EXAM 2 Flashcards
horizontal canals cause vertigo sx when you move your head
side to side
a VOR less than ___ indicates the eyes are moving slower than the head
1
vestibular sx often produce a ____output to correct
motor
vestibular anatomy is broken into 3 main categories, what are they
peripheral sensory apparatus (inner ear)
central processing center
motor ouput sx
what is peripheral sensory apparaus
inner ear
Provides sensory input about BOTH angular and linear acceleration
Orients the head with respect to gravity
what is central processing center
Somatosensory and visual cues
Cerebellum
Reticular formation, cortex
what is motor output sx
Generates compensatory eye movements for gaze stability
Body movements for postural stability with locomotion (through vestibulospinal tract
explain how your body detects movement in the inner ear
Canals detect head movement (ant, post and lateral)hair cells are sensory organs, when endolymph fluid moves it effects hair cells
what makes up the labyrinth (inner ear)
Contains 5 sensory organs: 3 semicircular canals Anterior Posterior Lateral
2 otolith organs
Utricle
Saccule
Hair cells-motion sensors
each ear canal is ___to the other
perpendicular
explain the “push pull” reaction of the inner ear cannals
bc of the positioning of the canals, turning head 1 way would excite 1 canal but inhibit it’s opponent
information from the canals is used to
stabalize vision
Macula of the utricle is oriented in the ___plane
horizontal
macula of the sacule is oriented in the ___ plane
vertical
information from the otolith organs is used for
balance control
both the sacule and urtricle have
macula (hair cells and crystals here)
2 central processors (vestibular)
vestibular nuclei
cerebellum
explain how firing rate of nuclei can make a person feel dizzy
Both vestibular nuclei (each side) will fire at a certain frequency. For example, turning head to right, the right vestibular nuclei has higher frequency of firing (how your brain knows you have turned to the right) eyes and postural muscles will fall in line with what the brain tells them.
But, if one side of the nuclei is not firing as much, the other is firing all the time and the brain thinks the person is always turning head to the side it’s firing, so the eyes and postural muscles will try to fall in line (even though it’s not right) = dizziness
your eyes remain stationary during walking bc of your
VOR
deficit of the VOR results in
osscilopsia
the VOR is regulated by
Regulated by afferent input from semicircular canals
VOR is induced by ___ speed
FAST
nystagmus indicates
1 vestibular sx is more active than the other
when the vestibular nuclei aren’t equal
nystagmus is classified/named by
the direction of quick beat
explain hypo/hyper active sides with nystagmus
If sx come on when head is turned to the right, then right side is hypofunction side
what is disuse disequilibrium
sedentary lifestyle (they don’t move much, but when they do get up they get dizzy) NON vestibular issue
examples of disuse disequilibrium
ortho hypotension
panic attacks
migraine
TIA
Bacterial infection of the labyrinth
Can cause hearing loss
vestibular labyrinthitis
these occur at the round or oval window
these seperate the middle ear and the inner ear
d/t trauma or injury
perilymph fistula
peripheral vest. disorder
what irritates a perilymp fistula
auditory stimulus
strain/increase in pressure
causes sx of vertigo or imbalance
what is Meniere’s disease
a peripheral vestibular disorder
Onset in fourth- sixth decades of life (older pts get)
Malabsorption of endolymph in the endolymphatic duct and sac = too much endolymp
Devastating vestibular and HEARING LOSS
Fullness in ear, reduced hearing,
rotational vertigo, nausea.
bilateral vestibular Loss is often caused by
often caused by toxic drugs (if they are in sepsis)
Gentamyacin
sx of peripherial vestibular disorders
Hearing loss, tinnitus, VERTIGO, nystagmus, gait ataxia, impaired VOR
vertigo with head movement
list the anatomy or the disorders assct. with peripheral disorders
Peripheral sensory apparatus
Vestibular neuritis, labyrinthitis, BPPV, Meniere’s, Perilymphatic fistula, Acoustic Neuroma
sx of central vestibular disorders
saccades, Oscillopsia, nausea, disequilibrium, ataxia, impaired smooth-pursuit eye movements, impaired VOR, headache, diploplia, bad Balance probs
what constitues a central vestibular disorder
Damage to vestibular nuclei, or central pathways that serve VOR and VSR, brain stem or cerebellum
with VOR, moving your head in 1 direction…your eyes move the ___ direction (if normal)
opposite
at equal velocity
what is VSR
is a reflex body movement that maintains your posture and stabilizes your body; this reflex keeps you upright.
peripherial vestibular disorder, vertigo is brought on by
head mvmt
balance is really effected with ____ vestibular disorders
central and bilateral are bad
may have some issues with peripheral, but not as bad
hearing loss or tinnitus occur with ___ vestibular disorders
peripheral
compensation for peripheral vest. disorders occurs ___, whereas compensation for central disorders occurs ___
peripheral – fast
central–slow
What is DHI
dizziness handicapp inventory
higher score is worse
60 is fall risk
For each of the following activities, please indicate your level of self confidence by choosing a corresponding number from the following scale
0% 10 20 30 40 50 60 70 80 90 100%
No confidence completely confident
activities specific
balance
confidence scale
ABC under ___ increased fall risk
67
BPPV is usually
unilateral
sx with BPPV come on d/t
head position changes
the crystals fall out of place and land in one of the cannals
with BPPV, direction of nystagmus tells you___
duration of nystagmus tells you ___
Direction of the nystagmus will tell you which canal is involved
Duration will tell you the type of BPPV: canalithiasis or cupulolithiasis
anticipatory vs reactive control mechanisms
Anticipatory control mechanisms occur when you are expecting something to happen- ex: reaching to pick up a shoe from your chair so your back extensors kick in and you may grab the chair
Reactive control: occurs when you don’t know it’s coming
loss of selective mvmt is an issue with the
cortex itself
quiet stance (balance maintanance) is affected by
in a healthy adult
Body alignment/ position/posture
Muscle tone: Neural and non-neural factors
Postural tone: Influenced by somatosensory system, cutaneous afferent input, visual and vestibular systems
anticipatory control is ___ initiated
self
amt of anticipatory control is based on
experience
what are the 3 motor strategies to maintain balance
ankle
hip
stepping
what are 3 sensory strategies to maintain balance
vestibular
somatosensory (proprioception)
vision
what are the quicker motor strategies for balance
ankle = fast
these kick in first usually
ankle strategies usually occur with what amplitude of mvmt
smaller
if you push a person posteriorly, what muscle kicks in for ankle strategy (lower leg is opp of hip)
tib ant
if pt is on a balance beam (small surface and Med/Lat) what strategies are likely to be dominant to keep them balanced
hip
hip strategies are for smaller surface area
for hip strategies, if you are pushed forward what kicks in
quads
for medial lateral forces, what strategies are dominant
hip (like balance beam - heel to toe activities)
but remember - for narrow BOS it’s ankle
2 responses that occur with med/lat strategies
Cross-over response
Lateral step response
general reason why stroke pts have balance issues (adaptive)
for healthy people = Our balance responses are highly flexible – they adapt to forces and env around us
But – stroke pts don’t have variability and adaptability of movement (they are in synergy)
when eyes are closed, what sx is used (by adults)
proprioception
at quiet stance, what sx are used
all 3
at perturbed stance, what sx are used
in a healthy adult
Somatosensory/proprioception big role (bc they are faster)
Vestibular system becomes more active if:
Support surface moves vertically (up down)
lack of ____ is usually the issue of cognition with regards to balance
attentiveness/attention
what is the cycle of balance issues and fear of falls
Imbalance = leads to a big fear of falling
When someone fears falling they decrease their activity which leads to secondary impairment (like weakness) which can exacerbate future falls
most falls occur at ___ and are d/t ____
home - bathroom
tripping
big issue with pts who fall at home (the study listed)
51% cannot get up by themselves
this area of the brain controls adaptation abilities to modify muscle amplitude to respond to the need to move bc of env demands
cerebellum
number of meds for elderly that increase their fall risk
4 or more
classifications of meds that increase fall risk
Psychotropic Tricyclic antidepressants Seronin-reuptake inhibitors Cardiac medications Hypoglycemic agents
explain how stroke pts sequence their movement patterns
Stroke pts sequence proximal to distal
pts post stroke have better mvmt proximally than distally (using hip hike to walk)
These pts use proximal strategies over distal
based on the sequence of movement pattern of stroke pts, they use what strategies more
HIP (proximal)
issue of sequencing with PD pts
they co-contract
impaired adaptation (in order to move and respond) is due to
synergy
cognition issues
impaired timing is due to
timing occurs in cerebellum or fast twitch fiber loss dt coritical issue
what pts have impaired timing
stroke
PD
what pts have impaired scaling
Hypermetria – cerebellar issue (too much mvmt-issues regulating force)
Hypometria- Parkinsons pt
what LOWER (below knee) ext muscles kick in if COM is placed forward
gastroc
what is the issue with strategies (muscles firing) for pts with PD when their COM is displaced
instead of sequential muscles kicking in normally in order to respond, PD pts have co contraction and everything kicks in at same time so normal response does not occur
according to the study, what is the issue with strategies (muscle firing) for pts with cerebellar disorders when COM is displaced
they have the sequencial response, but it’s over done so the opposing muscle has to kick in too (this becomes cyclical)
loss of sensation or proprioception, pts have to rely on
vision
what is stability limit and why is it important
how far a person can move before losing balance
this is altered significantly if any of the 3 sx are lost/altered
what is inflexible weighting
a sensory selection prob
when pts dont use the correct sx for balance
ex: a pt post stroke who wont alter their stance or shift wt to effected side to prevent a fall
3 main reasons PD pts fall
postural instability
festiation/freezing
toppling over
pathology with highest risk for falls
PD
we should teach pts with stroke to fall to what side
non effected
fxs occur more when they fall on effected
post stroke, In pts are more likely to fall when
first 3 weeks of rehab (new normal and new env), then post dc from IP their risk increases again
balance deficits with stroke pts in quiet stance
⬆ reliance on uninvolved LE
⬆ sway
⬆ reliance on visual input
⬆deficits with dual-task conditions
balance deficits in stroke pts during anticipatory activity
⬇ weight shift involved LE
⬆ time to shift weight to involved LE
⬆ sway with UE movement with slowed motor latencies
balance deficits in stroke pts during reactive activity
slow muscle responses
synergistic responses
lack of coordination
when do MS pts typically fall
during movement (not quiet) turning, reaching
why do more men with MS fall typically
bc their MS is often more progressed
quick tests for ataxia
finger to nose
heel to shin
if vestibular sx is all a pt has (If that’s their best of the 3 sx) what is their likely outcome
bad balance probs
vest. is used last by healthy adults
Vest doesn’t stand well on its own
pts with MS fall usually bc of what 2 things
fatigue
distractions
important considerations when coming up with tx plan for balance (her general ones)
Static vs. progressive condition Acute vs chronicity Single- vs. multi-system involvement \+ and - prognostic indicators What can we change? What can’t be changed?
main concepts when tx balance with PD pts (the study we read)
With PD you are trying to help COM not be forward (alter their COM)
We want to give them increased excursions of motion
main concepts when tx balance in stroke pts (study we read)
use BEST test
if they have balance issues work on balance not gait
main concepts with tx balance in pts with MS (study we read)
incorporate sensation with dynamic balance
Flexibility in what muscles is most relevant for standing balance
ant tib for if you are pushed backwards, gastroc for pushed forward
how might ROM effect balance
loss of strategies if tone is effected
will strength training alone do anything for balance
no
what muscles can contribute to decreased lateral stability which increases fall/fx risk
hip abd
is closed or open chain better for balance tx
To help balance work on closed chain txs
how does timing/speed of muscle contraction play into tx for balance
Stepping responses are fast
Pts with neuro probs have more issues with fast speed
Responding quickly can be a coordination therex bc it’s working on timing
always do slow and fast speeds
tandem or single leg have to do with stance ___
position
what 2 pathologies do you want to increase excursion of mvmt
PD
stroke (towards effected side)
for ataxic pts you want to ____ excursion of mvmt
decrease
how would you increase challenge of perturbations
change:
force, frequency, surface level changes, eyes closed, velocity of the perturbation
balloon toss or badmitton are ex of ____ control reactions
reactive
3 sensory sx
visual
proprioception (somatosensory)
vestibular
when training balance, do you just want to do single task activities
no, incorporate dual task also
what is stroop task
a dual task activity
a neuro/psych test where color doesn’t match word
does altering env alone decrease fall risk
no
pts tend to add items to alter rather than take items away
for neuro pts is RW or SW better
RW requires least amt of attention
standard walkers require alot of attention
balance impariments, use what type of tests (OM)
predictive
psychometrics for predictive (diagnostic) tests
Sensitivity
Specificity
Probabilities
Likelihood Ratios
psychometrics for evaluative tests
MDC
MDIC
sensitivity tells you
tells you how accurate the test is at identifiying the condition
How confident can we be in the diagnostic capabilities of the test has to do with
LR
probabilities deal with
the pt
if it starts with ….the pt
Probability that a patient with a + test result will have the condition
high prob
Probability that a patient with a - test result will not have the condition
low prob
interpret this data
Postest prob test ≤ cut off
the Standards for the OM is 69/108
pt score is 61.3%
6 months 69%
12 months 43%
this is the LESS than
this means, if the pts score is less than the standard that is listed, than they have 69% chance of falls at 6 months and 43% chance of falls at 12 months
Retro-pts score
prospective -comparison scores
you want pos LR to be ___ and neg LR to be __
pos you want value to be high
neg you want to be low
In order to be in the green/confident category
formula for LR
Probability of + test in pt WITH condition/Probability of - test in pt WITHOUT condition
high confidence of LR (for pos and neg)
5 or greater (this is a pos LR)
.2 or lower (this is neg LR)
moderate confidence of LR
+ LR 2-5
- LR 0.2 – 0.5
a LR of 1 or close to 1 is
not relevant, like it’s neutral (.5-1 dont use)
list some specifics of the activities balance confidence scale
generic
16 items
self reported
Scoring: items rated on 0 – 100% continuous scale (higher = better); summed and divided by 16 = total score on 0 – 100 point scale
use ABC for what type of pts
community dweller, high level tasks, higher functioning pts.
ABC is for balance
specifics of the Tinettes (FES) OM test
Type of measure: Generic
Self-report
Purpose: perception of ability to complete various tasks without falling
Items: 10 – mainly household tasks
Scoring: 0 – 10 point scale (higher = better); scores summed; total score 0 - 100
Limitations:
Ceiling effect
lower level functioning and concerns/fear of falling,
SNF pts
what OM to use
Tinetti (FES)
FES is for FALLS
target population for Tinetti (FES)
SNF pts
homebound pts
specifics of BEST Test
Generic
Performance-based
Purpose: assist with identifying the underlying postural control systems responsible for poor functional balance
Items: 27 tasks / 36 items testing 6 systems
Scoring: 3 – 4 point scale; total score and subtest scores are obtained and calculated as a percentage of the total score
Limitations: time consuming (20 – 30 min.)
dimensions tested in BEST test
biomechanical stability limits reactive anticipatory sensory gait
BRAGSS
4 components tested in mini BEST
anticipatory
reactive
sensory
gait
RAGS
immediatley post stroke, the pt tone is
flaccid
what OM is good for testing turning in place
BERG
4 approaches to vestibular rehab
Adaptation
Substitution
Habituation
compensation
4 main categories of vestibular disorders
Unilateral
Bilateral peripherial hypofunction
Central –ex MS
BPPV
difference in approach for partial vs full loss in regards to vest tx
partial - remediate
full -compensatory
Why are ROM exercises important to do with vestibular pts
ROM of head and neck is important bc they often develop muscle imbalances from compensation and not moving dt sx
tx approach of vestibular pts depends on
Unilateral or bilateral involvement
Complete or partial vestibular loss
neuroplasticity indicates what
CNS is adapting
gaze stabalization exercises are _____ approach
adaptation
explain gaze stabalization exercises
Gaze stabilization ex retrain/restore eye/head muscle mvmts and retrain the sensitivity of the VOR
Aim to improve VOR by inducing retinal slip
Involve active eye & head movement to improve coordination between the two
gaze stabalization (adaptation) is good for what pts
unilateral
or bilateral with incomplete loss
explain substitution as a tx approach
Aim to improve the patient’s ability to use various sensory systems to improve balance control (vision/proprioception)
Use central preprogramming to improve gaze stability and postural stability
Stress system by reducing sensory cues –>forces patient to rely on other systems/cues
what is central pre programming
uses compensatory eye movements (use eye mvmts that are slower and maybe don’t correlate with head mvmt equally) purposefully not equal
used in substitution
what approach do you use for pts with car sickness (motion sickness)
habituation
how long does habituation take
weeks to months
explain principle of habituation
Learned suppression of vertigo through repetitive exposure to provoking movements
compensation is used to improve__
NOT to improve VOR
but rather, to improve function
compensation is used for what pts
central issues
bilateral issues
complete loss
examples of compensation
lighting
railings
assistive devices
(alternative strategies for function)
peripherial unilateral pts, what approach to use
adaptation/restoration
how long does tx for peripherial unilateral take
6-8 weeks
how to tx peripheral unilateral pts
Gaze stabilization exercises (matching eye to head) Vestibular stimulation (X1 viewing) Visuovestibular stimulation (X2 viewing) High level balance retraining Conditioning Education
how could you progress gaze stabalization exercises (X1, X2)
change background of what they are looking at
change standing surface
increase distance btwn them and object
VOR is really bad for what pts
Bilateral peripheral
prognosis for bilateral peripheral pts
not good
can take years, but may not fully recover
____ is a sign of retinal slip
oscilopsia
balance is poor and assistive devices needed for what type of pts
bilateral
why will bilateral complete loss yield a neg head shaking test
For typical nystagmus issues, there is a mismatch btwn R and L that causes the imbalance (if there are B issues, there is no mismatch).
vertical nystagmus indicates a _____ problem
o Vertical nystagmus indicates central problem
sx of bilateral peripheral disorder
Gaze instability & oscillopsia
Negative head shaking test if a complete loss
Postural instability, especially when vision or proprioception is reduced
Gait abnormalities: WIDE BOS
INSENSITIVE to motion in environment
Deconditioning
tx approach for bilateral peripheral disorder
substitution
what sx do you want to increase when tx bilateral peripheral
increase vision and proprioception
fall risk for bilateral pts is
very high
focus of tx for bilateral pts is what 4 things
occulomoter ex (2 horizontal targets)
balance ex
education
conditioning
use ___ approach for central disorder pts
compensatory
dosing of habituation
Select up to 4 movements
Perform quickly - provoke symptoms
Rest after each movement until sx. stop
3 – 5 sets of each
2 – 3 x/day
for BPPV, what two canals are tx the same
ant/post same
hor different
most common tx for ant/post BPPV
Canalith Repositioning Maneuver (CRM; a.k.a. Epley)
explain Epley/Canalith positions
start seated
supine (head turns)
SL
ends seated
how often do you typically have to perform the Epley manuever
1 x
most common location of BPPV
right post
canalithiasis vs cupulothiasis
In canalithiasis the particles reside in the canal portion of the semicircular canals
Cupulolithiasis refers to densities adhering to the cupula of the crista ampulla.
education you should provide to pts post Epley manuever
take it easy for 1-2 days
you may feel “off”
Epley only treats which _____athiasis
canalithias
what ant/post BPPV manuever is self done, and is for both ___athiasis
Brandt-Daroff Habituation Exercises
More violent rapid movements –used as a last resort for canalithiasis ant/post BPPV
Liberatory (Semont) manuever
what do you need to assess before doing vertigo tx (neck/head movements)
Need to test for vertebral artery dysfunction before doing tests that involve neck motion.
For vert art test have them lean forward/sb/rotate
ataxia of the eye (difficulty stopping eye mvmt) is what
saccades
if the saccades test is pos, what should you do
refer bc it may indicates a CNS issue
more than 2 saccade jumps indicates what
cerebellar issues-CNS
to test for saccades, you only go about ___ degrees up/down/lateral
20
torsional nystagmus correlates with what disorder
BPPV
what degrees is uses with nystagmus
30 up/down/lateral
absence of nystagmus indicates normal vest sx, T or F
absence of nystagmus doesn’t mean normal vestibular system! (suppression or resolution could have occured)
upbeat/downbeat nystagmus indicates what type of disorder
CNS
frenzel lenses are used to test ___
nystagmus
they cannot stabalize gaze so it’s really evident
head thrust test, tests the ___ canals
hor
peripheral or central issue
steps to head thrust test
Patient seated in front of PT; PT grasps patient’s head and flexes neck to 30degrees; patients head is thrust (eyes open) either R or L in unpredictable manner (to about 5 to 10 degrees; PT observes for corrective saccades; repeat in each direction 3 times
with peripheral loss, head thrust results are what when going towards involved side
sx are worse
will not be able to hold gaze and saccades will be present
head shake test, tests what canals
hor
explain head shake test
back and forth x 20 cycles then keep ahold of head and have them open eyes and observe for nystagmus
so head thrust looks for___ while head shake looks for ___, and both tests you position pt at ____
thrust -saccades
shake -nystagmus
both 30 degrees neck flexion
pos head shake test indicates what disorder
UNILATERAL periperial disorder of a horizontal canal
dynamic visual acuity test, tests what canals
hor
Patient in front of a wall-mounted eye chart;
PT asks patient to read the lowest line s/he can see on the chart (test static first);
patient then asked to read the chart while the PT oscillates patient’s head at frequency of 2 Hz (dynamic); PT compares visual acuity in static vs. dynamic condition
abNormal: over 3 line difference indicating vestibular hypofunction (3 lines up or more is pos)
this is what test
dynamic visual acuity
test to dx ant/post BPPV
dix hallpike
contraindications for dix hallpike
o Vertebral artery syndrome
o Cervical spine instability or other issues
in dix hallpike, if pt has sx and nystagmus when head is turned to the post left, which canals are involved
the side you are turning towards is effected side
left post
what are the pairings of the semi-circ-canals
Horizontal canals: rotation in the horizontal plane
Left anterior and right posterior (LARP)
Right anterior and left posterior (RALP)
cranial nerve-controls the down and inward movement of the eye
trochlear
4
3 CN responsible for eye mvmt
3,4,6
occulomotor nerve movements
everything other than abduct and down and inward
what test would you perform for unilateral peripheral vest issue
head shake test for nystagmus
what tests would you perform for central vest issues
neuromotor functional tests
a series of neuromotor function tests
looking from nose to finger tests for
saccades
frenzel lenses are used when ___ is present
nystagmus
resting/static nystagmus indicates
can mean acute peripheral vestibular lesion (although not likely seen without Frenzel lenses) or brainstem/peripheral lesion
head thrust tests, tests what
assess the integrity of the VOR; tests horizontal canal
looking for sacaddes
head shake test, tests for what
assess the integrity of the VOR in patients with unilateral peripheral vestibular deficit
looks for nystagmus
chance that pt does or does not have the condition
probability
disequilibrium,
‘ataxia,
‘impaired’smooth-pursuit’eye’movements,’ (saccades)
impaired’VOR
all sx of
central disorders
test for CN function
H test
which lasts longer cupolithiasis or canalothiasis
cupolothiasis lasts longer than canalothias
typical motor strategies go ___ to ___
distal to proximal
ankle first usually
main sensory strategy used by adults
somatosensory
odds of pt having a disease based on pos or neg result
LR
3 self reported OM for this unit
have to do with participation
FES - low function
DHI
ABC - high function
X1 X2 viewing is for
unilateral peripheral disorder
hypofunction
dosing of X1 X2 viewing exercises
1-2 min x 5 x/day
going up in an elevator would enact which of the 3 sensory sx
vestibular
if vertical changes are made vestibular is enacted
dynamic visual acuity test is for what type of disorders
bilateral of hor canals
Roll test is for
HORIZONTAL BPPV
horizontal targets - move eyes then head
imaginary targets- turn head, close eyes, image
these treat what
bilateral disorders
peripheral disorder associated with CN 8 (non malignant tumor)
acoustic neuroma
Cranial N test
H test
how to test for saccades (2 ways)
nose to finger eye follow
head thrust
with saccades nose to finger follow test, what degrees to rotate L/R
20 for saccades
head shake is flex neck to ___ degrees, rotate head ___ degrees L/R, for ___ cycles
30/30/ 20 cycles
