Lab 1: BPPV exam Flashcards
Of vestibular PT issues, what percent is BPPV?
21%
what is the second most common complaint in Dr. offices?
Dizziness
70% will have dizziness in USA population at sometime in their lives
when does peripheral spontaneous nystagmus occur? Fixation/nonfixation
fixation in room light DECREASES nystagmus
*Frenzels: cannot fixate, so nystagmus appears
oculomotor issues indicate:
central involvement
CN issues (3, 4, 6)
oculomotor issues to screen:
- ocular alignment: vertical skew deviation
- vertical skew deviation (alternate cover test)
- smooth pursuits
- saccades
- vergence
- ocular ROM
- GEN
- spontaneous nystagmus
What are the HINTS exam components and when to perform?
When: constant ongoing vertigo w/ spontaneous nystagmus, diagnose vestibular neuritis and rule OUT stroke
components:
Head impulse test
nystagmus
test of skew
used to determine peripheral: vestibular neuritis OR CENTRAL (stroke)
results of HINTS for peripheral vertigo:
+ HIT: loss of eye fixation with head impulse, positive HIT
- N: no nystagmus or horizontal/unidirectional
- TS: no skew
central vertigo HINTS exam results:
- HIT: intact VOR
+ nystagmus: vertical, rotatory, horizontal bidirectional
+ TS: positive skew
stroke!
CONTRAS for cervical position provocation testing
hx of neck surgery
recent neck trauma
severe RA
AO or OA instability
cervical myelopathy
cervical radiculopathy
carotid sinus syncope
chiari malformation
vascular dissection syndromes
5Ds and 3 Ns
dizziness, drop attacks, dysarthria, dysphagia, diplopia
nausea, numbness/tingling in face, nystagmus
order of comprehensive vestibular clinical exam
- subjective/systems review
- self report measure: DHI, ABC
- gaze stability: oculomotor, VOR
- balance
- position provocation testing
canalithiasis symptoms
latent onset of vertigo/nystagmus
gradually intense, then subside: episodic
lasts few seconds to less than 1 minute
cupulolithiasis (adhere to cupula)
immediate symptoms
-intensity remains
-constant as long as canal is provoked or varies depending on side of involvement
-lasts as long as head is held in provoking position
For BPV testing, which side do you test first?
less affected side
Before BPV testing, what are 3 things to do:
- ask contras
- in sitting check AROM c-spine, asking about 5Ds, 3Ns, then active rotation + extension.
- clear alar, transverse, and VBAI
BPV test sequence
- Dix Hallpike
if negative, - roll test
if negative, - side lying test
ewald’s 1st law
vertical canal (posterior/anterior) BPPV:
*eye movements are in plane of canal being stimulated
ASCC and PSCC
posterior canal BPPV
corrective fast phase is UPBEAT and TORSION towards down ear
*side of torsion: R or L
*whether it stays or goes, cupula or canal
R posterior canal nystagmus
upbeat, right torsional
R anterior canal nystagmus
downbeat, right torsional
R or L horizontal canal observed nystagmus
horizontal ageotropic and geotropic
head roll test
+ posterior canal test results:
+ DHT: upbeat, same side torsional
reversal phase: downbeat, opposite torsional
return to sit: downbeat, opposite torsional
right anterior canal + test:
+ DHT: downbeat, R torsion
reversal phase: upbeat, L torsion
return to sit: upbeat, L torsion
+ roll test: if geotropic nystagmus,
beating towards same side GROUND
(beat down with right side being worse = HSC BPV canalithiasis)
apogeotropic nystagmus
beating UP/away from ground
cupulolithiasis = side involved has LESS nystagmus
illusion of movement (spinning, rocking, swaying,
falling)
vertigo
sense of being off-balance (unsteady,
wobbly, drunk, tilted)
Disequilibrium
foggy-headed, heavy-headed, light-
headed, motion-sickness
gaze-instability
Light-headed, pre-syncope, tunnel vision
Cardiovascular: decreased blood flow to the brain
floating, swimming, rocking
anxiety symptoms
diplopia, oscillopsia (vision jumping)
oscillopsia: visual, but also bilateral hypofunction
both: visual
motion sickness is caused by a
visual-vestibular mismatch
What is the cause?
Aggs: Positional: lying down, sitting
up or turning over in bed,
bending forward
Eases: Holding still, time
BPPV
What is the cause?
Aggs: Head movement, visual-
vestibular mismatch
Eases: Holding still, closing
eyes
gaze-instability (vestibular hypofunction!)
What is the cause?
Aggs: Walking, darkness, unstable
surfaces, standing up
Eases: Sitting, Support from UEs
Imbalance
What is the cause?
Aggs: Spontaneous, exacerbated
by head movement
Eases: Holding still, closing eyes, medication
Vestibular Neuritis
What is the cause?
Aggs: Spontaneous, exacerbated
by head movement and
common triggers
Eases: Holding still, closing
eyes, medication
Vestibular Migraine or Meniere’s
What is the cause?
Aggs: Spontaneous
Eases: N/A
CVA/TIA
What is the cause?
Aggs: Positional: standing or sitting up
Eases: Sitting supported, time
Orthostatic Hypotension
What is the cause?
Aggs: Cardiovascular strain, exercise
Eases: Rest
ISCHEMIA
Name 3 vestibular suppressants
Meclizine
Dramamine
Valium
What are some medications that are ototoxic?
-some antibiotics
-chemotherapy
-some diuretics
-some NSAIDs
4 precautions to BPPV/Vestibular HEP
- drainage/discharge
- ringing
- sudden hearing loss
- sudden fullness/pressure
Oculomotor Screen: what is strabismus?
hypotropia or esotropia
drooping eye
ocular alignment: vertical skew deviation
central sign deviation
*ocular tilt reaction
*
What is Ewald’s 2nd law?
excitation of any canal creates a stronger vestib stimulus and creates greater response than inhibition
inability of inhibitory stimuli to decrease the vestibular nerve firing rates to less than zero.
for horizontal canal BPPV and horizontal VOR
What is inflammation of the inner ear/vestib nerve, causing vestib hyperstimulation and may result in damage, leading to hypofunction
neuritis: nerve, no hearing loss
labryinthitis: inner ear, hearing loss
causes of Neuritis/Labyrinthitis
Viral infection
98%, head injury
SS of what DX:
Sudden onset of vertigo, nausea/vomiting, lasting 3-7 days
with residual balance and dizziness lasting 1-2 weeks.
Often follows other illness (30% following respiratory infection)
neuritis/labyrinthitis
Damage to the inner ear or vestibular nerve that results in a diminished or weaker neurological signal. Uni or Bil
hypofunction!
caused by:
Neuritis, Labyrinthitis
Meniere’s Disease
Acoustic Neuroma,
Ototoxic medication
Gentamicin (aminoglycosides), Meningitis,
Ear surgeries, etc.
Benign, slow-growing tumor of the myelin sheath
(Schwann cells) covering the Acoustic/Cochlear or vestibular nerve
causing compression of CN 8.
what Dx?
Acoustic Neuroma
SS of this Dx:
Gradual onset of
unilateral hearing loss
Tinnitus,
Imbalance
Motion-sensitivity
Facial numbness/weakness
Acoustic Neuroma
Build-up of endolymphatic fluid within the inner ear, causing pressure on the inner ear membranes and hair cells. Can cause inflammation and damage over time.
* Unilateral or bilateral
what Dx?
Endolymphatic Hydrops/Meniere’s
caused by:
idiopathic (Meniere’s),
sodium/potassium imbalance
Middle ear congestion (milder)
*men’s ears cause high drops –> pressure
Recurring episodes of
vertigo lasting 1-3 days with gradual
improvement over 1-2 weeks. Low-
frequency hearing loss.
cause: sodium potassium imbalance, middle ear congestion, ideopathic
what Dx?
Endolymphatic Hydrops/Meniere’s
recurring spells of vertigo, possibly
associated with loud sounds and barometric
pressure changes, hearing hypersensitivity,
imbalance, motion-sensitivity
caused by trauma, head injury, valsalva. RARE
what Dx?
fistula! hole in ear
- Stroke
- Brain tumor
- Multiple Sclerosis lesions
- Degenerative neurological conditions
- Vestibular Migraine
- PPPD
- MDDS
these are examples of ____ pathophysiology
central vestibular system
- Symptoms: Recurring episodes of vertigo, lasting 1-5 days. Often
associated with headache, photophobia, phonophobia, brain fog,
anxiety, dissociative symptoms, visual issues
vestibular migraine
Risk factors: female, Magnesium deficiency, migraine history
* Common tr
Autonomic and emotional hyper-responsiveness to
vestibular stimuli
* Fight or flight: sympathetic nervous system
* AKA: Chronic Functional Dizziness
PPPD
SS: constant visual motion-
sensitivity and imbalance coupled with
anxiety, kinesiophobia, “visual vertigo,”
“space motion discomfort”, persisting
>3 months
cause: abnormal adaptation following
vestibular trauma
PPPD
persistent sensation of rocking or
swaying that lasts beyond the expected
period of adaptation. Worse when being still.
patho: Mal-adaptation following
disembarking a moving vehicle
Mal de Debarquement (MDDS)
self report outcome measures
DHI
ABC
VADL
VAP Questionaire
