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NMR II > Vestibular Rehab Part 2 > Flashcards

Vestibular Rehab Part 2 Flashcards

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1
Q

What does the vestibular ocular reflex do?

A
  • Maintain stability of an image on the fovea of the retina during rapid head movements
  • Eyes move opposite the head
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2
Q

Peripheral Vestibular system connects to Central vestibular system pathways where?

A

Brainstem

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3
Q

What is VOR gain?

A

Relationship of eye velocity to head velocity (head & eyes move in opposite direction at equal speeds)

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4
Q

What is VOR Phase?

A

Relationship of amplitude between eyes & head

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5
Q

What is the definition of Unilateral Vestibular Hypofunction (UVH)?

A

One vestibular apparatus is “hypo functioning” = low tonic firing rate

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6
Q

What are some common diagnoses of UVH?

A
  • Vestibular Neuritis/Labyrinthitis
  • Meniere’s Disease
  • Perilymph Fistula
  • Vestibular Schwannoma/ Acoustic Neuroma
  • Chronic BPPV
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7
Q

What is Vestibular neuritis and what does it result in?

A
  • Inflammation of the vestibular part of the nerve
  • Results in vertigo only
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8
Q

What is Vestibular labyrinthitis and what does it result in?

A
  • Inflammation of both branches of CN VIII
  • Results in vertigo & hearing loss
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9
Q

What should be done during the acute phase of Vestibular labyrinthitis?

A
  • Rest
  • Medication for dizziness
  • Antibiotics if bacterial
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10
Q

What should be done during the chronic phase of Vestibular labyrinthitis?

A

Vestibular rehab may be helpful

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11
Q

What is Ménière’s disease?

A

Abnormal fluctuations in endolymphatic fluid

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12
Q

Should you treat a patient during an episode of Meniere’s disease?

A

No

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13
Q

How long do Meniere’s attack last? And what are some of the symptoms?

A
  • 2-4 hours
  • Low frequency hearing loss
  • Episodic vertigo
  • Sense of fullness in ear
  • Tinnitus
  • Nausea, vomiting
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14
Q

What is the medical treatment of Ménière’s disease?

A
  • Reducing fluid buildup
  • Reduced sodium diet
  • Avoid caffeine
  • Alcohol
  • Smoking
  • Surgery (may be considered)
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15
Q

What is Perilymph Fistula?

A
  • Rupture of the oval or round window (separate middle from inner ear)
  • Perilymph leaks into the middle ear
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16
Q

What is Perilymph Fistula caused by?

A

Excessive pressure changes (diving), blunt head trauma, extremely loud noise

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17
Q

What are the symptoms of Perilymph Fistula?

A
  • Vertigo
  • Hearing loss
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18
Q

Is vestibular rehab supported for Perilymph Fistula?

A

Contraindicated but may be beneficial after surgery

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19
Q

What is the medical treatment for Perilymph Fistula?

A
  • Bed rest
  • Surgical repair
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20
Q

What is Vestibular Schwannoma/ Acoustic Neuroma?

A
  • Benign tumor from the Schwann cells that gradually compress CN VIII
  • CN VII may also be impacted
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21
Q

What are the symptoms of Vestibular Schwannoma/ Acoustic Neuroma?

A
  • Unilateral Healing Loss
  • Tinnitus
  • Vertigo
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22
Q

What is the medical treatment for Vestibular Schwannoma/ Acoustic Neuroma?

A

Surgical excision

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23
Q

When is vestibular rehab recommended to started if someone has a Vestibular Schwannoma/ Acoustic Neuroma?

A

Early after surgery

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24
Q

What are the acute symptoms (first 2 weeks) of Unilateral Vestibular Hypofunction?

A
  • Vertigo
  • Nausea
  • Spontaneous Nystagmus (unidirectional)
  • Oscillopsia
  • Disequilibrium,
  • Gait/Postural instability may be present
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25
What are the subacute (2wk to 3 months) and chronic (>3 months) symptoms?
- Reduction of vertigo, nystagmus & nausea within 14 days (spontaneous rebalancing of the resting tonic firing rate) - Gait instability - Oscillopsia - Head movement induces symptoms
26
In spontaneous nystagmus during UVH the fast phase does toward the good ear or the bad ear?
Good ear - Slow phase goes to bad ear
27
Why does the patient with an acute unilateral vestibular lesion experience spontaneous nystagmus?
- Brain stem is receiving greater afferent input from the intact labyrinth, which responds by generating nystagmus - Patient interprets this as rotation (vertigo)
28
What is oscillopsia?
Stationary objects in the environment appear to be in motion when the patient is in motion
29
What is Bilateral Vestibular Hypofunction?
Caused by reduced or absent function of both peripheral vestibular sensory organs and/or nerves
30
What are some common diagnoses of Bilateral Vestibular Hypofunction?
- Idiopathic - Ototoxcity - Meningitis - Autoimmune disorders - Bilateral Meniere's Disease or vestibular neuritis - Neurotoxicity from cancer treatment - TIA of blood vessels - Bilateral Schwannoma
31
How does BVH: ototoxicity occur?
Certain classes of antibiotics are gradually taken by the hair cells & continue to build in the system rendering the cells unable to respond accurately to head movements
32
How does BVH: Neurotoxicity from chemotherapy occur?
Platinum- based chemo (cisplatin) damage sensory hair cells
33
What are the symptoms of Bilateral Vestibular Hypofunction?
- Imbalance - Gait ataxia - Oscillopsia causing decreased visual acuity with head movements - Difficulty walking in dark and on uneven surfaces
34
Do patients with Bilateral Vestibular Hypofunction have vertigo or nystagmus?
NO
35
What is the definition of Central Vestibular Dysfunction?
- Pathology of vestibular system proximal to the vestibular nuclei - Begin in brainstem, or beyond (connections with reticular formation, thalamus, cerebellum, cortex)
36
What are common diagnoses of Central Vestibular Dysfunction?
- Stroke - TBI or Concussion - MS - Multiple System Atrophy - Cerebellar Pathology - Migraine related dizziness - Brain Tumor
37
What are the symptom of Central Vestibular Dysfunction?
- Nystagmus - Vertigo (if present very mild. little change in head position) - Dysequilibrium & balance deficits - May see: Laterpulsion, Head tilt, oculomotor dysfunction, perceptual; deficits - Other neuro findings: Dysphagia, dysmetria, dysarthria, diplopia, dysphonia
38
What does nystagmus look like in Central Vestibular Dysfunction?
- Pendular - Oscillate at equal speeds (no slow/fast phase) - Bilateral nystagmus on lateral gaze - Typically never resolves - Unable to stop with visual fixation
39
What is motion sickness due to and can vestibular rehab help?
- Due to sensory conflicts - Vestibular rehab may help
40
What is Mal de Debarquement? Can PT help?
- Feeling sick upon disembarkment (exciting from water or airborne vessel) - Persistent rocking, swaying while at rest that typically resolved during motion - Persists >24 hours - PT may not offer benefit
41
What causes cervicogenic dizziness and what is the treatment?
- From cervical spine or soft tissue, affects proprioceptive input & alter afferent inout - Cervical spine sends proprioceptive input to contralateral vestibular nucleus - Treatment: address musculoskeletal impairments first then do vestibular rehab
42
What should be ruled out before beginning vestibular rehab?
- Orthostatic hypotension - Hypoglycemia - LE somatosensory loss
43
A patient demonstrates a fast beat nystagmus to the left. Where is the pathology?
Right vestibular system
44
What are some Vestibular System red flags?
- Unilateral hearing loss (Not Menieres) - Discharge of fluid from the ear - Syncope with light headedness - Alterations in consciousness - Positive VBI - If no known central pathology and presenting with new onset central signs
45
Smooth Pursuits/ Tracking is used to rule out what?
Central pathology
46
What is an abnormal response to Smooth Pursuits/Tracking?
If patients is unable to achieve full ROM in any plane or if there is impaired quality of movement
47
What CN does Smooth Pursuits/ Tracking test?
CN III, IV, VI
48
How is Smooth Pursuits/ Tracking performed?
Move tip of pen up & down, back & forth slowly at 30 degrees from midline while the patient follows with eye movement
49
What is a positive finding of Smooth Pursuits/ Tracking?
- Unable to follow pen - Catch up saccades - Reports diplopia
50
What pathologies could a patient have if they have a positive finding on Smooth Pursuits/ Tracking?
- Central lesion - CN III, IV, VI lesion - Acute peripheral nerve impairment
51
What is saccades assessing and what CN are involved?
- Assessing coordination/ Ocular metria - CN III, IV, VI
52
How is saccades performed?
- Hold finger out to the side 15 degrees from patient - Have patient look from examiners nose to one finger, back to the nose & then to the other finger (horizontal) (or finger to finger) - Examine if both eyes move at the same time to each finger - Repeat with finger 15 degrees up & down (vertical)
53
What is a positive finding when performing saccades?
Dysmetria (hypometria or hypermetria)
54
What pathologies could be present if a patient has a positive finding when performing saccades?
- Central lesion - Acute peripheral nerve impairment
55
How is Convergence performed?
- Use pen with 14 font X taped to cap - Start around 24" from eyes - Move pen in towards the nose slowly while instructing the patient to look at the X - Have person stop the pen when they see 2 distinct images - Measure the distance from the tip of the nose to pen
56
What is an abnormal finding for convergence test?
> or equal to 6cm
57
What is the CNS: Cover/Uncover test also known as?
Test of Skew or Ocular Malalignment
58
How is CNS: Cover/Uncover test performed?
- Pt focuses on examiner's nose while covering 1 eye (keeping it open) (hold approx 3 sec) - As patient maintains their gaze, uncover eye - Observe for any ocular malalignment or movement
59
If a patient has a vertical skew deviation during the CNS: Cover/Uncover test, what does that indicate?
Concern for central lesion (up or down)
60
If a patient has strabismus during the CNS: Cover/Uncover test, what does that indicate?
- May be due to ocular muscle weakness or peripheral nerve pathology - Exotropia (eye abducted) - Esotropia (eye adducted)
61
If CNS: Cover/Uncover test is negative what might this indicate?
Typical for peripheral vestibular pathology
62
How is Gaze Evoked Nystagmus performed?
- Have patient gaze left (observe nystagmus) - Have patient gaze right (observe nystagmus)
63
During Gaze Evoked Nystagmus what does the nystagmus look like for a peripheral lesion (UVH)?
- Remains in same direction no matter which direction you look - Greater when looking in the direction of the fast phase
64
During Gaze Evoked Nystagmus what does the nystagmus look like for a central lesion?
- Nystagmus is bidirectional - Change depending on which direction the patient looks
65
What are positive findings for VOR: Horizontal & Vertical?
Complaints of vertigo or corrective saccade
66
If there is a positive finding for VOR: Horizontal & Vertical what pathologies could that indicate?
- CN VIII pathology - Central lesion beyond CN VIII nuclei (negative /normal) - UVH or BVH
67
How is VOR: Horizontal & Vertical performed?
- Have patient look at tip of pen or X in front - Patient moves their head back & forth at 2 cycles/ second - Repeat as they move their head up & down - Ask & rate any reports of dizziness
68
How is VOR Cancellation performed?
- Patient sitting with their hands clasped in front of them with their thumbs up - Patient can also look at index card in their hands with letter on it - As patient rotates their arms, body & head back & forth, their eyes stay on the target
69
What are positive finding for VOR Cancellation?
- Corrective saccades - Vertigo
70
What are the implications of positive findings on VOR Cancellation?
- Cerebellar pathology (cerebellum is unable to override or inhibit the VOR)
71
How is Head Impulse Test (HIT) performed?
- Patient neck is passively flexed to 30 degrees - Patient looks at a close target (examiner's nose) - Examiner turns head slowly back & forth in small amplitude (15 deg) at moderate velocity - Examiner rapidly rotates head to one side (towards midline) while the patient tries to maintain their gaze - Repeat both sides (also can be performed in vertical semi-circular canals)
72
What is a positive finding of the Head Impulse Test?
Corrective saccade (rapid eye movement back towards the target)
73
When performing the Head Impulse Test why might a patient have corrective saccade?
- In a patient with a loss of vestibular function, the VOR will not move they eyes as quickly as the head rotation & the eyes move off the target - Can't maintain gaze when the head is rotated towards the side of the lesion
74
What pathologies might be present if during the Head Impulse Test there is a positive finding to one side, both sides or negative bilaterally?
- Positive to one side: UVH - Positive to both sides: BVH - Negative bilaterally: Central
75
Why is it important to perform the head impulse test using rapid velocity?
- Contralateral vestibular labyrinth can detect the head rotation signal for lower velocity rotations only (inhibitory cut off) - To ensure an accurate exam, ipsilateral labyrinth should be tested with high velocities to ensure the contralateral labyrinth does not contribute to gaze stability
76
How is the Head Shaking Nystagmus Test performed?
- Head flexed to 30 degrees (eyes closed) - Examiner shakes the patient's head from side to side for 20 cycles at a frequency of 2 reps per second - Stop shaking the head & have the patient open their eyes - Check nystagmus - Repeat with vertical head moments
77
What is a positive finding for the head shaking nystagmus test?
- Nystagmus more the 3 beats - Fast phase is towards the intact ear - Slow phase is towards involved
78
What pathologies may be present if the head shaking nystagmus test is positive, negative or the patient has a vertical nystagmus?
- Positive: Unilateral peripheral lesion - Negative: BVH due to no imbalance of tonic firing rate - Vertical Nystagmus: Central lesion
79
How is Dynamic Visual Acuity Test performed?
- Pt sits or stands 10 ft away from Snellen Chart - Pt read the lowest line that they can see with the head still (static visual acuity) - W/ pt neck flexed at 30 degrees the examiner moves the head back & forth at 2 turns/sec - Repeat w/ vertical head movement
80
What findings from the Dynamic Visual Acuity Test may indicate a vestibular hypofunction?
If patient cannot read 3 lines or more from baseline indicates hypofunction (bilaterally typically more severe)
81
What must a patient have in order to perform HINTS exam?
Nystagmus
82
What is performed in the HINTS exam?
- Head Impulse Test - Nystagmus during lateral gaze - Test of Skew (Cover uncover test)
83
What is found during the Head Impulse Test if there is stroke concern vs peripheral concern?
- Stroke Concern: Negative bilaterally - Peripheral Concern: Positive in one or both direction
84
What is found during the Nystagmus during lateral gaze if there is stroke concern vs peripheral concern?
- Stroke Concern: Bi directional - Peripheral Concern: Unidirectional
85
What is found during Test of Skew/ Cover Uncover Test if there is stroke concern vs peripheral concern?
- Stroke Concern: Vertical movement to refixate eyes (up or down) - Peripheral Concern: Negative
86
How is cervicogenic dizziness tested?
- Pt sits in chair with wheels or on a mat or chair without armrests - Pt looks at a point ahead of then - They then turn their body to one side while their head & eyes stay straight ahead
87
What is a positive test for cervicogenic dizziness?
Vertigo, paresthesia, pain due to tension on posterior columns
88
What is the intervention for cervicogenic dizziness?
Musculoskeletal intervention at cervical muscles
89
Will Smooth Pursuits be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Negative - Peripheral Bilateral: Negative - Central: Positive
90
Will Saccades be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Negative - Peripheral Bilateral: Negative - Central: Positive
91
Will Convergence be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Negative - Peripheral Bilateral: Negative - Central: Positive
92
Will Cover/ Uncover Test be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Negative - Peripheral Bilateral: Negative - Central: Positive
93
Will there be nystagmus during Gaze evoked nystagmus in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Unilateral towards intact side, spontaneous in acute in horizontal plane - Peripheral Bilateral: None - Central: Bilateral, spontaneous, vertical
94
Will CN VIII (VOR) be intact or not in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Positive - Peripheral Bilateral: Intact unless imbalance - Central: VOR gain typically normal
95
Will VOR Cancellation be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Negative - Peripheral Bilateral: Negative - Central: May be positive
96
Will Head Shaking Nystagmus Test be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Positive - Peripheral Bilateral: Negative - Central: sometimes
97
Will head impulse test be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Positive one direction - Peripheral Bilateral: Positive bilateral direction - Central: Negative
98
Will Dynamic Visual Acuity be positive or negative in: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: Positive - Peripheral Bilateral: Positive - Central: Sometimes
99
Describe the findings found in HINTS Exam (3 part) for: - Peripheral Unilateral - Peripheral Bilateral - Central
- Peripheral Unilateral: ( +HIT, - TS, & horizontal and unilateral direction nystagmus) - Peripheral Bilateral: (Should not have nystagmus) - Central: ( - HIT, + TS, & vertical or bilateral nystagmus)
100
What does Videonystagmography examine?
Nystagmus in different head positions
101
What does Vestibular- evoked myogenic potential (VEMP) examine?
- Otolith function - Saccule: Cervical Testing - Utricle: Ocular mm testing - EMG testing of cervical (SCM) & ocular mm (inferior oblique). No contraction occurs on the side of the UVH
102
How is the Caloric Test performed and what does it examine?
- Temperature gradient of either cold or warm in the ear canal - Examines horizontal canals & an equal response between ears - Nystagmus is normal response
103
Why was the Vestibular Rehabilitation Benefit Questionnaire (VRBQ) developed?
Identify the benefits of Vestibular Rehab
104
What topics are within the Vestibular Rehabilitation Benefit Questionnaire (VRBQ)?
- Dizziness - Anxiety - Motion provoked dizziness - Quality of life
105
How is Motion Sensitivity Quotient performed?
Patient is placed in different positions & symptoms are rated for intensity & duration
106
What does the Dizziness Handicap Inventory measure?
Self-report to measure individuals perception of disequilibrium & impact on activity
107
When using the Clinical Test of Sensory Interaction & Balance which conditions will the patient sway if they have vestibular dysfunction?
5,6
108
What are DGI & FGA common gait findings with UVH?
- Acute: Wide based, slow, limited trunk rotation - After 2 weeks: normal
109
What are the DGI & FGA common gait findings with BVH?
- Acute: Wide based, slow, limited trunk rotation - After 2 weeks: Mild impairment may be present
110
What are the DGI & FGA common gait findings with central?
Impaired/ ataxia may be present
111
What are the common findings of DGI & FGA walking with head turns in UVH?
- initially off balance - After 2 weeks: normal
112
What are the common findings of DGI & FGA walking with head turns in BVH?
Impaired
113
What are the common findings of DGI & FGA while walking with head turns in central?
Impaired/ ataxia may be present

NMR II (14 decks)

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