Lecture 9: Vestibular Assessment and Treatment Flashcards
What is first important part to distinguish in a potential vestibular assessment?
is it vertigo or just dizziness
What is the difference in how long sx last?
BPPV- short duration
UVH- long lasting
Under what circumstances will sx occur?
only head turns- BPPV
with or without head turns, random- UVH
trouble in dark- bilateral VH
Does the patient experience double vision?
central finding
Does the patient experience hearing loss?
labyrinths or meniere’s
Which of the patient symptoms are disturbing function the most?
N/V, vertigo- BPPV, UVH
imbalance and persistent lightheadedness- bilateral or Central
What are the 5 neurological D’s that could indicate central pathology?
dizziness, diplopia, dysarthria, dysphagia, drop attacks
What other signs and symptoms that may be a red flag during an eval?
numbness, weakness, slurred speech, tremors, LOC, memory loss, rigidity, Babinski sign, clonus, spasticity
What is a commonly used outcome measure a patient can self report?
Dizziness handicap inventory
self perceived handi cap as a result of vestibular disorder
What are examples of objective ocular motor tests?
- ocular alignment
- smooth pursuit
- Saccades
- VOR Cancellation
What if any of these oculomotor tests are positive?
likely indicative of CNS problems
What are the components of the smooth pursuit test?
tests pts ability to track object
What are the components of the saccades test?
pt is asked to move eyes back and forth from finger to nose horizontally and vertically
abnormal if pt over shoots and under shoots target
What type of test is commonly seen in pts post concussion?
Vergence- eyes both adduct as an object moves closer towards nose
abnormal = likely CNS problem, ask pt about any recent trauma
What is VOR cancellation?
tests the calibration capability of the cerebellum
What are 4 types of VOR testing?
- Dynamic Visual Acuity
- VOR x 1
- Head Thrust
- Head Shake
If any of the VOR tests are positive what does this likely indicate?
UVH
What is the Dynamic Visual Acuity test?
looking at visual chart and if loss of 2-3 lines indicates hypo function
What is VOR x1?
pt will focus on object and turn head
if sx are provoked or pt has trouble focusing likely UVH
What is the procedure of head thrust test?
pt head flexed 30 degrees , random side to side thrusts to either side
most widely used clinical test hypo function
What does an abnormal head thrust finding indicate?
inability to maintain visual fixation on nose with corrective saccades
thrust to right and center = right UVH
thrust to left and center = left UVH
What is Head shake test?
done with frenzy goggles
pt flexes head and PT moves it 20 times with eyes closed and opens eyes and see if nystagmus is present
What are abnormal findings for a head shake test?
if nystagmus to right- left UVH
if to left- right UVH
What is an important concept to remember about nystagmus in general?
nystagmus will generally beat to the side of irritation in BPPV and away from side of lesion in hypo function
What is an example of a VSR test?
Fukuda step test - attempts to isolate the VSR, detects UVH if positive
What is procedure for Fukuda?
pt stands with eyes closed and arms elevated to 90 degrees and marches for 50 steps with eyes closed
if pt turns head more than 30 degrees to one side positive for UVH to that side
What are two recommended outcome measures specific to vestibular pathology?
- DGI- 19/24 indicates fall risk
2. FGA- 22/30 indicates fall risk
What is the motion sensitivity quotient?
objective measures a pts motion sensitivity, involves 16 rapid changes in head position and recorded by intensity, duration and number of positions that provoke it
What are three additional diagnostic tests for vestibular dysfunction?
- ENG- can determine whether dysfunction is peripheral or central
- Rotary Chair test- very expensive
- Dynamic posturography- fancy CTSIB
What is one of the main treatments for BPPV?
Canalith Repositioning maneuver or CRM is most advocated for pts with posterior canalathiasis
What are some guidelines for the CRM?
30 second in each position, requires 180 of head motion
retest after 15 mins
What should patient avoid for the rest of day after CRM?
excessive head movements, remain upright 20 mins after procedure , sleep on back with several pillows
What is another common manual technique used for BPPV?
Liberatory maneuver for cupulolithiasis
“face plant test”
What type of specific exercises can be used as a follow up treatment for BPPV?
Brandt Daroff
specific habituation exercises to help pts re use positions they may have been avoiding
What are three key treatment concepts for vestibular rehab?
- Adaptation
- Substitution
- Habituation
What is the rationale for adaptation exercises in vestibular rehab?
improves VOR gain by reducing retinal slip
What is retinal slip?
difference between eye and head velocity , if VOR is impaired then a retinal slip is generated which sends an error signal to brain
When are adaptation exercises implemented?
when residual vestibular function is present and recovery is expected
appropriate for UVH, bilateral, peripheral or central dysfunction
What is a common adaptation exercise?
VOR x 1, pt must always have a clear image and can continue with mod sx
progress to VOR x2
What are parameters for adaptation exercises and what are the progressions?
1-2 minutes, 3-4 times a day
progress by longer duration, faster movement and change position of body
What is the rationale for substitution for vestibular rehab?
implements visual and somatosensory input from cervical spine to compensate for vestibular loss
appropriate for complete or severe bilateral loss
What types of exercises are used for substitution rehab?
can use VOR x1, ocular exercises and balance exercises to enhance somatosensation
practice 2-5 mins, 3 x a day
What is the rationale for habituation for vestibular rehab?
repeated exposure to provocative stimuli results in a reduction of pathological response to a stimulus
aka Brandt Daroff exercises
What is the method for BD exercises?
execute a series of 4 provoking movements 2-4 times a day
What is important to remind patients about BD exercises?
symptoms will be provoked during these movements, sx should decrease within 15-30 mins of exercises, usually 7-10 days before body adjusts, may take 4 weeks for sx to diminish
