Final Exam Material Flashcards
3 main causes for dizziness
- otologic
- neurologic
- general medical
Otologic
- BPPV
- vestibular neuritis
- superior canal dehiscence
- meniere’s
Neurologic
- vertibrobasilar insufficiency
- stroke
- migraine
- low CSF
General medical
- B12
- orthostatic hypotension
- hypoglycemia
Balance control
input (visual, rotation, gravity, pressure)
brain
output (ocular reflex, postural control)
A discrepancy bw any of these 3 systems can cause nausea and vertigo
Vestibular system
- semicircular canals (post, ant, lateral)
- otolith organs
- nerve
- cochlea
Semicircular Canals
- Ampulla (bulbous bony opening that houses cupula)
- Cupula (sensor/sail that houses hair cells. Directly connected to vestibular nerve)
- Canals (orthogonal…ant, post, lateral/horizontal)
Peripheral vestibular dysfunction-causes
- vestibular apparatus
- vestibular portion of CN VIII
- some cerebellopontine angle tumors
Central vestibular dysfunction-causes
- vestibular nuclei
- central pathways
- also cerebellopontine angle tumors
Peripheral vestibular dysfunction categories
- unilateral vs. bilateral
- reduced vs. absent function
- acute (BPPV) vs. Chronic (meniere’s)
Examples of peripheral diagnoses
- acoustic neuroma/other tumors
- meniere’s disease
- gentamicin otolithic ablation
- local trauma
- guillan barre or MS at CN VIII root entry
- BPPV
- infection: labyrinthitis, vestibular neuritis
- perilymphatic fistula (breakage in membrane bw middle and inner ear)
Benign Paroxysmal Positional Vertigo (BPPV)
- most common cause of vertigo
- brief episodes of vertigo precipitated by rapid change of head posture (30sec-2mins)
- ex. every time they roll over in bed it happens
BPPV epidemiology
Women>men
-spontaneous remissions common, but recurrences can occur
BPPV-cupulolithiasis
- otoconial material gets stuck in canal
- disrupts cupula’s response to gravity
BPPV-canalithiasis
- otoconial debris gets into a semicircular canal
- post/ant>lateral
- creates a suction moment which acts on the cupula and fluid can’t continue through the canal
BPPV prognosis
- tends to be self limiting (6-12 mos)
- vestibular rehab can speed up recovery SIGNIFICANTLY
- antivertiginous drugs ineffective (anavert/meclazine)
- elderly respond more slowly
- if symptoms persist, MRi indicated (acoustic neuroma, cerebellar or 4th ventricle tumor)
Vestibular Neuritis
- second most common cause of vertigo
- swelling in vestibular area
- probable viral etiology
- similar to bell’s palsy
- sometimes epidemic occurences
- upper respiratory or GI infections
- concurrent or preceded by 2 weeks
Vestibular Neuritis epidemiology and S/S
Primary ages: 30-60 (women-40, men-60)
- acute onset of prolonged severe rotational vertigo which increases with movement of the head (hits you all at once)
- associated with horizontal-rotatory nystagmus, postural imbalance, and nausea/vomiting
- could be unilateral or bilateral
Vestibular neuritis management
- vestibular suppressants (anavert/meclazine)
- bedrest x 24-72 hrs
- gradual return to functioning
- total recovery in about 6 weeks
Vestibular neuritis and vestibular rehab
- significantly speeds recovery
- slowly increases ambulation
- general conditioning
- gaze stabilization exercises
- facilitate central compensation
Meniere’s disease etiology
- hereditary or sporadic
- damage to hair cell inside cupula (changes amt of vestibular info being sent to CNS from vestibular nerve)
- distension of endolymphatic system with hair cell damage
Meniere’s disease S/S
- vestibular and AUDITORY involvement (complaints of hearing lost in 1 or both ears, sense of fullness in ears)
- vertigo usually lasts hours (preceded by ear pressure/fullness)
- change in tinnitus (ringing)
- change in hearing function
Meniere’s management
- meds for vertigo (anavert/meclazine)
- diuretics
- middle ear injections (gentamicin, steroids, surgery)
- no cure
Examples of central vestibular diagnoses
- TBI
- CVA
- MS
- Tumors
- Meningitis
Sensation testing for vertigo issues
- could be a neuropathy issues
- part of balance
- is info coming in from the periphery accurate?
- possible rule out a central diagnosis
Symptom: dysequilibrium/imbalance
Central: moderate to severe
Peripheral: moderate
Symptom: nausea/vomiting
Central: mild-moderate
Peripheral: severe
Symptom: oscillopsia
Central: severe
Peripheral: mild
Symptom: tinnitus
Central: rare
Peripheral: may occur
Symptom: hearing loss
Central: rare
Peripheral: common
Symptom: neurologic
Central: common
Peripheral: rare
Symptom: nystagmus
Central: pure vertical, unchanged with fixation, no fatigability, no latency
Peripheral: mixed torsional, dampens with fixation, fatigues, latency post-maneuver
Duration and disease
Seconds-BPPV, TIA
Minutes-TIA, migraine
Hours-Meniere’s, migraine
Days-vestibular neuritis, trauma, labyrinthine infarct
Nystagmus
- named by the fast phase
- composed of slow and fast movements
- involuntary movement of the eyes
Spontaneous nystagmus
- stationary head tests
- have pt look straight ahead
- normal=no movement
- vertical=central pathology
- horizontal=peripheral hypofunction
- L=R hypofunction
- R=L hypofunction
- repeat with fixation removed
Gaze holding nystagmus
- have pt follow finger 30 degrees in all directions
- nystagmus=suggests central pathology
Eye ROM/smooth pursuit
- use object or finger
- check vertical, horizontal
- look for smooth coordinated movement
- ask if pt has double vision (if yes, refer to neurologist)
- vertical eye movement <older)
- abnormal=central pathology
Convergence
- begin 2 ft away
- ask pt to focus on finger or object
- bring toward face–pupils should adduct
- may be absent in pts with PMH of cataract surgery
- abnormal test suggests central pathology
Saccades
- have person quickly move vision between 2 targets (finger, nose, 2 fingers)
- test horizontal and vertical
- look for correction after over or undershooting
- abnormal test suggests central pathology
Dynamic visual acuity
- check C-spine before doing this
- same as for static but with head motion
- tilt head 20-30 degrees
- grasp from behind and move side to side-2 complete mvts per second
- record lowest line read and compare to state
- > 2 line different=VOR problem
- abnormal test is peripheral or central
VOR
-vestibular ocular reflex
VOR cancellation
- pt should be able to override the vestibular ocular reflex
- abnormal test=central pathology
Head thrust test
- test named by direction of head mvt
- peripheral vestibular hypofunction
- +rht=R hypofunction
- +LHT=L hypofunction
- +BHT=B hypofunction
Head shaking test
- use room light or goggles
- pt closes eyes
- shake head 20x side to side
- have pt open eyes
- vertical nystagmus=central
- horizontal nystagmus=peripheral hypofunction
- L=R hypofunction
- R=L hypofunction
Dizziness can mean…
- vertigo
- motion sickness
- lightheadedness
- dysequilibrium
- compilation of one or more above
Vertigo
- illusion of motion
- two types-
- subjective (you feel the motion)
- objective (you see the motion)
- commonly associated with inner ear disorder
Motion sickness
- mismatch bw visual and vestibular systems
- commonly occurs with
- cars
- boats
- airplanes
- trains
Lightheadedness
- pre-syncope
- may indicate CV origin
Dysequilibrium
- feeling of unsteadiness
- vestibular ataxia (mismatch bw vestibular system and communication to the brain stem)
What diagnoses benefit most from vestibular rehab
- BPPV
- Vestibular neuritis/labrynthitis
- dysequilibrium with age
- meniere’s disease (stable, surgical, less than 1 attack per month)
- central vestibular (brainstem, cerebellar)
- central (MS, PD, stroke)
Goals for vestibular rehab
- to optimize function
- decrease dizziness
- improve balance and the ability to walk
- decrease fear and anxiety
- prevent falls
- increase gait speed
- improve the patient’s ability to perform daily activities
Treating BPPV
- canalithiasis
- CRT
- Brandt-Daroff Exercises
- cupulolithiasis
- liberatory maneuver
- habituation exercises
- general conditioning
Treating vesitbular hypofunction
- vertiginous position adaptation training
- used to assist restoring gaze stability
- trains the VOR to work with CNS oculomotors
- habituation training
- helps desensitize the patient to positions/movements
- gaze stabilization exercises
- static/dynamic balance training
- substitution or compensation (if 1 system is working, develop the other 2)
Adaptation
- aka habituation activities
- ocular stabilization exercises
- brandt/daroff exercises (also working to resolve the problem of canlithiasis in BPPV)
- vertiginous positions
- general conditioning
Substitution or compensation
- working toward dependence on another sensory system and/or assistive device
- use of visual cues
- use of somatosensory cues
Vestibular examination progression
- Central
* rule out
* if undiagnosed, unexplained, or new onset, refer out - Peripheral
* vertebrobasilar artery insufficiency
* vestibular - Cervical
* whiplash or cervical vertigo
Cervicogenic Dizziness
- diagnosis of exclusion
- consider cervical origin
- trauma
- pain
- chronic posturing
Cervicogenic Dizzinss Evaluation
- history of acute cervial/head trauma
- R/O upper cervical hypermobility
- onset: immediate vs. delayed
- stage, irritability, nature, symptom severity
- observation
- willingness to move
- motor control (ataxia, UMN signs)
- mental state
- gait (balance and fall risk)
- other signs of trauma
Differentiating capital vs. cervical involvement- HEAD STILL, NECK MOVES
- rotate body underneath head, stabilize head in space
- positive reproduction of symptoms-neck is positive, head is unknown (cannot r/o vestibular)
- negative reproduction of symptoms-neck involvement is not suspected, head is uknown
Differentiating capital vs. cervical involvement-NECK STILL, HEAD AND NECK MOVE EN BLOC
- rotate head and neck together
- positive reproduction of symptoms–head is positive, suspect vestibular involvement, neck is unknown
- negative reproduction of symptoms–head/vestibular not suspected, neck is unknown
Cervicogenic Intervention
- manual intervention to the cervical spine
- treat jt restrictions
- passive physiologic intervertebral movement
- segmental mobility testing and accessory mobilization
- treat soft tissue restrictions
- balance and postural training
- vestibulo-ocular reflex (VOR) exercises
Four square step test-populations
- geriatric
- vestibular
- transtibial amputees
- stroke
Four square step test-cut offs and test
- tests dynamic balance and ability to change direction
- older adults/geriatric=>15 at risk for multiple falls
- vetibluar=>12 sec
- tt amputees=>24 sec
- acute stroke=failed attempt or >15 sec
- MCID not established
Balance evaluation systems test (BESTest)-population
- balance
- cerebellar infarct
- parkinson’s
- peripheral neuropathy
- vestibular
BESTest-categories
- grouped into 6 systems
- biomechanical constraints
- stability limits, anticipatory postural adjustments, postural responses, stability in gait
BESTest-scoring
- score of 108 points total, calculated into a percentage score (0-100%)
- MCID not established
- 69% differentiates fallers from non-fallers (greater than 69 is no risk for falls, and vice versa)
Motion sensitivity test-population
- community dwelling individuals with complaints of motion provoked dizziness during routine ADLs
- geriatrics
- TBI
- vestibular
Motion sensitivity test
- different head/body movements
- duration of dizziness is recorded with stop watch (1 pt for 5-10sec, 2 for 11-30, 3 for >30)
- subject asked to rate dizziness on 0-5 scale
Motion sensitivity test-scoring
-no MCID
-0-10% mild
-11-30% moderate
31-100% severe
Bucket test-pt population
- unilateral vestibular hypofunction
- BPPV
- cervicogenic headache
Bucket test scoring
-unilateral vestibular weakness and BPPV-1.3 degrees on normal side for those<50
Dizziness handicap inventory-pt population
- vestibular
- BPPV
- individuals with dizziness
- MS
- brain injury
- geriatrics
Dizziness handicap inventory-test
- 25 items
- self report questionnaire
- three domains: functional, emotional, physical
- max score of 100
Dizziness handicap inventory-scoring
- higher score=greater perceived handicap due to dizziness
- MCID=vestibular=18 pts
- mild-0-30
- mod-31-60
- severe 61-100
Activities-specific balance confidence scale (ABC)-pt population
- elderly
- Ms
- parkinson’s
- stroke
- unilateral TT amputation
- vestibular
ABC-test
- 16 item self report
- balance confidence with different activities
- items rated from 0-100
ABC-scoring
0=no confidence
100=complete confidence
-<67% indicates risk for falling, can accurately classify people who fall 84% of the time
TBI and dizziness
- 15-78% of head traumas cause dizziness
- 32-61% of patients with TBI have abnormal vestibular testing
- 88% show at least one vestibular deficit
- 61% recieved diagnosis of BPPV
Causes of TBI dizziness
- lesions of peripheral vestibular system
- BPPV
- perilymphatic fistula
- labyrinthine conussion
- lesions of central vestibular system
- brainstem concussion/post-concussive syndrome
- cerebellar contusion
Why concerned about TBI and dizziness?
- dizziness may be the underlying cause of the TBI
- dizziness may complicate rehab
- dizziness may mimic cognitive impairments
- cognitive impairments due to TBI may complicate vestibular rehab
Strategies for dizziness in a TBI patient
- reduce confusion
- improve motivation
- encourage consistency of performance
- improve attention
- improve problem solving
- encourage declarative as well as procedural learning
- seek moderate level of arousal
- provide increased supervision
- progress may be slower
