Lecture 9: Vestibular Assessment and Treatment

Question 1

What is first important part to distinguish in a potential vestibular assessment?

Answer 1

is it vertigo or just dizziness

Question 2

What is the difference in how long sx last?

Answer 2

BPPV- short duration

UVH- long lasting

Question 3

Under what circumstances will sx occur?

Answer 3

only head turns- BPPV

with or without head turns, random- UVH

trouble in dark- bilateral VH

Question 4

Does the patient experience double vision?

Answer 4

central finding

Question 5

Does the patient experience hearing loss?

Answer 5

labyrinths or meniere’s

Question 6

Which of the patient symptoms are disturbing function the most?

Answer 6

N/V, vertigo- BPPV, UVH

imbalance and persistent lightheadedness- bilateral or Central

Question 7

What are the 5 neurological D’s that could indicate central pathology?

Answer 7

dizziness, diplopia, dysarthria, dysphagia, drop attacks

Question 8

What other signs and symptoms that may be a red flag during an eval?

Answer 8

numbness, weakness, slurred speech, tremors, LOC, memory loss, rigidity, Babinski sign, clonus, spasticity

Question 9

What is a commonly used outcome measure a patient can self report?

Answer 9

Dizziness handicap inventory

self perceived handi cap as a result of vestibular disorder

Question 10

What are examples of objective ocular motor tests?

Answer 10

1. ocular alignment
2. smooth pursuit
3. Saccades
4. VOR Cancellation

Question 11

What if any of these oculomotor tests are positive?

Answer 11

likely indicative of CNS problems

Question 12

What are the components of the smooth pursuit test?

Answer 12

tests pts ability to track object

Question 13

What are the components of the saccades test?

Answer 13

pt is asked to move eyes back and forth from finger to nose horizontally and vertically

abnormal if pt over shoots and under shoots target

Question 14

What type of test is commonly seen in pts post concussion?

Answer 14

Vergence- eyes both adduct as an object moves closer towards nose

abnormal = likely CNS problem, ask pt about any recent trauma

Question 15

What is VOR cancellation?

Answer 15

tests the calibration capability of the cerebellum

Question 16

What are 4 types of VOR testing?

Answer 16

1. Dynamic Visual Acuity
2. VOR x 1
3. Head Thrust
4. Head Shake

Question 17

If any of the VOR tests are positive what does this likely indicate?

Answer 17

UVH

Question 18

What is the Dynamic Visual Acuity test?

Answer 18

looking at visual chart and if loss of 2-3 lines indicates hypo function

Question 19

What is VOR x1?

Answer 19

pt will focus on object and turn head

if sx are provoked or pt has trouble focusing likely UVH

Question 20

What is the procedure of head thrust test?

Answer 20

pt head flexed 30 degrees , random side to side thrusts to either side

most widely used clinical test hypo function

Question 21

What does an abnormal head thrust finding indicate?

Answer 21

inability to maintain visual fixation on nose with corrective saccades

thrust to right and center = right UVH

thrust to left and center = left UVH

Question 22

What is Head shake test?

Answer 22

done with frenzy goggles

pt flexes head and PT moves it 20 times with eyes closed and opens eyes and see if nystagmus is present

Question 23

What are abnormal findings for a head shake test?

Answer 23

if nystagmus to right- left UVH

if to left- right UVH

Question 24

What is an important concept to remember about nystagmus in general?

Answer 24

nystagmus will generally beat to the side of irritation in BPPV and away from side of lesion in hypo function

Question 25

What is an example of a VSR test?

Answer 25

Fukuda step test - attempts to isolate the VSR, detects UVH if positive

Question 26

What is procedure for Fukuda?

Answer 26

pt stands with eyes closed and arms elevated to 90 degrees and marches for 50 steps with eyes closed if pt turns head more than 30 degrees to one side positive for UVH to that side

Question 27

What are two recommended outcome measures specific to vestibular pathology?

Answer 27

1. DGI- 19/24 indicates fall risk | 2. FGA- 22/30 indicates fall risk

Question 28

What is the motion sensitivity quotient?

Answer 28

objective measures a pts motion sensitivity, involves 16 rapid changes in head position and recorded by intensity, duration and number of positions that provoke it

Question 29

What are three additional diagnostic tests for vestibular dysfunction?

Answer 29

1. ENG- can determine whether dysfunction is peripheral or central 2. Rotary Chair test- very expensive 3. Dynamic posturography- fancy CTSIB

Question 30

What is one of the main treatments for BPPV?

Answer 30

Canalith Repositioning maneuver or CRM is most advocated for pts with posterior canalathiasis

Question 31

What are some guidelines for the CRM?

Answer 31

30 second in each position, requires 180 of head motion retest after 15 mins

Question 32

What should patient avoid for the rest of day after CRM?

Answer 32

excessive head movements, remain upright 20 mins after procedure , sleep on back with several pillows

Question 33

What is another common manual technique used for BPPV?

Answer 33

Liberatory maneuver for cupulolithiasis "face plant test"

Question 34

What type of specific exercises can be used as a follow up treatment for BPPV?

Answer 34

Brandt Daroff specific habituation exercises to help pts re use positions they may have been avoiding

Question 35

What are three key treatment concepts for vestibular rehab?

Answer 35

1. Adaptation 2. Substitution 3. Habituation

Question 36

What is the rationale for adaptation exercises in vestibular rehab?

Answer 36

improves VOR gain by reducing retinal slip

Question 37

What is retinal slip?

Answer 37

difference between eye and head velocity , if VOR is impaired then a retinal slip is generated which sends an error signal to brain

Question 38

When are adaptation exercises implemented?

Answer 38

when residual vestibular function is present and recovery is expected appropriate for UVH, bilateral, peripheral or central dysfunction

Question 39

What is a common adaptation exercise?

Answer 39

VOR x 1, pt must always have a clear image and can continue with mod sx progress to VOR x2

Question 40

What are parameters for adaptation exercises and what are the progressions?

Answer 40

1-2 minutes, 3-4 times a day progress by longer duration, faster movement and change position of body

Question 41

What is the rationale for substitution for vestibular rehab?

Answer 41

implements visual and somatosensory input from cervical spine to compensate for vestibular loss appropriate for complete or severe bilateral loss

Question 42

What types of exercises are used for substitution rehab?

Answer 42

can use VOR x1, ocular exercises and balance exercises to enhance somatosensation practice 2-5 mins, 3 x a day

Question 43

What is the rationale for habituation for vestibular rehab?

Answer 43

repeated exposure to provocative stimuli results in a reduction of pathological response to a stimulus aka Brandt Daroff exercises

Question 44

What is the method for BD exercises?

Answer 44

execute a series of 4 provoking movements 2-4 times a day

Question 45

What is important to remind patients about BD exercises?

Answer 45

symptoms will be provoked during these movements, sx should decrease within 15-30 mins of exercises, usually 7-10 days before body adjusts, may take 4 weeks for sx to diminish