lab 2: PVH exam (non BPPV) Flashcards
what are the oculomotor tests that we would perform on a non BPPV patient (central test that must be done before proceeding to VOR)
•Spontaneous Nystagmus (not on practical)
•Gaze Evoked Nystagmus
•Ocular ROM (not on practical)
•Vergence
•Skew-Eye Deviation, OTR (not on practical)
•Smooth Pursuit
•Saccades
what are the vestibulo ocular reflex (VOR) test that can be done (exact sequence)
•Head Shake Nystagmus Test
•Head Impulse Test
•Dynamic Visual Acuity
•VORx1
•VOR x 2
•VORc
what should u do before conducting visual and vestibular test
how do u test spontaneous nystagmus (not on practical)
test 1st with fixation (room light) and then with frenzels (no fixation)
normal if no nystagmus
what is a positive for central vestibular with spontenoaus nystagmus
no change in intensity of nystagmus
direction changing
pure horizontal/vertical
is not fatigable with frenzels
what is postivie for peripheral vestibular when dong the spontaneous nystagmus test
- nystagmus intensity increased
- is unidirectional/ direction fixed
- rotary component
- fatgiagle with frenzels
Nystagmus is named for the ____ phase directed towards the healthy/intact/unaffected ear.
fast
when is nystagmus greatest ? minimal or absent?
greatest wehn gaze is dreicted towards the healthy ear followed by a center gaze
minimal or absent when gaze is directed towards the impaired ear
when does the intensity of nystagmus increased
when the eye moves in the direction of the fast phase (towards healthy ear(
how do u perform gaze evoked nystagmus
pt head is still and have pt follow target (X) held at eye level 12-18” away with fixation (room light) and have patient gaze center then L and R to determine degress of nystagmus then do it without fixation (w frenzels)
what is a positive central sign for gaze evoked nystagmus test
intensity of nystagmus will increase with gaze in ANY direction; NOT FATIGABLE
what is a positive peripheral sign (non BPPV) show from the GEN test
intensity of nystagmus increased with gazing in direction of fast phase (alexander’s LAW) ; fatigable
what is 3rd degress (1st day ; acute lesion) for a positive non BPPV GEN test
nystagmus present with gaze center, gaze toward & gaze away from side of lesion; most intense when gaze directed towards healthy ear.
what is 2nd degress (after a few days) for a positive non BPPV GEN test
nystagmus present with gaze center & away fromn side of lesion (healthy ear)
what is 1st degress (within 1 week , chronic) for a positive non BPPV GEN test
nystagmus present only with gaze away from
side of lesion (healthy ear)
what will determine acute v chronic lesion ? and what will that determine
degress of nystagmus
determine dosage of vestibular exercise
what is alexander’s law
nystagmus increases in intensity as patient gazes
further in the direction of the fast component of the nystagmus
(intact ear)
if a patient has L Peripheral Vestibular Hypofunction (PVH) (non-BPPV), you would see what if it was acute (1-2) days… what degree of nystagmus
R beating horizontal nystagmus with L face that increased in center gaze and further increased with R gaze (toward healthy ear; away from side of lesion)
3rd degree
if a patient has L Peripheral Vestibular Hypofunction (PVH) (non-BPPV), you would see what if it was after 2-3 days… what degree of nystagmus
No nystagmus in L gaze position, R
beating nystagmus in center gaze that increases when looking toward R
(towards healthy ear; away from side of lesion)
2nd degree
if a patient has L Peripheral Vestibular Hypofunction (PVH) (non-BPPV), you would see what if it was chronic ; within a week … what degree of nystagmus
no nystagmus in center gaze or gaze towards L side (lesion side) but R beating horizontal nystagmus present in R gazed (towards healthy ear)
1st degree
how to test vergence for non BPPV
slowly bring target (X) twaords pateints nose , ask the patient to keep their eyes on the target and inform you at what point do they get diplopia (double vision)
what is the normal and abnormal test for vergence
normal: target at least 6cm from nose before double vision
abnormal: disconjuate eye movement or double vision before target is at 6 CM
what will a skewed eye do with the skew deviation test
will jump back to target with uncover
what will a non skewed eye do during the skew deviation test
eye will cause skewed eye to jump back to the target with cover
what are the 2 visual tracking test done
smooth pursuit and saccades (both central signs)
how do u perform smooth pursuit ? how far is the target held and what °
With head still, ask pt to follow a
target (X) held 12-18” in front at eye
level; move target slowly ~ 30 deg in
each direction
what is abnormal with smooth pursuit
saccadic intrusions
how do u perform the saccades test and how far in front and at what angel is the target held
with head held still, ask pt to quickly look
back-forth between your nose (center target)
and X held to R or L of center; target is eye level
and 12 -18 “ in front; R/L target held ~30 deg
from center. Repeat up/down, diagonally.
what is the abnormal sign for saccades
overshooting or undershooting
how fast do u need to move the head to elicit VOR
2 Hz
how do u perform the VOR: head shake nystagmus test w frenzels
Place frenzels on patient. Ask pt to close eyes. Then, pitch pt’s head down 30 deg, & passively shake their head side to side quickly (2 Hz velocity) for 20 sec. using a metronome (120/240 bpm). After 20 sec, stop, have them open eyes and look straight ahead (gaze center). Observe for nystagmus. If present, have them then look to R and L to degree (acute v chronic)
what does teh VOR: Head Shake Nystagmus
Test (HSNT) w Frenzels stimulate
horizontal canal VOR
what is the abnormal response to VOR: Head Shake Nystagmus Test (HSNT) w Frenzels
peripheral vestibular imbalance w direction fixed nystagmus beating towards the active/intact side
what test for the VOR do u have to use frenzels with
head shake nystagmus test
what is the sequence for testing non BPPV peripheral vestibular hypo function
Head Shake Nystagmus Test (HSNT) *
Head Impulse or Head Thrust Test
(HIT/HTT)
Dynamic Visual Acuity (DVA)
VOR x 1
VOR x 2
VORc
In the Horizontal (or Lateral) canals, ampullopetal flow (towards ampulla) creates a stronger response (is stimulated more) bc why
it
deflects the cupula away from the canal.
how do u perform the VOR: Head Impulse or Head Thrust Test (HIT or HTT)
sit in front of th pet at eye level about 12-18” away then pitch pts head down about 30° then ask pt to fixate on ur nose while you PASSIVELY and SLOWLY move pt head side to side each direction several times (this stimulates horizontal canal VOR))
then QUICKLY and unexpectedly thrust patients head 10-20° to one side then stop
observe if their eyes remain on ur nose or if they jump to one side then come back
repeat 3 times
what is the abnormal testing for VOR: Head Impulse or Head Thrust Test (HIT or HTT)
pt eye jump to side of the thrust then refixate indicating vestibular hypo function to the side of the head thrust (2nd law)
how do u perform VOR: Dynamic Visual Acuity
(DVA) Test
ask pt to flex their head 30° and place eye chart at eye level
test static visual acuity first by asking the patient to read the lowest line possible
then w the patients head still tiled passively move their head side to side at 2hz (120/240 bpm) and ask them to read the lowest line
when performing the VOR: Dynamic Visual Acuity
(DVA) Test how do u know if the abnormal finding are unilateral or bilateral
Unilateral Vestibular Hypofunction: >3-line difference or (+) dizziness
Bilateral Vestibular Hypofunction: >3-line difference, (-) dizziness, (+) oscillopsia, (+) postural instability
what is VORx1
active head movement at 2 Hz w target stable
how to preform VOR x1
Ask pt to actively move their head side (20-30 deg) at 120/240 bpm on metronome while
keeping their eyes on the (X) in the center, held 12 – 18 inches away at eye level. Keep going
until and when X blurs.
what is the abnormal finding for VOR x1
target becomes blurry or jumping and/or (+) dizziness or unable to move head at 2 Hz (before 2 mins)
document speed at which target become blurry
if cant move heard at 2Hz then determine speed they can do it at (baseline )
what is VOR x 2
active head movement w target moving opposite to head as fast as they can
do u use a metronome for VOR 2
naur
what is the Mechanism for suppressing VOR during combined eye-head tracking when eyes and head
move together in same direction; assesses visual-vestibular integration in CNS
Lesions in cerebellum (flocculus or paraflocculus)
VOR cancellation
how to perform VORc ? (you are only performing this as an intervention on the practical not a test even tho it is part of the oculomotor and VOR testing)
patient is in rotary stool and then extend arms in front of them while focusing on thumb
PT flexed head down to 30° then passively moves pts head side to side as the pt keeps their eyes on their thumbs to a beat of 50bpm
what is the sensory organization test
modified CTSIB (not on practical)
what is the motion sensitivity test used for ? )not on practical)
identify movements that cause symptoms for the purpose of habituation
what are the vestibular specific functional measures (not on practical)
- fukuda step test
- functional gait assessment
- vestibular disorders activities of daily living scale (VADL)
