggs: Walking, darkness, unstable surfaces, standing up Eases: Sitting, Support from UEs

Imbalance

What is the cause? Aggs: Spontaneous, exacerbated by head movement Eases: Holding still, closing eyes, medication

Vestibular Neuritis

What is the cause? Aggs: Spontaneous, exacerbated by head movement and common triggers Eases: Holding still, closing eyes, medication

Vestibular Migraine or Meniere’s

What is the cause? Aggs: Spontaneous Eases: N/A

CVA/TIA

What is the cause? Aggs: Positional: standing or sitting up Eases: Sitting supported, time

Orthostatic Hypotension

What is the cause? Aggs: Cardiovascular strain, exercise Eases: Rest

ISCHEMIA

Name 3 vestibular suppressants

Meclizine Dramamine Valium

What are some medications that are ototoxic?

-some antibiotics -chemotherapy -some diuretics -some NSAIDs

4 precautions to BPPV/Vestibular HEP

1. drainage/discharge 2. ringing 3. sudden hearing loss 4. sudden fullness/pressure

Oculomotor Screen: what is strabismus?

hypotropia or esotropia | drooping eye

ocular alignment: vertical skew deviation

central sign deviation *ocular tilt reaction *

What is Ewald's 2nd law?

excitation of any canal creates a stronger vestib stimulus and creates greater response than inhibition inability of inhibitory stimuli to decrease the vestibular nerve firing rates to less than zero. for horizontal canal BPPV and horizontal VOR

What is inflammation of the inner ear/vestib nerve, causing vestib hyperstimulation and may result in damage, leading to hypofunction

neuritis: nerve, no hearing loss labryinthitis: inner ear, hearing loss

causes of Neuritis/Labyrinthitis

Viral infection 98%, head injury

SS of what DX: Sudden onset of vertigo, nausea/vomiting, lasting 3-7 days with residual balance and dizziness lasting 1-2 weeks. Often follows other illness (30% following respiratory infection)

neuritis/labyrinthitis

Damage to the inner ear or vestibular nerve that results in a diminished or weaker neurological signal. Uni or Bil

hypofunction! caused by: Neuritis, Labyrinthitis Meniere’s Disease Acoustic Neuroma, Ototoxic medication Gentamicin (aminoglycosides), Meningitis, Ear surgeries, etc.

Benign, slow-growing tumor of the myelin sheath (Schwann cells) covering the Acoustic/Cochlear or vestibular nerve causing compression of CN 8. what Dx?

Acoustic Neuroma

SS of this Dx: Gradual onset of unilateral hearing loss Tinnitus, Imbalance Motion-sensitivity Facial numbness/weakness

Acoustic Neuroma

Build-up of endolymphatic fluid within the inner ear, causing pressure on the inner ear membranes and hair cells. Can cause inflammation and damage over time. * Unilateral or bilateral what Dx?

Endolymphatic Hydrops/Meniere’s caused by: idiopathic (Meniere’s), sodium/potassium imbalance Middle ear congestion (milder) | *men's ears cause high drops --> pressure

Recurring episodes of vertigo lasting 1-3 days with gradual improvement over 1-2 weeks. Low- frequency hearing loss. cause: sodium potassium imbalance, middle ear congestion, ideopathic what Dx?

Endolymphatic Hydrops/Meniere’s

recurring spells of vertigo, possibly associated with loud sounds and barometric pressure changes, hearing hypersensitivity, imbalance, motion-sensitivity caused by trauma, head injury, valsalva. RARE what Dx?

fistula! hole in ear

* Stroke * Brain tumor * Multiple Sclerosis lesions * Degenerative neurological conditions * Vestibular Migraine * PPPD * MDDS these are examples of ____ pathophysiology

central vestibular system

* Symptoms: Recurring episodes of vertigo, lasting 1-5 days. Often associated with headache, photophobia, phonophobia, brain fog, anxiety, dissociative symptoms, visual issues

vestibular migraine | Risk factors: female, Magnesium deficiency, migraine history * Common tr

Autonomic and emotional hyper-responsiveness to vestibular stimuli * Fight or flight: sympathetic nervous system * AKA: Chronic Functional Dizziness

PPPD

SS: constant visual motion- sensitivity and imbalance coupled with anxiety, kinesiophobia, “visual vertigo,” “space motion discomfort”, persisting >3 months cause: abnormal adaptation following vestibular trauma

PPPD

persistent sensation of rocking or swaying that lasts beyond the expected period of adaptation. Worse when being still. patho: Mal-adaptation following disembarking a moving vehicle

Mal de Debarquement (MDDS)

self report outcome measures

DHI ABC VADL VAP Questionaire