Lab 1: vestibular screeen and BBPV examination Flashcards
what is the second most common complaint heard in the doctor offices
dizziness
what is the purpose for a comprehensive vestibular examination
screen for vestibular involvement
determine differential diagnosis through examination and eval
develop POC
what is the most important part of a vestibular exam
subjective
what is vertigo
illusion of movement (spinning , rocking , swaying , falling)
what is gaze instability
foggy- headed, heavy headed , light headed , motion sickness
when should u do BPPV testing
only if nystagmus + vertigo
provoked w positional head movement
change
what are components of a vestibular screen
- subjective report
- oberseve for (spontaneous) nystagmus
- observe for oculomotor issues ( skew eye , deviation , ocular tilt)
- ocoulator motor test (smooth pursuit and saccades)
- VOR tests : HSNT , HTT< DVA
- HINTS exam
- postural control screen
what are the co morbidities to a vestibular screen
Diabetes, blood pressure, auto-immune conditions, anxiety, depression, peripheral neuropathy
what medications for vestibular suppressants
Meclizine, Dramamine, Valium
if someone has spontaneous nystagmus and then they put on the freezers the fixation decreases.. would u think it was peripheral or center ? wonder if they put on the fresnels and there was no effect w the fixation
peripheral
central
if u are looking at someone’s ocular alignment and u see a vertical skew would u think central or peripheral
center
when doing the oculomotor test smooth pursuit anf saccades is this from the central or peripheral
central - CNs 3,4,6
what is the difference between smooth pursuit and saccades
smoother prusuit is smooth tracking of a moving target w the eyes
saccades is a rapid movement from one target to another
is the vestibular ocular reflex testing the peripheral or centerl
peripheral
what is the vestibulo ocular reflex test
the head thrust test (HITT)
test VOR to the SIDE of the thrust
if u are doing the head thrust test for a patient and they have corrective saccades what do u think
hypo function
what is the HINTS exam for
diagnose stroke (central) vs vestibular neuritis (peripheral) in a patient with acute vestibular syndrome
when do u perform the HINTS exam for a vestibular screen
patients with hours or days of
constant ongoing vertigo and with spontaneous
nystagmus; can reliably diagnose vestibular neuritis
and rule out stroke
t/f: is the HINTS exam more sensitive than MRI in dx of stroke
true
a normal test of skew (HINTS) indicated what
Peripheral
Vestibular Neuritis
what does HINTS “plus” also reset for
unilateral hearing loss
how would the head impulse test , nystagmus and test of skew be for a peripheral vertigo
head impulse - loss of eye fixation with head impulse “positive” or “ abnormal”
nystagmus: none or horizontal unidirectional
test of skew” negative
how would the head impulse test , nystagmus and test of skew be for a central vertigo
head impulse test: intact vestibulo ocular relex: “negative”
nystagmus: vertical , rotatory or horizontal bidirectional
test of skew: postivie
if after u perform the vestibular screen and u think the patients problem could be peripheral vestibular in origin what would u do
a further comprehensive vestibular clinical examination
if after u perform the vestibular screen and u think the patients problem could be central vestibular in origin and it is non stable and unknown what would u do
referral to MD or ED immediately
what are the contraindications to rule out before conducting position pronation testing (BPV)
- r/o contraindications (ask about hx. of neck surgery, recent neck trauma. , sever RA , AO , or OA instability , cervical myelopathy or radiculopathy , carotid sinus syncope , chiral malformation, vascular dissection syndromes )
what parameters must be met before conducting position provocation testing in sitting
in sitting , check ACTIVE cervical ROM
- verbalize the 5Ds and 3 Ns when the patient o performs active cervical ROM
(dizziness, diplopia, dysarthria , dysphagia , drop attaches)
(nausea, nystagmus , numbness (facial)) - if no symptoms then ask the patient to actively rotate head to one side and then extend their neck and then have them count out loud back from 10 and observe and ask about the 5d and 3n and if negative do it to the other side
- DO NOT PROVIDE PASSIVE OVERPRESSURE WHILE PATIENT IS SITTING
after u r/o the contras and met the parameters in sitting before conducting a positional provocation testing what do u do if u have no symptoms with active cervical ROM in sitting
check alar ligament (in supine< transverse lig (in sitting) and screen from VBA (body moves on head test in standing) while patient counts backwards from 10 and PT observes from 5D and 3N
what is the clinicians checklist before beginning BPV testing
- test less affected/suspected side first
- with hx of severe nausea/comitting perfomr test slow w trash can near by
- perfomr test in room light but WITH frenzel or IR goggles
what are the patient instructions before BPV testing or treatment -
-I am going to quickly move you from sitting to lying down with your head tipped back and to the side
and I will hold your head in this position for about 1 minute.
- keep ur eyes open and dont look around
-u may get dizzy during the test, if they happens play stay int he position until dizzy goes away . if it doesn’t go away within a min i will help u up
- if u cant remain in the position ill help u back up
- i wont let u fall
how to detemine the canal involvement in BPV
by observing the direction of nystagmus
BPV treatment is diagnosis driven so what do u need to determine and identify
identify the canal invovlment
determine canalithiasis and cupulolithiasis
determine which side
what is the difference between canalithiasis and cupulolithiasis in terms on onset, symptoms and how long it last
Canalithiasis (free floating debris)
Latent onset of vertigo &
nystagmus
Symptoms gradually intensify then
subside (episodic)
Lasts for a few seconds to less than
1 minute
Cupulolithiasis (adherent to cupula)
Immediate onset of vertigo &
nystagmus
Symptom intensity remains
constant (posterior canal) as long
as that canal is provoked or varies
(horizontal canal ) depending on
side of involvement
Lasts as long as head held in
provoking position
what is the BPV test sequence
- perform Dix Hallpike test , with less suspected/affected side. if not vertigo or nystagmus, slowly bring PT up to sitting and then perform to the other side . IF it is (+) then determine if it was canal or cupulo , then go into PSSC treatment
- if DHT (_) then have pt slide down on plinth then flex the pt head slightly (30) and perform the roll test to less affected side followed by the affected side
- If roll test (+) determine if geotropic or apogeotropic nystagmus , and side of invovled by the intensity of nystagmus then go into HSSC treatment maneuver for canal(slow) or cupol (fast)
- If roll test is (-) then bring pt up to sitting anf perform side lying test to less affected side (fast) , if not vertigo or nystagmus slowly return to sitting and perform test to affected side (FAST). if (+) determine canal or cupulo then go into treatment maneuver
until head is supported
in Ewald’s 1st law (in vertical canal BPPV) the eye movement are in the plane of what
the canal being stimulated
what corresponds to eye movements observed in BPPV when generated from the canals in
the Dix-Hallpike Test position.
direction of eye drift (slow phase) and correction (fast phase)
what would indicated the posterior (inferior) canal in the DHT positions
up beating (fast phase) and rotary (torsional) nystagmus towards under most or down ear
what would indicated the anterior (superior) canal in the DHT positions
down-beating (fast phase) and rotary (torsional)
nystagmus
So if the L posteior canal was inidcated in a DHT position what nystagmus would u notice
upbeat , left torsional
With the posterior and anterior
canal, deflection of the cupula
towards the canal creates a
stronger excitatory response than when it deflects away from the
canal
what law states this
Ewalds 3rd law
so if you did a R dix hallpike test what would you are for a (+) R PSC
up beating and R torsional
so if you did a R dix hallpike test what would you are for a (+) R ASC
downbeating and R torsional
main difference between anterior and posterior is the down and up beating
so if you did a R dix hallpike test what would you are for a (+) L ASC
downbeating and L torsional
excitation of any canal creates a stronger vestibular stimulus and
creates a greater response than inhibition.
what law stated this
ewalds 2nd law
If otoconia are free floating in posterior arm of the HC, turning head ____
affected side will cause otoconia to move closer to the cupula. This will push the
endolymph into the cupula and deflect it away from the canal. Thus causing a
_____ response (____ symptoms and nystagmus) than when the head is turned
away from affected side, when the cupula will deflect towards the canal
towards
greater
more
If otoconia are stuck to the cupula (or floating in the anterior arm), turning head
towards affected ear will cause cupula to deflect towards the canal due to
weight of otoconia being stuck to the cupula (or otoconia moving away from
cupula) Thus, causing ____ of a response than when head is turned away from
the affected side and cupula deflects away from canal.
less
how is the horizontal canal oriented
30° upwards and horizontal
what test is done for horizontal semicircular canal BPV
the roll tes
how do u perform the roll test for HSC BPV
from the DHT position have pt slife down on the mat till head is supported then the PT will flex neck to about 30° then PT will quickly roll head to one side (less affected side first) turning it 90° and hold this position for 1 min
neck roll head slowly back to midline then quickly roll it to the other side also turing it to 90° and hold for a min
what is a (+) test for the roll test
vertigo and nystagmus occur bilaterally bc debris moves back and forth within affected canal
with the roll test are are teh 2 types of nystagmus u can see
geotropic nystagmus= beating towards ground/earth (canalithiasis - side invovled has worse nystagmus)
apogeotropic nystagmus = beating away from group (cupulo- side invovled has less nystagmus)
if a patient can not tolerate the DHT what is an alternative test for them to test for PSC or ASC BPV
side lying test
how do u perform the side lying test
sit patient at edge of plinth , turn head 45° to one side (less suspected side ) then pt quickly lies down in side lying position towards the suspected side then repeats to other side
so if u think the patient has a R sided PSC how would u do the side lying test
turn their head 45° towards the left and then quickly bring them into a side lying position towards the R side
what is a (+) test for the side lying test
1st determine canal or cupulo
upbeat and rotary nystagmus towards down ear= BPV of downsides PSC
downbeat and rotary nystagmus = BPV of downsides ASC
how are u gonna test anterior canal on the practical
DHT
downbeat wand rotary nystagmus then downsides ASC
if a pt has mild postural instability and vertigo what do u treat first
vertigo
