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Neuromuscular PT II > Vestib Rehab Foundation > Flashcards

Vestib Rehab Foundation Flashcards

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1
Q

2 Subdivisions of Vestibular System

A

Peripheral: inner ear / 8th CN

Central: vestibular nuclei / cerebellum / higher cortical connections

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2
Q

What three things contribute to Spatial Awareness?

A

Vestibular system

Vision

Somatosensation (proprioception)

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3
Q

Spatial Awareness further subdivides into ___ and ___.

A

balance, gaze-stability

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4
Q

Vestibular Rehab Definition

A

Using neuroplasticity to re-train the brain to interpret / utilize vestibular inputs more accurately

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5
Q

The Vestibular system functions to sense ___.

A

movement

Inner Ear senses movement of head

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6
Q

What are the resulting symptoms of Vestibular System malfunction?

A

Vertigo (sensing ANY movement that isn’t really there) - spinning / rocking / swaying

Movement-related dizziness

Motion sickness

Imbalance

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7
Q

Path A Sound Wave Takes to Become A Sound

A

Wave passes through Outer Ear (External Auditory Canal)

Passes through Ossicles to Tympanic membrane (which vibrates)

Tympanic Membrane and Ossicles transmit sound waves to Inner Ear through Endolymph

Cochlea: receptive hair cells stimulated by vibration

Endolymph within Cochlea transmits mechanical energy from sound/movement to electrical energy for NS (bending of hair cells)

Electrical signal goes through Auditory N. to the brain

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8
Q

Semi-Circular Canals are filled with ___.

A

endolymph

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9
Q

Alignment of Semi-Circular Canals

A

Anterior aligns with posterior canal on the opposite side

Posterior canal aligns with anterior canal on the opposite side

Horizontal canal aligns with horizontal canal on the other side

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10
Q

Cupula

A

Hair cells within Ampulla that bend in response to endolymph movement

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11
Q

What occurs within the Cupula when you rotate your head to the left?

A

Left cupula is depolarized (excited) / right cupula is hyperpolarized (inhibited)

Endolymph moves over the cupula and the direction in which the hair cells bend determines whether excitatory or inhibitory NT are released

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12
Q

Utricle / Saccule vs. Semi-Circular Canals

A

Utricle / Saccule receives info related to linear movement and gravity (up and down / forward and back / left and right)

SSCs only receive angular / rotational info

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13
Q

Otoconia

A

Sit on top of hair cells in Utricle / Saccule and bend them

Microscopic calcium carbonate crystals

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14
Q

Saccule vs. Utricle Movement Processing

A

Saccule - vertical / gravity bends cilia

Utricle - horizontal / endolymph bends cilia

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15
Q

How does the Vestibulocochlear Nerve divide regarding info being sent to the brain?

A

Electrical energy travels over the Vestibular Nerve for movement info to be sent to the brainstem

Electrical energy travels over the Auditory Nerve for hearing info to be sent to the brainstem

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16
Q

Vestibular-Ocular Reflex (VOR)

A

Maintains gaze stability during head motion

Controls eye-head coordination (equal and opposite movement of the eyes in relation to the head)

Directly from Inner Ear

CN III nucleus / CN IV (motor) nucleus / CN VI (motor) nucleus

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17
Q

Vestibulo-Spinal Reflex (VSR)

A

Maintains head and body equilibrium by facilitating or inhibiting skeletal muscle activity (to maintain upright position)

Controlling coordination for balance

Signal from brainstem to SC / spinal muscles

Cerebellum / Vestibulospinal Tract

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18
Q

Cervical-Ocular Reflex (COR)

A

Reflex output to motor cells

Signals head position on body / maintains gaze stability secondary to VOR

Comes from cervical proprioceptive output rather than the inner ear

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19
Q

Otolith-Ocular Reflex (OOR)

A

Input from Utricle and Saccule / output to eye muscles

Controls horizontal and vertical eye movements via linear VOR

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20
Q

Higher Cortical Connections to Vestibular System

A

Thalamus

Visual Cortex

Hippocampus

Amygdala

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21
Q

The Peripheral Vestibular System affects ___ and ___ of movement, while the Central Vestibular System affects ___ and ___.

A

sensation, perception

perception, integration

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22
Q

Conditions Related to Malfunction of Peripheral Vestibular System

A

BPPV

Neuritis / Labyrinthitis

Acoustic Neuroma

Hypofunction (Unilateral / Bilateral)

Endolymphatic Hydrops / Meniere’s

Fistula / Dehiscence

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23
Q

Benign Paroxysmal Positional Vertigo (BPPV) Pathophysiology

A

Otoconia become dislodged from Utricle / Saccule and displaced into a semi-circular canal - affects endolymph flow through the canal and cupula deflection

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24
Q

Benign Paroxysmal Positional Vertigo (BPPV) Causes / Risk Factors / Symptoms

A

Causes: Idiopathic / head trauma / inflammation / ischemia / pressure fluctuations

Risk Factors: Age / female / vitamin D deficiency / HTN / migraine / hyperlipemia

Symptoms: Brief (10 - 60 second) spells of vertigo with changes in head position against gravity

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25
___ is the most common cause of Vertigo.
BPPV
26
In the case of BPPV, what contributes to the "false movement" sensations? What determines the duration of these symptoms?
Otoconia move with gravity, causing endolymph to deflect cupula and continue to mov despite being done with a change in position Spinning lasts until Otoconia returns to proper placing
27
Canalithiasis (BPPV)
Otoconia free-floating in semicircular canal, causing abnormal flow of endolymph with changes in head position against gravity Delayed onset of vertigo and nystagmus upon achieving head position (seconds) Symptoms gradually intensify and then subside (episodic) Lasts < 1 minute
28
Cupulolithiasis (BPPV)
Otoconia adhered to Cupula, causing deflection of the cupula with changes in head position against gravity Lasts longer than Canalithiasis More immediate onset of vertigo and nystagmus Symptom intensity remains constant Lasts as long as head held in provoking position Rare
29
Eustachian Tube
Connection between ear and nose / throat
30
Neuritis / Labyrinthitis Pathophysiology
Inflammation of the inner ear (Labyrinthitis, includes hearing loss) or vestibular nerve (Neuritis, no hearing loss involved) Causes vestibular hyperstimulation and may result in damage leading to hypofunction
31
Neuritis / Labyrinthitis Causes and Symptoms
Causes: Viral infection (98%) / head injury Symptoms: Sudden onset of vertigo / n/v / lasting 3-7 days with residual balance and dizziness lasting 1-2 weeks / often follows other illness (e.g., respiratory infection)
32
Hypofunction Pathophysiology
Damage to inner ear or vestibular nerve that results in a diminished or weaker neurological signal Asymmetrical signals / difficulty interpreting movement Unilateral OR Bilateral
33
Hypofunction Causes
Neuritis / Labyrinthitis Meniere's Disease Acoustic Neuroma Ototoxic meds Gentamicin (aminoglycosides) Meningitis Ear surgery
34
Hypofunction Symptoms
Affects VOR and VSR Postural instability Gaze - instability Movement-related dizziness Motion sensitivity Foggy-headedness Kinesiophobia Oscillopsia
35
In the context of Hypofunction, ___ allows for ___ compensation.
neuroplasticity, CNS
36
Acoustic Neuroma Pathophysiology
Benign, slow-growing tumor of the myelin sheath (Schwann cells) that cover CN 8 therefore causing compression of the nerve
37
Acoustic Neuroma Causes / Symptoms
Causes: Idiopathic / genetic Symptoms: Gradual onset of unilateral hearing loss first - followed by Tinnitus / imbalance / motion-sensitivity / facial numbness + weakness Lack of true vertigo symptoms
38
Endolymphatic Hydrops Pathophysiology
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 - hyperstimulation and eventual hearing loss / hypofunction Unilateral OR Bilateral
39
Endolymphatic Hydrops Causes / Symptoms
Causes: Idiopathic (Meniere's Disease) / Na or K imbalance / middle ear congestion (milder) Symptoms: Recurring episodes of vertigo lasting 1-3 days with gradual improvement over 1-2 weeks / low-frequency hearing loss
40
Fistula / Dehiscence
Structural "hole" in the inner ear, causing an inability to regulate endolymph fluid pressure and flow Causes: trauma / head injury / Valsalva Symptoms: recurring spells of vertigo (possibly associated with loud sounds and barometric pressure changes / hearing hypersensitivity / imbalance / motion-sensitivity
41
Conditions Related to Malfunction of Central Vestibular System
Stroke Brain tumor MS lesions Degenerative neurological conditions Vestibular migraine PPPD MDDS Anything affecting central vestibular connections in the brain / brainstem
42
Vestibular Migraine
Sensory perceptual disorder affecting the vestibular system Risk Factors: Female / magnesium deficiency / migraine history Common Triggers: Stress / hormone fluctuations / weather changes / poor sleep / caffeine / alcohol Symptoms: Recurring episodes of vertigo (lasting 1-5 days) / HA / photophobia / phonophobia / brain fog / anxiety / dissociative symptoms / visual issues
43
Persistent Postural Positional Dizziness (PPPD)
Autonomic and emotional hyper-responsiveness to vestibular stimuli (fight or flight - sympathetic NS) Causes: Abnormal adaptation following vestib trauma (BPPV, vestibular migraine) Symptoms: Constant visual motion-sensitivity and imbalance / anxiety / kinesiophobia / "visual vertigo" / "space motion discomfort" / persists >3 months
44
Mal de Debarquement (MDDS)
Mal-adaptation following disembarking a moving vehicle (boats) Associated with anxiety and emotional responses to the dizziness Symptoms: Persistent sensation of rocking or swaying that lasts beyond the expected period of adaptation / worse when being still
45
Non-Vestibular Pathology Associated w/ Vestibular Symptoms
Cardiovascular: Orthostatic hypotension / low or high BP / vertebral basilar artery insufficiency Metabolic: Low or high blood sugar / dehydration / infection (UTI/URI) / meds
46
Self-Report OMs Related to Vestibular Issues
Dizziness Handicap Inventory (DHI) - how does dizziness impact function / 0 = no handicap perception, 100 = complete handicap perception Activity-Specific Balance Confidence (ABC) Scale - pts rate their confidence level with various balance tasks / great for measuring success of treatment Vestibular Disorders Activities of Daily Living Scale (VADL) Vestibular Activities and Participation (VAP) Questionnaire
47
Movement-Related Dizziness
Could be vestibular Vertigo: Illusion of movement (spinning / rocking / swaying / falling) Disequilibrium: Sense of being off-balance (unsteady / wobbly / drunk / tilted) Gaze-Instability: Foggy-headed / heavy-headed / light-headed / motion sickness
48
Cardiovascular Dizziness
Decreased blood flow to the brain Light-headed / pre-syncope / tunnel vision
49
Anxiety- and Visual-Related Dizziness
Anxiety: Floating / swimming / rocking Visual: Diplopia / oscillopsia (vision jumping)
50
"Tempo" of Symptoms
Sudden/Acute: Vestibular Neuritis or Labyrinthitis (single event) / Meniere's or Vestibular Migraine (recurring spells) / Wallenberg infarct (single event) Short Spells: BPPV / Orthostatic Hypotension Constant/Chronic: Bilateral hypofunction / MDDS or PPPD
51
Aggravating / Easing Factors Related to Movement (Vestibular Issues)
Aggravating: Positional / head movement / challenging balance situations / busy visual environments Easing: Holding still makes it better
52
Vestibular Suppressant Medications
Meclizine (motion sickness med to control n/v + dizziness) Dramamine Valium (anxiety med)
53
Which medications can contribute to Ototoxicity?
Some antibiotics Chemotherapy Some diuretics Some NSAIDs
54
Nystagmus
Rapid / repeating eye movement Fast phase (corrective saccade) in one direction / slow phase (caused by VOR) in the other - vestibular system Named for fast phase (from pt's perspective) Nystagmus caused by CNS - smooth pursuits and saccades (cerebellum / brainstem)
55
Nystagmus - Peripheral Vestibular System
Slow phase (VOR) / fast phase (corrective saccade) Direction-fixed Usually horizontal (R or L) Decreases in intensity with fixation Gaze towards fast phase increases intensity and vice versa (Alexander's Law) BPPV is exception (transient / positional / direction depends on otolith movement through canals)
56
Nystagmus - CNS
Direction changing - often follows gaze Can be vertical or pendular (R/L) Not affected by fixation Congenital Trauma: stroke, BI
57
Physiologic Nystagmus
Normal Optokinetics (watching a train pass - eyes saccade and reset) Spinning On a train
58
Frenzel Goggles
"Take away" fixation Illuminate the patient's eyes so examiner can see any spontaneous nystagmus Can conduct testing in the dark
59
VNG/ENG
VNG: Infrared goggles and video recording ENG: Electrodes over eye muscles Quantify nystagmus / smooth pursuit / saccades / positional nystagmus and calorics
60
What is the gold standard for identifying Unilateral Vestibular Hypofunction?
Caloric Vestibular Test Pressure differential introduced to endolymph via warm or cold air in ear - measure nystagmus intensity
61
What is the gold standard for identifying Bilateral Vestibular Hypofunction?
Rotary Chair
62
Other Diagnostic Tests
Audiogram - hearing test Electrocochleography (ECoG): Measures inner ear activity in response to sound / Meniere's Cervical or Ocular Vestibular Evoked Myogenic Potential (cVEMP, oVEMP): neck and eye muscles response to sound / utricle and saccule function Auditory Brainstem Response (ABR): CN 8 function Vestibular Autorotation Test (VAT): Assesses VOR Posturography: Balance patterns / how balance is affected
63
Label the following diagram:
d. External Auditory Canal e. Tympanic Membrane r. Inner Ear m. Vestibular Nerve n. Auditory Nerve p. Outer Ear q. Middle Ear f. Eustachian Tube
64
Label the following diagram:
o. Semicircular Canals j. Cupula i. Otoconia g. Utricle h. Saccule l. Cochlea k. Endolymph

Neuromuscular PT II (9 decks)

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