Final Exam-Vestibular Lab Flashcards
VBI Testing
- pt can be in sitting
- rotate their head to the side and then extend slightly
- hold for 10 seconds and asses for dizziness, blakcout, drop attack
- return head to neutral and hold for at least 10 sec
- repeat on opposite side
- can also do this in supine
- if pt is coming to you for dizziness and you do this in supine you can get a false positive
- can also have patient put arms in the air and close eyes and watch for an arm to drop
- talk to the pt
- symptoms will increase if it’s VBI
- symptoms will be bad at the beginning and decrease if it’s BPPV
Hallpike-Dix Test Procedure–right side testing
- Tests for BPPV
- patient in long sitting so that when you lay them back their head, neck, and part of shoulders will be off the table
- hold both sides of patients head (near their ears, unless hearing aide)
- remind pt to keep eyes open
- turn patients head 45 degrees to the right
- quickly lay them in supine and extend neck 30 degrees
- hold this position and observe for nystagmus
- sit the patient back up and repeat for the other side
HallPike-Canal tested with Head Rotation to the Right
- Right posterior
- Left anterior
Hallpike-Canals tested with head rotation to the L
- Left posterior
- Right anterior
Brandt/Daroff Side lying Test–procedure
- for BPPV
- Position patient in short sitting at edge of plinth with enough room that when they side lie the head/neck will be supported
- rotate patients 45 degrees and extend 30 degrees
- sidelie them on the OPPOSITE shoulder
- hold for 2 mins and observe for nystagmus
- return to short sitting and observe for reverse nystagmus
- then test other side
Brandt/Daroff Canal Testing
R Post-rotate L, extend
R Ant-rotate R, flex
L Post-rotate R, extend
L Ant-rotate L, flex
Right posterior canlithiasis
-hall pike dix test (head rotated R)
-or brandt/daroff (head rotated L, extend 30)
Will see:
1. transient nystagmus
2. upbeat and R torsion
Treat:
-CRT beginning R HPD position (if nystagmus switches, debris is going wrong direction, start over)
-brandt/daroff exercises bilateral
Left posterior canilithiasis
-hall pike dix test (head rotated to the L)
-or brandt/daroff (head rotated R, extend 30)
Will See:
1. transient nystagmus
2. upbeat and L torsion
Treat:
-CRT beginning L HPD position (if nystagmus switches, debris is going wrong direction, start over)
-brandt/daroff exercises bilateral
Right posterior cupulolithiasis
-hall pike dix (head rotated R)
-or brandt/daroff (head rotated L, extend 30)
Will See:
1. Persistent nystagmus
2. Upbeat and R torsion
Treat:
-liberatory maneuver R sidelying, head L with 1 min hold, PT hand on forehead
-brandt/daroff exercises 10-15x 3-5x/day until 2 days without vertigo
Left posterior cupulolithiasis
-hall pike dix (head rotated L)
-or brandt/daroff (head rotated R, extend 30)
Will See:
1. Persistent nystagmus
2. upbeat and L torsion
Treat:
-liberatory maneuver R sidelying, head R with 1 min hold, PT hand on forehead
-brandt/daroff exercises 10-15x 3-5x/day until 2 days without vertigo
Right Anterior Canalithiasis
-hall pike dix (head rotated L)
-brandt/daroff (head rotated R, flex 30 degrees)
Will See:
1. transient nystagmus
2. downbeat and R torsion
Treat:
-neck ext particle repositioning maneuver (esp when side of involvement is unknown)
-FWD roll particle repositioning maneuver with head L
-CRT beginning R HPD position
-Brandt/daroff exercises bilaterally
Left anterior canalithiasis
-hall pike dix (head turned R)
-brandt/daroff (head turned L, flex 30 degrees)
Will See;
1. transient nystagmus
2. downbeat and L torsion
Treat:
-neck ext particle repositioning maneuver (if side of involvement is unknown)
-FWD roll particle repositioning with head R
-CRT beginning L HPD position
-Brandt/daroff exercises, treat bilaterally
Right anterior cupulolithiasis
-hall pike dix (head rotated L)
-brandt/daroff (head rotated R, flex 30 degrees)
Will See:
1. persistent nystagmus
2. downbeat and R torsion
Treat:
-liberatory maneuver R Sidelying, head R with 1 min holds, PT hand on occiput
-brandt daroff exercises 10-15x 3-5x/day until 2 days w/o vertigo
L anterior cupulolithiasis
-hall pike dix (head turned R)
-brandt/daroff (head turned L, flex 30 degrees)
Will See:
1. persistent nystagmus
2. downbeat and L torsion
Treat:
-liberatory maneuver L Sidelying, head L with 1 min holds, PT hand on occiput
-brandt daroff exercises 10-15x 3-5x/day until 2 days w/o vertigo
CRT
- canalith repositioning treatment
- used to treat canalithiasis BPPV in ant or post semicircular canals
- if it’s a right sided problem, you turn their head R
CRT procedure (for R side)
- hall pike dix positioning is 1st treatment position (if you get a positive during this test, go immediately into this without checking the other side, check the other side next visit)
- patient in supine with head, neck and part of shoulders off plinth
- head rotated R and extended=2 mins
- turn head rotated L and extended (DO NOT LET PATIENT LIFT HEAD, NEED TO STAY IN EXT OR START OVER)=2 mins
- pt turns into L sidelying, head stays rotated, once positioned in sidelying head will be looking towards ground=2 mins
- then sit them up maintaining rotation and slight flexion
- wait at least 15 mins before repeating if it doesn’t work, recommended 30 min-1hr
Brandt/Daroff CRT
- rotate patients head based on the canal to be treated
- always lay them down on the affected side (no matter which way the head is turned)
- hold for 2 mins
- return pt to short sitting
- hold for 2 mins
- rotate patients head to the opposite side and into opposite sidelying
- hold for 2 mins
- return to 90/90
- repeat 10-20x 3-5x/day until vertigo is absent for 2 consecutive days
Semont Liberatory Maneuver for Cupulolithiasis-procedure for R post cupulolithiaisis
- pt in sitting at edge of plinth
- turn head L and PT places hand on forehead
- lay them into R sidelying quickly, maintaining the head position
- hold 2 mins
- 1 hand behind head and 1 hand on forehead
- throw patient all the way into L sidelying, protecting forehead from hitting mat
- stay in this posiiton for 2 mins
Semont Liberatory for R anterior cupulolothiathisis
-same as for R post, but this time you are rotating the head right and going down on toward the effective side
Roll test for horizontal canal
- clear C/S
- position patient in supine
- flex head 20 degrees
- rotate patients head to the right=hold 2 mins
- rotate patients head to neutral=hold 2 mins
- rotate patients head to the left=hold 2 mins
Geotropic
nystagmus toward the ground
Ageotropic
nystagmus toward the sky
Right horizontal canalithiasis
Will see; 1. postive roll test 2. geotropic R>L Treat: -CRT supine R with roll to L maintaining neck in 20 degrees flexion -appiani maneuver (begin in L sidelying)
Left horizontal canalithiasis
Will see: 1. positive roll test 2. geotropic L>R Treat: -CRT supine (L) with roll to (R) maintaining neck in 20 degrees flexion -Appiani maneuver (begin in R sidelying)
Right horizontal cupulolithiasis
Will See:
- ageotropic R s preferred: rapid CRT Bar-B-Que
- modified semont maneuver: move pt into R sidelying 1st
Left cupulolithiasis
Will see:
- ageotropic Ls preferred: rapid CRT Bar-B-Que
- modified semont maneuver: move pt into L sidelying 1st
Horizontal Canal CRT (BBQ) for canalithiasis in the R horizontal canal
- roll test position
- head turn right=hold 2 mins
- 2 mins neutral
- 2 mins left
- patient rolls to prone, maintain head position (don’t let head extend)
- looking straight down=2 mins
- push up into quadriped with head supported by PT
Appiani (start with unaffected)–for R horizontal canalithiasis
- pt in short sitting
- lie on left side for 2 mins
- rotate head 45 degrees downward toward mat, hold 2 mins
- support patients head so it stays neutral
Phase I vestibular hypofunction treatment
- visula fixation
- EO
- stationary target
- slow head movements
- active eye and head movements between stationary targets in sitting
- static stance (EO, EC) feet together, arms out
review increasing difficulty of habituation exercises
on handout
smooth pursuit and gaze holding
- track slowly
- hold each position for a little bit to check for gaze holding nystagmus
- everyone will have nystagmus at end range (3 beats is normal, more is abnormal)
Saccades
- have them switch back and forth from object to your nose when you say “switch”
- overshooting or undershooting=positive test
VOR cancellation
- pt seated with arms out in front and you move their head while they focus on your nose (move with them)
- or pt holds arms outstretched in front
- eyes should not move off target
- big red flag if they do because it relates to the cerebellum
Head thrust
- grab on to sides of head, flex neck, move their head slowly and then stop quickly to one side
- positive=eyes will go to the side the head is turned and then recorrect to the middle
Dynamic visual acuity
-should be able to read within 2 lines of static visual acuity
Head shaking
- only done with fixation blocked
- head shaking is the same as the dynamic visual acuity (do this for 20 seconds), then have them open eyes, anything more than 3 beats is abnormal
Active eye-head movements bw 2 targets
FOR CENTRAL PROBLEMS
- sit 2-4 feet away from plain wall
- write 2 separate letters on 2 separate post-it notes
- place the letters 2 feet apart on the wall
- look at one with head and eyes, and then keeping your head on the 1st one, look at the 2nd one with only your eyes
- then turn to face the 2nd one with your eyes still focused on it
- repeat in opposite direction
- practice 1-3 mins, resting if necessary, 2-3 times per day
- can also be done with vertical targets
- vary the speed
Ball circles
- stand in relaxed, upright position, equal weight on both feet
- hold ball in both hands with arms out straight
- keep eyes on the ball
- turn the ball in a large circle following the balls path with your head and eyes
- repeat 15-20 times in each direction, 2-3 times daily
- if dizziness increases, stop until dizziness subsides and then begin again
Ankle sways
- stand with feet shoulder distance apart, equal weight on both feet, arms relaxed
- look straight ahead with eyes open
- slowly shift your weight, midline to forward (with wall/corner behind you or in front of you), midline to backward
- do not move far
- do not bend at back, hips, knees, only ankles
- then shift from side to side
- 10-15 reps, 2-3 times per day
- progress by swaying diagonally
Brock string exercise
- tie one end of the string to a stable object (like a door knob)
- pull string taught to your nose
- focus on closest bead on the string with both eyes for 3-5 sec
- move back and forth along the string with your eyes focusing on each bead for 3-5 sec
- repeat for 1-2 mins
- progress by sliding beads closer to your nose
Circle sways
- stand with feet shoulder width apart
- breathe deeply and relax
- practice swaying your body in a circle (sway forward, right, rear, left)-look straight ahead and find an object to focus on
- begin with small circles, do not bend at the hips
- gradually increase how far you can move
- repeat 15-20 times in each direction, 2-3 times daily
general body conditioning and balance
- marching
- toe taps
- heel raises
- toe raises
- lift ups
- modified step ups
- step ups
Gait with head movements
- find distant target
- begin walking forward near a wall
- focus on target
- walk at normal speed
- after 3 steps, turn your head and look to the right, but continue walking straight ahead
- after 3 steps, turn to center
- after 3 steps, turn to left
- repeat 15-20 times, 2-3 times daily
- to increase difficulty try doing this while holding onto a shopping cart or on uneven surfaces
Saccades exercise
- sit comfotably
- hold small card with picture to focus on in each hand, level with eyes, 18 inches apart
- place cards side by side horizontally
- while keeping head still move eyes from one card to the other without stopping, repeat 15-20 times
- do the same thing vertically
- repeat diagonally
- 2-3 times daily
Vestibular habiutation exercises
- 3 times per day
- often make dizziness worse in the beginning, but it gets better
- stay in the position until dizziness subsides
- go from sitting to flat on your back (5 times)
- go from flat on back to left side (5 times)
- repeat to the right (5 times)
- sitting on the side of the bed, turn head to left and lie down quickly on the right (5 times)
- then opposite
- in sitting touch nose to left knee (5 times)
- ” “ right knee (5 times)
- in sitting turn head left, then right (5 times, repeat 3 times)
- right, then left “ “
- move head up, then down 5 times (repeat 3 times)
- from sitting, stand up (5 times)
- from standing turn body right (5x)
- ” “turn body left (5x)
Targets
FOR CENTRAL PROBLEMS!
- comfortable position
- find 3 targets in your room that are at eye level
- one that would be over left shoulder, on in front of you, one over right shoulder
- move head looking at left target, then center, then right
- repeat 10-15 times with out stopping
- then repeat 10-15 times stopping at each target
- 2-3 times/day
VOR x 1
- sitting in comfortable position
- finger or small card 10 inches from nose
- focus on object while turning your head side to side
- gradually increase speed of head turns
- repeat 15-20 times
- 2-3 times/day
VOR x 2
- same set up
- move object opposite from the side you turn your head to now
Visual tracking
- comfortable position
- card about 12 inches from eyes
- keep head still, move card right, center, left, center. follow card with only your eyes. 15-20x
- keeping head still, move card up, center, down, center, 15-20 times
- keeping head sstill, follow up and left, center, down and right, center, 15-20 times
- 2-3 times/day
Head circles
- clockwise (nose circles)1 15-20 times
- repeat with eyes closed
- counter clockwise 15-20
- repeat with eyes closed
- 2-3 times daily
- in sitting or standing
