Balance and Vestibular Disorders

Question 1

What is balance?

Answer 1

The control of relative positions of body parts by skeletal muscles with respect to each other.

Question 2

What sensory systems are responsible for maintaining balance?

Answer 2

Somatosensory
Visual
Vestibular

Question 3

How can the somatosensory, visual and vestibular systems be assessed?

Answer 3

Somatosensory = examine proprioception, cutaneous sensation (touch/pressure), examine feet and LE when standing on different surfaces

Visual = examine visual acuity, depth perception and visual field defects

Vestibular = observe balance with changes in head position

Question 4

Describe the 4 different balance strategies.

Answer 4

Ankle strategy = ankle muscles (DF and PF) maintain balance by shifting the COG forward and back using a long axis of motion (LE is relatively fixed)

Hip strategy = hip and lower trunk muscles maintain balance by shifting COG using hip motions (flexion or extension)

Stepping strategy = rapid steps are taken to realign COG within BOS

Suspensory strategy = Used to lower the COG during standing or ambulation in order to better control the COG (i.e. knee flexion, crouching or squatting)

Question 5

Explain the vesitbuloocular reflex (VOR).

Answer 5

VOR allows for head and eye movement coordination . This reflex supports gaze stabilization through eye movement that counters movement of the head. This maintains a stabile image on the retina during movement.

Question 6

Explain the vestibulospinal reflex (VSR).

Answer 6

VSR attempts to stabilize the body and control movement. This reflex assists with stability while the head is moving as well as coordination of the trunk during upright postures.

Question 7

What is vertigo?

Answer 7

Sense of movement and rotation of oneself or the surrounding environment

Typically a sensation of spinning but can also present as linear motion or falling

Question 8

Provide 6 examples of conditions that can cause peripheral vertigo.

Answer 8

BPPV
Meniere's disease 
Infection
Trauma/tumor 
Metabolic disorder (i.e. diabetes) 
Acute alcohol intoxication

Question 9

Provide 6 examples of conditions that can cause central vertigo.

Answer 9

Meningitis
Migraine headaches
Complications of neurologic origin post ear infection
Trauma/tumor
Cerebellar degeneration disorders (i.e. alcoholism)
Multiple sclerosis

Question 10

What is benign paroxysmal positional vertigo (BPPV)?

Answer 10

Compromised of repeated episodes of vertigo that occur subsequent to changes in head position. Episodes last for a few seconds.

Otoconia in the inner ear loosen and travel into the semicircular canals, causing vertigo

Question 11

What canal is most commonly affected in patients with vertigo? How can BPPV be treated?

Answer 11

Posterior semicircular canal

Treated using the Epley maneuver or Brandt-Daroff exercises

Question 12

What test is used to assess for the presence of BPPV? Describe how to perform this test.

Answer 12

Dix-Hallpike test

1. Patient is in long sitting with head rotated to 45 degrees
2. Rapidly move the patient into supine position with the head rotated to 45 degrees and extended 30 degrees off the edge of the table
3. Hold the head in this position for 20-30 seconds while observing for nystagmus and onset of sxs

Question 13

What is Meniere’s disease?

Answer 13

Recurrent and progressive vestibular disease associated with vertigo, DEAFNESS, tinnitus, and sensation of pressure or fullness in the ear

Question 14

What is nystagmus?

Answer 14

Involuntary, cyclical movement of the eye ball that can be bidirectional or unidirectional

Question 15

List 5 characteristics of central nystagmus.

Answer 15

Direction = bidirectional or unidirectional
Visual fixation = no inhibition with fixation
Vertigo = mild
Length of symptoms = may be chronic
Etiology = demyelination of nerves, vascular lesion, cancer/tumor

Question 16

List 5 characteristics of peripheral nystagmus.

Answer 16

Direction = unidirectional with fast segment of movement indicating the opposite direction of lesion
Visual fixation = will inhibit nystagmus and vertigo
Vertigo = significant
Length of symptoms = minutes, days, weeks, but finite period of time; recurrent
Etiology = Meniere’s disease, vascular disorders, trauma, toxicity, infection of inner ear

Question 17

What MUST be screened prior to assessing for vestibular dysfunction?

Answer 17

Cervical ROM

Vertebral artery test

Question 18

How is the vertebral artery test performed?

Answer 18

In supine position, extend, laterally flex and rotate the head, hold for 30 seconds; test each side separately

Compression of the vestibular artery can produce vestibular symptoms

Question 19

Describe the Berg Balance Scale.

Answer 19

1. Used to assess a patient’s risk for falling
2. Assess 14 tasks including static/dynamic tasks and transitional movements in sitting and standing positions
3. Maximum score is 56, with a score less than 45 indicating increased risk for falling

Question 20

Describe the Fugl-Meyer Sensorimotor Assessment.

Answer 20

1. Used to assess balance specifically in patients with hemiplegia
2. Assesses 7 tasks
3. Maximum score is 14, but patients can get max score and still have balance impairements

Question 21

Describe the functional reach test.

Answer 21

1. Used to assess standing balance and risk of falling
2. Person is required to stand upright with static BOS. Yardstick is positioned to measure the forward distance that a person can reach without moving the feet. Three trials are performed and then averaged together.
3. A person who falls below the age related standards is at an increased risk of falling

Question 22

List the age related standards for the functional reach test.

Answer 22

20-40 years = 14.5-17 inches
41-69 years = 13.5-15 inches
70-87 = 10.5-13.5 inches

Question 23

Describe the Romberg Test.

Answer 23

1. Used to assess balance and ataxia
2. Patient stands in normal standing position, first with eyes open and then with eyes closed.
3. Normal if patient can maintain each position for 30 seconds

Question 24

Describe the Sharpened Romberg Test.

Answer 24

1. Used to assess balance and ataxia
2. Patient stands in a tandem heel-to-toe position, first with eyes open and then with eyes closed.
3. Normal if patient can maintain each position for 30 seconds

Question 25

Describe the Timed Up and Go Test.

Answer 25

1. Functional performance screening tool used to assess mobility and balance.
2. Person sits in supported chair, transfers to standing position, and walks 10ft. Person then turns around, walks back towards the chair and returns to a sitting position
3. Scored based on amount of postural sway, excessive movements, reaching for support, sidestepping or other signs of LOB.

Question 26

Describe the Tinetti Performance Oriented Mobility Assessment.

Answer 26

1. Used to screen for increased risk of falling
2. Assess STS, standing balance, and gait
3. Maximum score is 28. Score of less than 19 indicates HIGH risk for falls.

Question 27

What is the difference between static and dynamic balance?

Answer 27

Static = ability to maintain a position and response to perturbation

Dynamic = Response to dynamic movement challenges

Question 28

Describe the Dynamic Gait Index.

Answer 28

1. Used to assess dynamic gait (changing speed, head turns, pivots, stairs, obstacles)
2. Maximum score of 24. Score of 22/24 indicates safe ambulation while scores <19/24 are predicted of falls in the elderly.