Vestibular Practical

Question 1

Screen your patient (as appropriate) before running through the BPPV Test Sequence.

Answer 1

Ruling Out Contras: Ask about history of neck surgery / recent neck trauma / severe RA / OA or AA instability / cervical myelopathy or radiculopathy / carotid sinus syncope / chiari malformation / vascular dissection syndrome (in the head, neck)

In Sitting: Cervical AROM (ask about 5 Ds and 3 Ns as they perform this) - if no symptoms have patient ACTIVELY rotate head to one side and extend neck before counting back from 10 out loud - ask about 5 Ds and 3 Ns during this procedure as well and have them repeat on the other side if negative

Cervical Ligament + VBI Testing: If no symptoms in previous sequence, check Alar Ligament (Supine) / Transverse Ligament (sitting) / and screen for VBAI (Pt’s hands at pt’s temples and have patient fully rotate body to 1 side - count backwards from 10 and observe / ask about 5 Ds and 3 Ns - both sides)

Question 2

5 Ds and 3 Ns

Answer 2

Dizziness / Diplopia / Dysarthria / Dysphagia / Drop Attacks

Nausea / Nystagmus / Numbness, Tingling (facial)

Question 3

In BPPV testing, which side should you test first?

Answer 3

Less affected / suspected side

Question 4

In BPPV testing, what should you do if a patient has a history of severe n/v?

Answer 4

Perform test slowly and have trashcan handy

Question 6

What characteristics of a patient’s symptoms would make you think Canalithiasis (free floating debris)?

Answer 6

Latent onset of Vertigo / Nystagmus

Symptoms gradually intensify then subside (episodic) - symptoms subside when endolymph stops moving

Lasts for a few seconds to less than 1 minute

Question 7

What characteristics of a patient’s symptoms would make you think Cupulolithiasis (adherent to Cupula)?

Answer 7

Immediate onset of Vertigo / Nystagmus

Symptom intensity remains constant (Posterior Canal) as long as that canal is provoked OR varies (Horizontal Canal) depending on side of movement

Lasts as long as head is held in provoking position

Question 8

Provide a general breakdown of BPPV Test Sequence.

Answer 8

1: Dix-Hallpike Test - Less suspected side first / (if no vertigo or nystagmus) slowly bring pt up to sitting and perform the test on suspected side / if (+) determine Canal vs. Cup and go into PSCC treatment

IF DHT (-)

IF ROLL TEST (-)

Question 9

Appearance of Nystagmus in Diagnosis Related to Posterior Canal Issue

Answer 9

Up-beating and rotary nystagmus towards undermost or down ear in DHT position

R: Upbeat, R torsional

L: Upbeat, L torsional

Question 10

Appearance of Nystagmus in Diagnosis Related to Anterior Canal Issue

Answer 10

Down-beating and rotary nystagmus

R: Downbeat, R torsional

L: Downbeat, L torsional

Question 11

Perform the Dix-Hallpike Test.

Answer 11

PUT FRENZELS ON / pt starts in long sitting position with head turned 45 degrees to less affected side / rapidly bring pt into supine with head hanging ~30 degrees into extension / hold for 1 minute OR until dizziness subsides + 30 seconds

Perform on affected side if first test is (-)

Observe for nystagmus / vertigo and determine Canal vs. Cup

(+) PSC Test = Up beating / rotary nystagmus towards undermost ear

(+) ASC Test = Down beating / rotary nystagmus

Question 12

Perform the Roll Test.

Answer 12

KEEP FRENZELS ON / From DHT position, have pt slide down on the mat til head is supported on the mat / flex neck to 30 degrees (puts HC in neutral) and support in that position / quickly turn head 90 degrees to less affected side first and hold position for 1 minute / roll head slowly back to midline and quickly roll it to other side (same procedure)

(+) Test: Bilateral Symptoms
Geotropic Nystagmus = Beating towards ground / earth (Canal - side involved has worse nystagmus)

Apogeotropic Nystagmus = Beating away from ground (Cup - side involved has less nystagmus)

Question 13

Perform the Side-Lying Test (PSC / ASC BPV).

Answer 13

KEEP FRENZELS ON / pt assisted to sitting at edge of plinth from Roll Test position / turn head 45 degrees to less suspected side / have pt QUICKLY lay down in side-lying position on suspected side (maintain 45 degree rotation in SL and when sitting position up initially) / test repeated to other side

(+) Test = Upbeat and rotary nystagmus towards down ear (BPV of downside PSC) / downbeat and rotary nystagmus (BPV of downside ASC)

Question 14

Why would we perform the Side-Lying Test (PSC / ASC BPV)?

Answer 14

Alternative for pts that cannot tolerate DHT due to postural restrictions / medical precautions / pain, discomfort / (+) screen for VBI or cervical ligament instability

OR

DHT / Roll Test is negative but patient is still symptomatic

Question 15

What red flags should you advise your patient to be aware of as they are performing their HEP?

Answer 15

If the pt experiences any of the following: sudden loss of hearing or fluctuations in hearing / increased pressure or fullness / discharge of fluid from the ear / severe ringing in the ear

STOP exercise immediately and contact PCP

Question 16

If both BPPV and Non-BPPV findings are present, what should you treat first?

Answer 16

BPPV

Question 17

What is a key distinction between treating Canalithiasis vs. Cupulolithiasis?

Answer 17

Repositioning maneuvers are done slowly for Canal / fast for Cup

Question 18

What is the Canalith Repositioning Maneuver (CRM) used to treat?

Answer 18

Canalithiasis PSC

Take the pt through this treatment immediately if vertigo / nystagmus elicited during DHT or Side-Lying Test

Question 19

Perform the CRM for Canalithiasis PSC.

Answer 19

KEEP FRENZELS ON

Remain in DHT position on affected side until symptoms cease + 30 seconds / slowly rotate patient’s head (maintaining neck extension) to opposite DHT position / remain in this position until symptoms cease + 30 seconds (30 seconds only if no symptoms) / have pt roll into SL on unaffected slide while maintaining 45 degree rotation (no extension) / tuck pt chin so nose pointed to the mat (“dump” position) / remain here until symptoms cease + 30 seconds (30 seconds only if no symptoms) / maintain 45 degree rotation as pt slowly sits up and remain in sitting position until symptoms cease + 30 seconds (30 seconds only if no symptoms) / return head slowly to neutral

Question 20

If a patient ultimately presents with Canalithiasis in the PSC, what HEP could you provide them with?

Answer 20

Self-CRM (Home Epley Maneuver)

Demonstrate this to the patient first!

Sit in bed with pillows behind middle of back / turn head towards affected side / lay down with head turned towards affected side and ensure extension of the head (over the pillows) / turn head slowly towards unaffected side / turn body towards unaffected side and tuck chin + point your nose into the bed / return slowly to sitting

Stay in each position for 30 seconds or until symptoms subside + 30 seconds

Perform 1 rep every morning (starting day after treatment) until there are no symptoms 3 days in a row - record symptom intensity / duration AND schedule F/U visit in 1 week

Question 21

What is the Semont (Liberatory) Maneuver used to treat?

Answer 21

Cupulolithiasis PSC

Question 22

Perform the Semont (Liberatory) Maneuver.

Answer 22

Pt sits at edge of plinth with head turned 45 degrees toward unaffected side / pt quickly moved to SL on affected side while maintaining 45 degree rotation (looking up) / hold for 1 minute / quickly move in upward arc through sitting to opposite SL position while maintaining 45 degree rotation and facilitating 30 degrees of flexion (“dump” position) - nystagmus and vertigo should appear (if not, shake head 1-2x to free debris) / hold for 1 minute / slowly move pt to original sitting position while maintaining 30 degree flexion / wait 1 minute / return head to neutral / wait 1 minute

Repeat 2-5x in one session (2 on practical, symptoms should lessen in intensity with reps)

Question 23

What is the Reverse Semont (Liberatory) Maneuver used to treat?

Answer 23

ASC Canlithiasis or Cupulolithiasis

Question 24

Perform the Reverse Semont (Liberatory) Maneuver.

Answer 24

Pt sits at edge of plinth with head turned 45 degrees toward affected ASC side / pt moved quickly onto affected side while keeping nose down on mat / hold this position for 1 minute / pt then quickly moves in upward arc to opposite SL while maintaining 45 degree rotation so pt is now looking up (“dump” position) - nystagmus and vertigo should appear (if not, shake head 1-2x to free debris) / hold this position for 1 minute / pt slowly moves to sitting position (keeping head turned 45 degrees towards affected side / hold here for 1 minute / return to neutral / wait 1 minute

Repeat 2-5x in one session (2 on practical, symptoms should lessen in intensity with reps)

Question 25

What HEP should you prescribe for PSC and ASC Cupulolithiasis?

Answer 25

Provide pt with Semont (Liberatory) or Reverse Semont Maneuvers as HEP - perform 3-5 reps daily until they are vertigo free for 3 consecutive days Have pt record their symptom intensity and duration each day Symptoms should lessen / resolve as debris continues to dislodge from cupula Canal conversion to PSC Canalithiasis may occur - if this happens treat with CRM / Self-CRM

Question 26

What treatment should you utilize if a patient presents with HSC Canalithiasis?

Answer 26

*BBQ / Log Roll (Lempert Maneuver)* Pt begins in supine with head flexed 30 degrees and rotated 90 degrees toward affected ear / remain here for 30 seconds or until symptoms cease + 30 seconds / *slowly* roll pt's head 90 degrees toward unaffected side (maintaining flexion) / hold here for 30 seconds or until symptoms cease + 30 seconds / *slowly* roll head AND body towards unaffected side while maintaining 30 degrees of flexion / pt *slowly* rolls onto stomach until face is down (30 degrees of flexion / "dump" position) / hold here for 30 seconds or until symptoms cease + 30 seconds / *slowly* roll pt's head 90 degrees toward affected side (while maintaining 30 degrees neck flexion) / have pt *slowly* roll head and body in direction of affected side while maintaining 30 degrees of neck flexion ("dump" position) / pt slowly sits up (keeping head flexed to 30 degrees) / hold here for 30 seconds or until symptoms cease + 30 seconds / return *slowly* to neutral / hold here for 30 seconds or until symptoms cease + 30 seconds

Question 27

What treatment should you utilize if a patient presents with HSC Cupulolithiasis?

Answer 27

*Casani (Gufoni)* Start with pt sitting EOM with head neutral (supported by examiner) / ask pt to *quickly* lie down on affected side while maintaining neutral head position / hold here for 2 minutes or until nystagmus and vertigo have stopped or decreased / *quickly* rotate pt's head 45 degrees away from affected side and hold for 2 minutes / *slowly* return to sitting with head in 45 degrees of rotation / wait 2 minutes / *slowly* bring head to neutral Repeat 2-5 times as needed (2 reps on practical)

Question 28

What HEP should you prescribe for HSC Canalithiasis?

Answer 28

*Forced Prolonged Positioning (FPP)* Lay on affected ear for 1 minute / lay on your back for 1 minute / *quickly* roll so that you are laying on your unaffected ear and sleep in this position for the night (provide support behind you to maintain this position) Finish self-BBQ roll in the morning Perform this HEP once every night until vertigo free for three days in a row Have pt record symptom intensity / duration F/U with clinician in 1 week

Question 29

What HEP should you prescribe for HSC Cupulolithiasis?

Answer 29

Perform Self-Casani (Gufoni to affected side) Perform 3-5 reps daily until vertigo free 3 days in a row Symptoms should lessen / resolve as debris continues to dislodge from cupula Have pt record symptom intensity / duration F/U with clinician in 1 week

Question 30

Perform Gaze Evoked Nystagmus (GEN) assessment.

Answer 30

Instruct pt to keep head still / have them follow a target (pen or "X") held at eye level 12-18" away / move the target to the L, R, then center with fixation first (room light) / then have them follow the object without fixation (FRENZELS) Observe their nystagmus at each point (+) Peripheral Vestibular Sign (Non-BPPV): Intensity of nystagmus increases when gazing in direction of fast phase (fatigable)

Question 31

GEN (Central NS Origin)

Answer 31

Seen with fixation (in room light) due to acute or chronic (> 3 mo) lesion of CNS Direction changing / bi-directional (R beat with R gaze, L beat with L gaze) Pure vertical / torsional / rebound More intense with fixation present and little to no change when fixation removed (Frenzels) NOT FATIGABLE

Question 32

GEN (Peripheral NS Origin)

Answer 32

Nystagmus increases in intensity as patient gazes further in the direction of the fast component of the nystagmus (INTACT EAR, lesion is on the opposite side) Nystagmus increases when fixation is removed (Frenzels) FATIGABLE Nystagmus is direction fixed (R beating with R gaze / center gaze / L gaze)

Question 33

GEN: Degrees of Nystagmus in Peripheral Vestibular Lesions (Non-BPPV)

Answer 33

3rd Degree (Acute): Nystagmus present in all directions / most intense when gaze is directed towards healthy ear - could be seen with room light but would intensify with Frenzels 2nd Degree: Nystagmus present with gaze center and away from side of lesion (towards healthy ear - increases when looking in this direction) 1st Degree (Chronic): Nystagmus ONLY present with gaze away from side of lesion (towards healthy ear)

Question 34

Perform Vergence Assessment.

Answer 34

Slowly bring target towards patient's nose / ask pt to keep eyes on the target and inform you at what point they get diplopia Normal: Target at least 6 cm from nose before patient sees double Abnormal: Diplopia (central) before target is 6 cm from nose Aversion reaction (jerking away) is also possible (Sympathetic NS)

Question 35

Perform the Smooth Pursuit eye movement assessment.

Answer 35

With head still, ask pt to follow a target 12-18" in front of them at eye level / move target slowly 30 degrees in each direction (horizontal - within ears / vertical - top of head, bottom of chin / diagonal) for several reps / ask pt to make you aware if they are experiencing any symptoms Observe smoothness of movement Abnormal: Saccadic intrusions (central signs)

Question 36

Perform the Saccades eye movement assessment.

Answer 36

With head held still, ask pt to quickly look back and forth between your nose (center target) and "X" held to R or L of center - target at eye level 12-18" in front / repeat up, down, diagonally "Quickly look from my nose to the 'X' as I tell you and let me know if this causes any symptoms." Observe accuracy and quickness of movement Abnormal: Overshooting / undershooting / slow scan instead of quick jump (central signs)

Question 37

Administer the Head Shake Nystagmus Test (HSNT).

Answer 37

Stimulates Horizontal Canal VOR Place FRENZELS on patient / ask pt to close their eyes / pitch patient's head down 30 degrees and passively shake their head side to head at 2 Hz for 20 seconds / have pt open their eyes and look straight ahead (center gaze - observe Nystagmus) / if nystagmus is present, have them look to the R and L to determine degree (also inquire about symptoms at each point of gaze) Abnormal: Peripheral vestibular imbalance with direction-fixed (3+ beat) nystagmus beating towards intact ear

Question 38

Perform the Head Impulse / Head Thrust Test (HIT or HTT).

Answer 38

Sit in front of patient at eye level (12-18 inches away) / pitch their head down 30 degrees / ask pt to fixate on your nose while you passively and slowly move pt's head side to side (each direction, several times) / then quickly and unexpectedly thrust pt's head to one side and stop - observe if eyes remain on your nose or jump to one side and return (abnormal) / repeat 3x to each side in random order Remind pt to make you aware of any symptoms along the way Abnormal: Pt's eyes jumping to side of the thrust before re-fixating on your nose *(Corrective or Re-Fixation Saccade)* - this indicates vestibular hypofunction to the side of the head thrust Symptoms evoked when head thrusted to both sides indicator of Bilateral Vestibular Hypofunction

Question 39

Perform the Dynamic Visual Acuity (DVA) Test.

Answer 39

Ensure pt is in supported sitting / ask patient to flex head 30 degrees / place eye chart appropriate distance from patient at eye level / test static visual acuity first (have them read lowest line possible) / while maintaining flexion passively move pt's head side to side at 2 Hz velocity - then ask them to read lowest line with head moving Abnormal: Unilateral Vestibular Hypofunction = > or = 3-line difference or (+) dizziness / Bilateral Vestibular Hypofunction = > or = 3-line difference, (-) dizziness, (+) oscillopsia, (+) postural instability

Question 40

Administer VOR x1.

Answer 40

*Active* head movement at 2 Hz with target "X" stable Ask pt to actively move head side to side at 2 Hz velocity while keeping their eyes on the "X" in the center (12-18 inches away at eye level) / keep going until and when "X" blurs Abnormal: Target getting blurry or jumping and / or (+) dizziness or unable to move their head at 2 Hz Document speed at which target becomes blurry (their baseline) If unable to do at 2 Hz, determine speed they can do this task (baseline)

Question 41

Administer VOR x2.

Answer 41

Pt keeps their head on "X" at all times / PT moves "X" to the R and patient is asked to move their head to the L while keeping their eyes on the "X" and vice versa Goal is to do this *active movement* as fast as they can - if unable to do it quickly, find speed where they are able to do it (baseline) Remind pt to make you aware if the "X" becomes blurry or if symptoms come on / get worse Abnormal: Target becomes blurry or is jumping and / or (+) dizziness

Question 42

Non-BPPV Testing Sequence

Answer 42

Clear CNS with 2 of the 4 below: Gaze Evoked Nystagmus (GEN) Vergence Smooth Pursuit Saccades ~ Head-Shaking Nystagmus Test (HSNT) Head Thrust Test (HTT) Dynamic Visual Acuity (DVA) VOR1 VOR2

Question 43

Adaptation

Answer 43

Recover mechanism for VOR Allows for system to make long-term changes in how it responds to input by utilizing remaining capabilities Can be induced with periods of stimulation as short as 1-2 minutes at a time (pt will experience symptoms but must attempt to continue exercises for 1 full minute w/o stopping as long as target remains in focus) Decrease velocity if target becomes blurred - progress to full velocity (2 Hz) and then increase duration to 1 minute / 2 minutes

Question 44

Substitution

Answer 44

Increasing utilization of other strategies to replace lost vestibular function Useful after Bilateral VOR loss

Question 45

*Adaptation* exercises are indicated to treat what type of Non-BPPV diagnosis?

Answer 45

Unilateral Peripheral Vestibular Hypofunction (PVH / L)

Question 46

*Oscillopsia* is an indicator of which Non-BPPV Diagnosis?

Answer 46

Bilateral Vestibular Hypofunction

Question 47

Unilateral Vestibular Hypofunction Treatment

Answer 47

*VOR x1:* Head movement at 2 Hz for 1 minute at a time while maintaining focus on a stationary target at eye level (if unable to do at 2 Hz - start at speed they were able to do and progress from there) ~ Start in quiet environment / neutral background / on firm surface / wide BOS / wearing usual corrective lenses ~ Progress to VOR x1 (2 Hz for at least 2 minutes at a time) *VOR x2:* Progress to being able to do this for at least 2 minutes at a time *VORc:* Progress to performing actively at 50 bpm for 2 minutes at a time Need to complete 1-2 minute intervals of VOR exercises 3x/day for adaptation to occur (intense enough to make you dizzy, NOT sick) 12 minutes for acute / 20 minutes for chronic - throughout the day Symptom provocation that lasts 5-10 minutes after stopping exercise is desirable (ALL VOR exercises)

Question 48

What NEEDS to occur before progressing treatment / HEP in the context of adaptation exercise?

Answer 48

Should be able to do VOR x1 at 2 Hz for 2 minutes / VOR x2 for 2 minutes / VORc for 2 minutes at 50 bpm during your treatment

Question 49

Adaptation Progression Variables

Answer 49

*Speed:* Slow - fast (2 Hz minimum to activate VOR) *Duration:* 2 minutes recommended (12 minutes total per day - start with 20 seconds) *Amplitude:* Small - large (60 degrees max) *Target Distance:* Close - far target *Target Size:* Large - small target VOR x1 then VOR x2 *Multi-Task:* Add balance challenges / visual complexity / cognitive task *Direction:* Horizontal and vertical (progress to diagonal and angled positions)

Question 50

Bilateral Vestibular Hypofunction Treatment *Active Head Movement Between 2 Targets*

Answer 50

Oculomotor sub for vestibular input - goal is to keep target focused and steady ~ Place 2 targets on wall at nose level / have patient move their eyes toward one target before turning their head towards that target / do the same with the other target / repeat cycle for 1 minute / do at least 3x a day ~ Progression: More reps of 1 minute at a time along with varying other parameters (sitting on unsteady surface / standing / walking) - if unable to do 1 minute step it down by breaking up the minute in 2-3 intervals of 20-30 seconds as one set and then progress to 1 full minute without rest

Question 51

Bilateral Vestibular Hypofunction Treatment *Remembered or Imagined Target (Stationary Target)*

Answer 51

Cervical sub for vestibular input Look at target at nose level / have pt close eyes / turn head away from target while maintaining eyes on remembered target / instruct pt to open eyes and see if their eyes remembered the imagined target ~ Assess accuracy and repeat for 1 minute at a time (at least 3x / day) ~ Progress to more reps of 1 minute at a time along with varying other parameters (break up the minute in 2-3 intervals of 20-30 seconds as one set and then progress to doing 1 full minute without rest)