Week 8 Flashcards
(154 cards)
1
Q
What does the vestibular system include?
A
The parts of the inner ear and brain that process the sensory information involved with controlling balance and eye movements
2
Q
What can result if any part of the vestibular system is impaired?
A
Dizziness, imbalance, and disability can result
3
Q
What is Vestibular rehabilitation (VR), or vestibular rehabilitation therapy (VRT)?
A
A specialized form of therapy intended to alleviate both the primary and secondary problems caused by vestibular disorders. It is an exercise-based program primarily designed to reduce vertigo and dizziness, gaze instability,
and/or imbalance and falls.
4
Q
What are the potential peripheral causes for dizziness?
A
• Benign Paroxysmal Positional Vertigo (BPPV) • Vestibular Neuritis • Labyrinthitis • Meniere’s Disease • Acoustic (vestibular) neuroma • Superior Canal Dehiscence or Fistula
5
Q
What are the potential central causes for dizziness?
A
- Brainstem or Cerebellar Stroke
- Concussion
- TBI/DAI
- Migraine
6
Q
What are the potential other causes for dizziness?
A
- Cervicogenic, orthostatic hypotension
- Vertebral artery insufficiency
- B12 insufficiency
- Hypo- glycemia
- Psychiatric
7
Q
What are the components of a patient history to gather to determine cause of vestibular dysfunction?
A
1) Tempo
2) Symptoms
3) Circumstance
8
Q
What are the components of the tempo that we want to gather in a patient’s history in order to determine the cause of vestibular dysfunction?
A
- Acute (3 days or less)
- Chronic (more than 3 days)
- Spells or episodes (seconds, minutes, hours)
9
Q
What are the possible symptoms of a vestibular dysfunction that a patient can present with?
A
- Vertigo
- Disequilibrium
- Nausea and Vomiting
- Lightheadedness
- Motion Sickness
- Oscillopsia
- Rocking or Swaying as if on a Ship
- Visual Motion Sensitivity
10
Q
What are some non-vestibular symptoms that a patient with a vestibular dysfunction may experience?
A
- Visual Changes
- Hearing Changes
- Feeling “off”/floating sensation/can’t describe
11
Q
What is vertigo?
A
Illusion of movement of the self or environment (ie. Spinning) due to sudden imbalance of neural activity. Can occur with normal head movements or lesions than cause loss of vestibular function
12
Q
What is disequilibrium?
A
Imbalance or unsteadiness while standing or walking, caused by a variety of factors (visual disturbance, vestibular function loss, or proprioception deficits)
13
Q
What causes nausea and vomiting in vestibular dysfunction?
A
Due to stimulation of the vagus centers in the medulla, varies
depending on area of impairment
14
Q
What is lightheadedness?
A
Feeling faint or like passing out, usually related to momentarily decreased blood flow to the brain (ie. Hypotension). Patients with anxiety or depression may use this to describe their dizziness
15
Q
What is motion sickness?
A
Episodic dizziness, fatigue, pallor, diaphoresis, nausea and
occasionally vomiting induced by passive locomotion while standing/sitting still. Believed to be caused by mismatch of visual and vestibular cues
16
Q
What is oscillopsia?
A
Subjective illusion of visual motion, object bouncing in visual field (like a bad video recording), usually caused by bilateral vestibular loss
17
Q
When does rocking or swaying as if on a ship occur?
A
Frequently occurs for a few days after a prolonged sea or air voyage (ie. Mal de debarquement syndrome)
18
Q
What is visual motion sensitivity?
A
Dizziness provoked by full field repetitive or moving visual environments or visual patterns (such as watching a train pass
or walking on a patterned carpet), usually occurs with central vestibular dysfunction
19
Q
What are the presentations of the visual changes that could be a symptom for a vestibular dysfunction patient?
A
Blurry vision, double vision, light sensitivity
20
Q
What are the presentations of the hearing changes that could be a symptom for a vestibular dysfunction patient?
A
Loss of hearing, difficulty hearing, fullness in the ear, sensitive to sound
21
Q
What are the presentations of the feeling “off”/floating sensation/can’t describe that could be a symptom for a vestibular dysfunction patient?
A
Usually (not always) associated with cervicogenic dizziness or
underlying psychologic mechanism
22
Q
What are the “circumstance” portion of the patient history to gather when assessing for a vestibular dysfunction?
A
Dizziness may be provoked only by certain movements or situations:
• Standing up after prolonged lying down
• Lying down, sitting up, turning in bed
• Bending over, looking up
• Exertion
Spontaneous:
• With or without movement, or patient cannot explain
23
Q
What are the other helpful elements to gather in a patient history when assessing for a vestibular dysfunction?
A
- Fall history (how, when)
- How the dizziness affects the patient’s life
- Are certain movements or situations avoided
- What the patient believes is causing the dizziness
- Headaches/Migraines
- Neck pain or other joint pain
- Medications (dizziness can be a side effect)
24
Q
Usually, when a patient presents with “Room spins when turning in bed”, what is their diagnoses?
A
BPPV
25
Usually, when a patient presents with "Feeling “off” with negative vestibular signs", what is their diagnoses?
Cervicogenic dizziness
26
Usually, when a patient presents with "Oscillopsia/constant imbalance", what is their diagnoses?
Bilateral Vestibular hypofunction
27
Usually, when a patient presents with "Turning head or turning around in standing", what is their diagnoses?
Unilateral Vestibular hypofunction
28
Usually, when a patient presents with dizziness when "Standing up first thing in the morning", what is their diagnoses?
Orthostatic hypotension
29
Usually, when a patient presents with "Visual motion sensitivity", what is their diagnoses?
Concussion/TBI or other central dysfunction
30
What are the test done for peripheral vestibular dysfunction and under what conditions?
- Spontaneous Nystagmus (acute) (goggles)
- Gaze-Evoked Nystagmus (goggles)
- Head Shaking Nystagmus (goggles)
- Head Thrust (ambient light)
- Dynamic Visual Acuity (DVA) (ambient light)
- Dix-Hallpike and Roll Test (for BPPV) (goggles)
- Valsalva (goggles)
31
What are the test done for central vestibular dysfunction under what conditions?
- Spontaneous Nystagmus (ambient light or goggles)
- Smooth Pursuit (within oculomotor exam) (ambient light)
- Saccadic Eye Movement (within oculomotor exam) (ambient light)
- Vergence (within oculomotor exam) (ambient light)
- Dynamic Visual Acuity (DVA) (ambient light)
- VOR Cancellation (ambient light)
32
In what conditions are vestibular dysfunction clinical exams done?
* Some test are done in ambient light (which means current available light such as natural outdoor light or room lights) during which patients have the ability to fixate their eyes if needed (visual fixation)
* Other tests require the use of Frenzel lenses (blurred vision) or video infrared goggles (complete dark), during which the patient does not have the ability to fixate their eyes (fixation removed)
33
What are we looking for during the spontaneous nystagmus test?
* Look for abnormal eye beating in room light
* Also look for eye beating with goggles on (if available)
* Nystagmus has a fast phase and slow phase. Try to identify the direction of the “fast phase”
* Nystagmus can be up-beating, down-beating, left beating, right beating, and/or torsional
34
If nystagmus is observed in ambient light, what is it looked at in conjunction with?
* Abnormal smooth pursuit
* Abnormal saccadic eye motion
* Abnormal VOR cancellation
35
What is the interpretation of spontaneous nystagmus observed in ambient light when in conjunction with other test?
```
- Patient may have a known
neurologic condition that the
clinician is aware of.
OR
- Patient presents with central vestibular signs and needs to be referred to MD
```
36
What is the interpretation of spontaneous nystagmus observed in goggles?
- Patient may have an acute (not yet compensated by the central nervous system) peripheral hypofunction
OR
- Patient has central presents
with central vestibular sign and needs to be referred to MD
37
How is the smooth pursuit and convergence test assessed?
* Assessed during oculomotor exam; ambient light
* Ask the patient to follow finger
* Notice if the eye movement is smooth or “interrupted”
* Notice if both eyes converge and at what distance the patient reports double vision
38
What is the interpretation of the smooth pursuit and convergence test?
• Normal = smooth eye movements with minimal to no symptoms reported by patient
• Abnormal = delays or “saccadic intrusions” interrupting smooth eye
movement
• Abnormal = patient reports double vision greater than 3-4 inches from nose
• Possible central vestibular dysfunction
39
How is the saccadic eye movement test done?
* Therapist sits in front of patient approx 18 inches away, holding patient’s head stable
* Patient asked to look back and forth from 2 targets (ie finger and therapist nose) right/left, up/down
* Note if the eyes hit the target in 1 movement, multiple movements, or overshooting/under-shooting
40
What is the interpretation of the saccadic eye movement test?
* Normal = eyes hit the target in 1-2 movements with minimal to no symptoms reported by patient
* Abnormal = multiple eye movements to get to target, under or overshooting target
* Possible central vestibular dysfunction
41
How is the VOR Cancellation done?
* Visual fixation in room light; patient is sitting with eyes on a target (arms extended in front of nose with eyes on thumbnail)
* Have the patient place one arm extended with thumb up
* Patient asked to rotate their arm and trunk LEFT and RIGHT
* Patient’s head rotates with the trunk so that their NOSE and EYES remain on their thumb
* REPEAT with VERTICAL head motions
42
What is the interpretation of the VOR Cancellation test?
* Remember… the VOR is the ability of the eyes to move equal and opposite to head motion, to keep the image stable on the retina (aka gaze stabilization)
* Therefore… VOR cancellation is the ability to “cancel” the VOR and move the eyes together with the head
* Normal = head and eyes move together with minimal to no symptoms reported by the patient
* Abnormal = inability of eyes to stay on target, dizziness or other symptoms reported by patient
* Possible central vestibular dysfunction
43
How is the gaze-evoked nystagmus test done?
* Fixation is blocked (goggles on); ask patient to move eyes to the left, right, up, down, and back to center
* Observe nystagmus when patient holds each direction
* Do not go to end range as end range nystagmus could be normal; just need 30 degrees
44
What is the interpretation of the gaze-evoked nystagmus test?
Nystagmus from a PERIPHERAL lesion follows Alexander’s Law
• Direction FIXED nystagmus (eyes will beat in the same direction no matter which way patient looks)
Nystagmus from a CENTRAL lesion does not follow Alexander’s Law
• Direction CHANGING nystagmus (eyes might beat up when the patient looks up, beat down when looks down, etc)
45
How is the head shaking nystagmus test done?
* Fixation blocked (goggles on)
* Hold the patients head at about 30 degrees of cervical flexion
* Patient closes eyes, assist turning head right/left for 20 reps, asking patient to open eyes after 18 reps
* After 20 reps, head held stable, observe if nystagmus is present
46
What is the interpretation of the head shaking nystagmus test?
* Positive finding = nystagmus beats towards the intact neural side
* Fast phase towards intact/more active neural side (contralateral side has hypofunction)
* Usually will coincide with positive head thrust test and patient history for unilateral hypofunction
47
How is the head thrust test done?
* Visual fixation (room light); ask patient to fixate eyes on a target (ie. therapist nose)
* Hold patients head in about 30 degrees of cervical flexion
* Quickly rotate patient’s head about 30 degrees, while eyes try to remain on target
* Repeat to right and left in random order, pausing after each time
48
What is the interpretation of the head thrust test?
* Eyes will move off target, delay in returning to target
* Positive finding = delay will occur on impaired side
* Unilateral or Bilateral Peripheral hypofunction
49
How is the Dynamic Visual Acuity (DVA test) done?
• Patients sits approx 4 feet from chart
• Ask patient to read the lowest
line they can see clearly, without squinting or leaning
forward
• Manually move patient’s head quickly side to side at speed of 2HZ or 120 beats/min, AS THEY READ FROM TOP TO BOTTOM
• Note the difference between the static (head stable) line and dynamic (head moving) line
50
What is the interpretation of the Dynamic Visual Acuity (DVA test)?
Testing the Vestibulo-ocular reflex… the ability of the eyes to stabilize a target while the head moves
• 2 or less line difference = normal
• 3 lines or greater = abnormal
• Decreased Vestibulo-ocular reflex
• Possible peripheral hypofunction
• Possible underlying central dysfunction
51
What is Benign Paroxysmal Positional Vertigo (BPPV)?
A peripheral vestibular disorder, where the otoconia becomes dislodged from the utricle and enter the semicircular canals disrupting the: Vestibular ocular reflex (VOR).
52
What is the key symptom of Benign Paroxysmal Positional Vertigo (BPPV) and why?
Vertigo, caused by the incorrect reflexive repositioning of the eyes
53
What is key in Benign Paroxysmal Positional Vertigo (BPPV)?
The otoconia only disrupt fluid mechanics during movement, therefore symptoms of vertigo should only occur during movement and resolve quickly
54
What are the expected subjective history symptoms of Benign Paroxysmal Positional Vertigo (BPPV)?
1. Type of Dizziness: TRUE VERTIGO
2. Circumstance: With sudden head movements
3. Duration: Lasting less than 1-2 minutes
55
What is the overall goal of a Benign Paroxysmal Positional Vertigo (BPPV) exam?
To rule in the involved semicircular canal.
Remember: if you expect BPPV from a subjective history, do NOT perform other vestibular or ocular motor tests first – BPPV can cause you to have inaccurate findings
56
Why should a patient refrain from taking Meclizine 24 hours prior to a Benign Paroxysmal Positional Vertigo (BPPV) examination?
• MECLIZINE is a prescription drug (Antihistamine) that suppresses the vestibular ocular reflex in an attempt to reduce vertigo symptoms
*Many physicians (especially ED physicians) will prescribe Meclizine for people who have vertigo
• Correct BPPV diagnosis is dependent on visualizing the correct nystagmus
57
What are the clinical exams done for Benign Paroxysmal Positional Vertigo (BPPV)?
• Begin with clearing the cervical spine to insure that the exam will be safe for the patient
1. Vertebral Artery Test
2. For Suspected Trauma – Sharp Purser + Alar Ligament
• Follow with the recommended positional testing for each
semicircular canal while assessing for: nystagmus AND subjective vertigo
58
What is the goals for a Vertebral Artery Test?
Induce compression of the vertebral arteries
59
How is the vertebral artery test done?
1. Place the neck in full extension and rotation
2. Hold for 30 seconds
3. Repeat opposite side
• Looking for cranial nerve involvement!
60
What is the goal for positional testing for Benign Paroxysmal Positional Vertigo (BPPV)?
After clearing the neck we can use positional testing to rule in or rule out semicircular canal involvement
61
What are the positional testing done for Benign Paroxysmal Positional Vertigo (BPPV)?
1. Dix-Hallpike (Posterior and Anterior Canals)
| 2. Horizontal Roll Test (Horizontal Canals)
62
What are the key instructions for positional testing done for Benign Paroxysmal Positional Vertigo (BPPV)?
* Instruct the patient to maintain open eyes
* Assess for BOTH vertigo and nystagmus
* Note the DIRECTION (canal) and TIME (canalith vs. cupulo) of the nystagmus
63
In what direction will we see nystagmus in R posterior canal in Benign Paroxysmal Positional Vertigo (BPPV) on the Dix-hallpike test?
Up and RIGHT torsional
64
In what direction will we see nystagmus in L posterior canal in Benign Paroxysmal Positional Vertigo (BPPV) on the Dix-hallpike test?
Up and LEFT torsional
65
In what direction will we see nystagmus in R anterior canal in Benign Paroxysmal Positional Vertigo (BPPV) on the Dix-hallpike test?
Down and RIGHT torsional
66
In what direction will we see nystagmus in L anterior canal in Benign Paroxysmal Positional Vertigo (BPPV) on the Dix-hallpike test?
Down and LEFT torsional
67
In what direction will we see nystagmus in R horizontal canal in Benign Paroxysmal Positional Vertigo (BPPV) on the roll test {Canalithiasis}?
Geotropic (RIGHT Beating)
68
In what direction will we see nystagmus in L horizontal canal in Benign Paroxysmal Positional Vertigo (BPPV) on the roll test {Canalithiasis}?
Geotropic (LEFT Beating)
69
In what direction will we see nystagmus in R horizontal canal in Benign Paroxysmal Positional Vertigo (BPPV) on the roll test {Cupulolithiasis}?
Ageotropic (LEFT Beating)
70
In what direction will we see nystagmus in L horizontal canal in Benign Paroxysmal Positional Vertigo (BPPV) on the roll test {Cupulolithiasis}?
Ageotropic (RIGHT Beating)
71
What are some notes to keep in mind when doing the roll test for Benign Paroxysmal Positional Vertigo (BPPV)?
- Side affected for Canalithiasis is the SIDE with MORE active GEOTROPIC NYSTAGMUS
- Side affected for Cupulolithiasis is the SIDE with LESS active AGEOTROPIC NYSTAGMUS
72
Nystagmus lasting less than 60 seconds is considered ____
Canalthiasis
73
What does canalthiasis indicate?
This indicates that the otoconia are not adhered to the semicircular canals and able to be reduced back to the utricle with canalith repositioning
74
Nystagmus lasting longer than 60 seconds is considered
| ___
Cupulolithiasis
75
What does cupulolithiasis?
This indicates that the otoconia are adhered to the semicircular canals and need to be treated with a liberatory maneuver BEFORE you can use canalith repositioning
76
What are the directions for the Dix-Hallpike (Posterior and Anterior Canals) test?
1. Position the patient in long sitting
2. Turn the patient’s head into 45 degrees of cervical rotation
3. QUICKLY guide the patient back onto the mat with 20-30 degrees of cervical extension
77
What are the keys when doing the Dix-Hallpike (Posterior and Anterior Canals) test?
* Instruct the patient to maintain open eyes
* Assess for BOTH vertigo and nystagmus
* Note the DIRECTION and TIME of the nystagmus
78
What are the directions for the Roll Test (Horizontal Canal) test?
1. Patient placed supine
2. Position the head in 20-30 degrees of flexion
3. Roll the patient’s head to the RIGHT or LEFT
4. Repeat to the opposite side
79
What are the keys when doing the Roll Test (Horizontal Canal) test?
* Instruct the patient to maintain open eyes
* Assess for BOTH vertigo and nystagmus
* Note the DIRECTION and TIME of the nystagmus
80
What are some general clinical tips for Benign Paroxysmal Positional Vertigo (BPPV)?
1. Remind the patient that the treatment will reproduce their symptoms
2. It is important that they do not move or sit up during the treatment
3. Encourage them to keep their eyes open
• Remind the patient that this treatment will fix their condition. And even though they will feel dizzy and possibly nauseated, you will support them and make sure they do not fall.
81
What does Benign Paroxysmal Positional Vertigo (BPPV) primarily consist of?
Selecting the appropriate canalith repositioning maneuver to return the otoconia into the utricle
82
How can canalithiasis be directly?
Can be directly treated with repositioning
83
How is cupulolithasis treated?
First treated with a liberatory maneuver followed by repositioning
84
When should an oculomotor exam?
Always perform oculomotor test 1st
85
A BPPV exam uses a variety of patient positions that ______
A BPPV exam uses a variety of patient positions that *isolate each vestibular canal in a gravity dependent position*
86
What is the Benign Paroxysmal Positional Vertigo (BPPV) treatment for Anterior OR Posterior CANALITHIASIS?
Epley maneuver
87
What is the Benign Paroxysmal Positional Vertigo (BPPV) treatment for Left OR Right Horizontal CANALITHIASIS?
BBQ Roll
88
_____ are the first position for their respective treatments for BPPV treatment for canalithasis?
The testing positions (Dix-Hallpike) and (Horizontal Roll)
• Therefore, if you have a positive canalithiasis you have two options:
1. You can immediately begin treatment
2. Or you can assess for other canal involvement
89
What is the Benign Paroxysmal Positional Vertigo (BPPV) treatment Anterior OR Posterior
CUPULOLITHIASIS?
Semont Liberatory
90
What is the Benign Paroxysmal Positional Vertigo (BPPV) treatment Left OR Right Horizontal CUPULOLITHIASIS?
Gufoni (Casani)
91
For the BPPV treatment for cupulolithiasis, what should be done after performing a liberatory maneuver?
Reassess with positional testing.
• Following the maneuver you should:
1. Continue to see a cupulolithiasis nystagmus pattern and need to perform the liberatory maneuver again
OR
2. See a conversion of the nystagmus to a canalithiasis pattern and need to perform a
repositioning maneuver
92
What are the characteristics of patient tolerance and management in the treatment of BPPV?
• You should ALWAYS reassess immediately following a repositioning or liberatory maneuver to assess the effectiveness of your treatment
• If you did not clear a canal (or liberate the otoconia) on the first attempt, you can perform maneuvers multiple times in one treatment session
*This is primarily based on patient tolerance!*
93
What is one of the biggest things we want to avoid when treating BPPV?
CANAL Conversion
94
When is canal conversion thought to occur?
If patients move too quickly or in provoking postures following treatment
95
What are the tips to the prevention of conversion?
* After treating for BPPV, end the session
| * Have the patient avoid any sudden head movements for 3 hours following treatment
96
What is the POC for BPPV?
* Majority of individuals will have symptom resolution in 1-4 treatments
* Depending on the severity or length of time a patient has had BPPV, they may require follow up treatment for postural instability
97
What are some alternative BPPV treatment exercises?
• Individuals who visit an ENT or Audiologist are often prescribed BrandtDaroff exercises
• While these exercises can cure BPPV, they often have a much longer treatment duration and they have a high degree of symptom exacerbation as a side effect
• If you have a patient who is performing these you will want to encourage them to stop!
- These ARE NOT home exercises to accompany clinical treatment
98
What are the directions for the Brandt-Daroff Exercises?
1. The patient moves quickly into a side-lying position on the affected side
2. Hold for 30 sec after vertigo stops
3. Patient sits up
4. Hold for 30 seconds after vertigo stops
5. The patient moves quickly into a side-lying position on the unaffected side
6. Hold for 30 sec after vertigo stops
7. Patient sits up
*REPEAT 10-20x/day for 3x/day until vertigo is eliminated for
2 days in a row.
99
What are the directions for position 1 on the Epley Maneuver?
* Patient placed in long-sitting
* Asked to turn head toward clinician
* Patient holds clinicians arm
* Clinician holds patient’s upper body
* Patient lies back until their head is in 20 to 30 degrees of extension
Each position maintained for 60 seconds
100
What are the directions for position 2 on the Epley Maneuver?
* Patient’s head ROTATED 45 degrees the opposite side
* MAINTAIN cervical extension
Maintained for 60 seconds
101
What are the directions for position 3 on the Epley Maneuver?
* Patient asked to roll onto their side and tuck their chin
* The clinician will turn the patient’s head so that the forehead is towards the mat
Maintained for 60 seconds
102
What are the directions for position 4 on the Epley Maneuver?
* Patient returned to sitting
* Head in 20-30 degrees of flexion
* Wait for approximately 30 seconds
Maintained for 60 seconds
103
What are the directions for position 1 on the BBQ Roll?
* Patient placed in supine
* Place the patient’s head in 20-30 degrees of flexion (for the whole treatment)
* Rotate the head so that the affected side is down
Maintained for 60 seconds
104
What are the directions for position 2 on the BBQ Roll?
• Rotate the patient’s head to a neutral position
Maintained for 60 seconds
105
What are the directions for position 3 on the BBQ Roll?
Rotate the patient’s head so that the unaffected side is down
Maintained for 60 seconds
106
What are the directions for position 4 on the BBQ Roll?
* Rotate the patient’s head so that they are looking at the ground
* Have the patient roll onto their stomach for comfort
Maintained for 60 seconds
107
What are the directions for position 5 on the BBQ Roll?
• Rotate the patient’s head so that the affected side is down
• Have the patient roll onto their side for comfort
*This will return them to the starting position
Maintained for 60 seconds
108
What are the directions for position 6-7 on the BBQ Roll?
Have the patient slowly sit up from the sidelying
Maintained for 60 seconds
109
What is the start position of the Semont Liberatory?
Patient sitting edge of bed facing clinician
110
What are the directions for position 1 of the Semont Liberatory?
• Patient turns head away from suspected side (45 degrees rotation) Hold for 1 minute
• Patient moves sit-to-sidelying opposite side of head turn, maintaining head position
Hold for 1 minute
111
What are the directions for position 2 of the Semont Liberatory?
• Patient transferred in a SMOOTH and QUICK motion to sidelying on opposite side, maintaining head position
KEY: Use your arm on the patient’s head to prevent it from hitting the mat
112
What are the directions for position 3 of the Semont Liberatory?
* Patient returned to sitting
| * Head flexed 20-30 degrees
113
What are the directions of the Gufoni (Casani)?
1. The patient moves from sitting to sidelying with the AFFECTED ear DOWN
2. The patient quickly rotates the head so that the nose is angled at 45 degrees
3. Hold for 2-3 minutes
4. Return to sitting
114
What are some examples of the diagnoses in the Stable Unilateral Deficit (Unilateral Vestibular Hypofunction) rehab category?
- Post-acute vestibular neuritis or labyrinthitis
- Post-surgery on the vestibular system (neuromas)
- Inactive Meniere’s
115
What are some examples of the diagnoses in the Stable Bilateral Deficit (Bilateral Vestibular Hypofunction) rehab category?
Exposure to medications
116
What are some examples of the diagnoses in the Unstable Unilateral or Bilateral Deficit rehab category?
- Acute vestibular neuritis or labyrinthitis
- Acoustic Neuroma
- Chemotherapy
117
What are some examples of the diagnoses in the Central Vestibular Deficit rehab category?
- Stroke
- Motion Sensitivity
- Migraines
- Concussion
118
What are some examples of the diagnoses in the Non-vestibular Deficits rehab category?
- Psychological (anxiety)
- Peripheral neuropathy
- Postural Instability (fall risks)
- Cervigogenic Dizziness
119
What are the mechanisms of recovery for vestibular dysfunction?
* Adaptation
* Habituation
* Substitution
Some individuals have spontaneous recovery
120
What is the mechanism for adaptation in the recovery of vestibular dysfunction?
The vestibular system changes it’s response to accommodate
| for lost abilities. (ex: peripheral damage – unilateral hypofunction)
121
What is adaptation specific to in the recovery of vestibular dysfunction?
Only specific to changes that occur in the gain of the VOR with a goal of improving gaze stability to reduce disequilibrium
122
What kind of pathology is the adaptation mechanism commonly selected for?
Stable peripheral vestibular pathologies
123
What are gaze stability exercises designed to do?
Designed to progressively load the central nervous system in order for the Vestibular Ocular Reflex (VOR) to adapt to peripheral vestibular changes
124
What are the Gaze Stability Treatment Prescription?
1. Patient places a card with a letter at arms distance which they can see CLEARLY
2. Patient asked to rotate their head LEFT and RIGHT 30 degrees/side for 1 minute
* REPEAT with the card at a distance of 6 feet
* REPEAT with UP and DOWN head movements 20 degrees/direction for 1 minute at BOTH distances
125
What is the goal for gaze stability exercises for vestibular dysfunction?
For the patient to increase to the maximum speed while maintaining CLARITY of the letter.
126
What is the frequency at which the prescription of gaze stability exercises for vestibular dysfunction?
3x/day
127
What is the volume at which the prescription of gaze stability exercises for vestibular dysfunction?
Up to 2 minutes per exercise
128
What is the load at which the prescription of gaze stability exercises for vestibular dysfunction?
Determined by subjective disequilibrium complaints
129
What is the intensity at which the prescription of gaze stability exercises for vestibular dysfunction?
Progression from wide to narrow base of support
130
What should be monitored during gaze stability exercise?
Have the patient rate their dizziness from 0-10 prior to the exercise:
• Any increase in their rating after competition of the activity should reduce with in 5 minutes. IF it DOES NOT decrease DISCONTINUE exercises for that
day.
131
What should be sure to have the patient incorporate in gaze stability exercise?
Be sure to have the patient incorporate head turning VOR activities into daily
routines
132
What is the mechanism of habituation for the treatment of vestibular dysfunctions?
To gradually expose individuals to provoking stimuli in order to
reduce their symptomatic response
133
What type of individuals is habituation useful for in vestibular dysfunction?
When individuals have general nondescript dizziness to
| positional changes or visual stimuli
134
What type of deficits is habituation commonly selected for?
Stable bilateral or central vestibular deficits
135
What are the habituation treatment prescription?
1. Identify symptom provoking positions, movement or stimuli
2. Chose 3-5 exacerbating motions
3. Repeat each motion 3-5 times ADVANCE up to 5-10 times *Rest 20-30 sec between movements
4. 2-3 times per day
Always have the patient rate their dizziness from 0-10 prior to the exercise. Any increase in their rating after competition of the activity should reduce with in 5 minutes. IF it DOES NOT decrease DISCONTINUE exercises for that day.
136
What are the characteristics of the progression of habituation?
• As individuals become more comfortable, you can add more challenging or complex
movements that induce symptoms
• Ex: Change base of support, movement speed, direction, frequency
• Unfortunately, there is not always a transfer of improvement from one task to another
137
What is the overall goal for the habituation mechanism of treating vestibular dysfunction?
For the patient to gradually improve sensitivity to all
| provoking movements and have a framework for addressing future concerns
138
What is the mechanism of substitution for the treatment of vestibular dysfunctions?
To implement strategies that can replace or compensate for
lost and/or impaired function.
Examples include: increases in strength, ROM and proprioception; assistive
devices or activity modification
139
What type of diagnoses is substitution commonly selected for?
Stable bilateral vestibular deficits and nonvestibular deficits BUT can be used across all diagnoses
140
Why is it important to assess and treat the cervical spine in to ALL vestibular patients?
Afferent information from the cervical spine is known to influence postural stability by effecting the vestibular and ocular neural networks
141
What are the ways to make vestibular exercises harder?
* Modifying base of support
* Incorporating head and oculomotor movements
* Increasing speed of movements
* A good rule of thumb is to:
* Determine the intensity using patient response of their dizziness from 0- 10
* The sweet spot is to increase dizziness 2-3 points during the activity that resolves with 1-2 minutes of rest
142
What types of patients are not good candidates forPT until their condition is stable?
Unstable Unilateral or Bilateral Deficit
143
What are the mechanism of recovery for Stable Bilateral Deficit (Bilateral Vestibular Hypofunction)?
Substitution, Adaptation
144
What are the characteristics of a Visual Analog Scales?
• Similar to pain, you can have your patient rate their symptoms using a VAS
• Ex: Vertigo, lightheadedness, disequilibrium, etc.
“How intense are your symptoms?”
• 1 – not very intense
• 10 – the worst possible intensity
145
What are the characteristics of Dynamic Gait Index (DGI)?
```
• Individuals are asked to walk while invoking various vestibular sensory input
• 8 items : Scored from 0-24
Fall Risk Cut off score: Vestibular Dysfunction 19/24
• FGA Expands on the DGI to include:
1. Backwards walking
2. Tandem walking
3. Walking with eyes closed
4. REMOVES navigating obstacles from DGI
```
146
What are the characteristics of Activities-Specific Balance Confidence Scale (ABC)?
• Individuals are asked about their confidence in their ability to compete several tasks without falling
• Uses a scale of 0-100%
- 0 indicates no confidence and that an individual believes they will fall when doing the
task
Fall Risk Cut off score: Community dwelling older adults <67%
147
What are the characteristics of the Dizziness Handicap Inventory (DHI)?
• Individuals are asked about the effect of their dizziness on physical, social
and emotional well-being
• 25 Items : Scored as Yes, No, Sometimes
• Higher scores indicate more impairment
- Mild: 0-30
- Moderate: 31-60
- Severe: 61-100
Fall Risk Cut off score: >59
148
What are the characteristics of the Motion Sensitivity Quotient (MSQ)?
• The MSQ assess’ an individual’s symptom response to common provoking
positions
- Examples: Dix Hallpike positions, Sit to stand, rolling
• Individuals are scored based on the intensity and duration of their symptoms
• Provoking positions can be used as part of a habituation training program
149
What are the scoring scale for the Motion Sensitivity Quotient (MSQ)?
• Symptom Intensity: Patient report scale from 0 to 5
- (0 = no symptoms, 5 = severe symptoms)
• Symptom Duration: Scale from 0-3
- (5-10 sec = 1 point; 11-30 sec = 2 points; >30 sec = 3 points)
• TOTAL SCORE = Intensity + Duration for each position change
150
What are the scoring interpretation for the Motion Sensitivity Quotient (MSQ)?
MSQ = (# Positions Total Score) /20.48
• Mild: 0-10
• Moderate: 11-30
• Severe: 31-100
151
What is the goal of the sensory organization testing?
The goal of SOT testing is to identify sensory or afferent feedback impairments to postural control
152
Why is each test on the sensory organization testing performed in stages?
To isolate either vestibular, visual or somatosensation sensory systems
153
What are the conditions of the CTSIB “Foam and Dome"?
* Stand on floor: EO, EC, Visual-conflict dome
* Stand on Foam: EO, EC, Visual-conflict dome
```
EO= eyes open
EC= eyes closed
```
154
What are the characteristics of neurocom?
* Computerized posturography version of the CTSIB
| * Provides quantitative data on postural stability
