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Vestibular > Non-BPPV > Flashcards

Non-BPPV Flashcards

1
Q

non-BPPV Exam Order

A
  1. Observe Spontaneous Nystagmus
  2. Observe Oculomotor Issues
  3. Oculomotor Tests
  4. VOR Tests
  5. HINTS Exam
  6. Balance Screen
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2
Q

non-BPPV Determinants

A
  1. Vestibular or not
  2. Central or peripheral
  3. Acute or chronic
  4. Unilateral or Bilateral
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3
Q

Frequency and Duration: Vestibular Neuritis

A

-Sudden onset
-lasts days

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4
Q

Frequency and Duration: Bilateral Hypofunction

A

-gradual onset
-constant/chronic

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5
Q

Frequency and Duration: Mennniere’s or Vestib Migraine

A

-Sudden
-Recurrent spells (hours/days)

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6
Q

Frequency and Duration: Orthostatic Hypotension

A

-short spells
-Recurring

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7
Q

Frequency and Duration: PPPD of MDDS

A

-Constant
-Chronic

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8
Q

Aggs and Eases: Gaze Instability

A

Ag: head movement
Eas: holding still and closing eyes

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9
Q

Aggs and Eases: Vestibular Neuritis

A

Ag: Spontaneous made worse by head movement
Eas: Holding still, closing eyes, meds

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10
Q

Aggs and Eases: Vestibular Migraine or Meniere’s

A

Ag: Spontanous made worse by head movement
Eas: Holding still, closing eyes, meds

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11
Q

Oculomotor Tests

A

On practical:
1. Gaze Evoked Nystagmus (frenzels)
2. Vergence
3. Smooth Pursuit
4. Saccades

Not on Practical:
-spontaneous nystagmus
-ocular ROM
-Skew-eye deviation

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12
Q

Spontaneous Nystagmus

A

-not on practical
-non-BPPV
-test with frenzels and observe eyes

Central:
-nystagmus doesn’t change with fixation
-direction of beating changes
-not fatiguable

Peripheral:
-nystagmus dec with fixation
-unidirectional
-Direction doesn’t change (Alex law)
-fatiguable

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13
Q

Alexander’s Law

A

-non-BPPV
-Peripheral vestitbular dysfuncntion will not change the direction of nystagmus
-named for fast phase toward the HEALTHY ear

3rd Degree (1st day):
-nystagmus moves in all 3 directions
-toward HEALHY ear
-acute

2nd Degree (few days):
-nystagmus at center and toward HEALTHY ear

3rd Degree (1 week):
-chronic
-nystagmus only with gaze toward HEALTHY ear

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14
Q

Vestibulo-ocular Reflex (VOR) Tests

A

-Head Shake Nystagmus Test
-Head Impulse Test
-Dynamic Visual Activity
-VOR 1
-VOR 2
-VORc

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15
Q

Before Visual/Vestibular Tests

A

-record baseline (0-5)
-Record change (0-5)
-Ask if they can clearly see the target

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16
Q

Gaze Evoked Nystagmus (GEN)

A

-non-BPPV
-have target arm arm away from patient
-move L/R and U/D slowly

-repeat with frenzels

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17
Q

Gaze Evoked Nystagmus (GEN): Central

A

-intinsity of nystagmus changes direction
-doesn’t improve with fixation
-not fatiguable
-vertical nystagmus

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18
Q

Gaze Evoked Nystagmus (GEN): Peripheral

A

-nystagmus dec with fixation
-unidirectional
-Direction doesn’t change (Alex law)
-fatiguable

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19
Q

Vergence

A
  1. Slowly bring target to nose and ask them to keep their eye on it

Normal: target is att least 6cm before Pt sees double
Abnormal: disconjugate eye movement before 6 cm OR aversion reaction (SNS)

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20
Q

Skew Deviation

A

not on practical

  1. Cover one eye to determine if there’s a compensation

-Skewed eye will jump back with uncover
-Non-skewed eye will cause skewed eye to jump back with cover

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21
Q

Smooth Pursuit

A
  1. Follow target an arms length away slowly
  2. Move to 30deg on each side

Abnormal:
-saccadic intrusions

22
Q

Saccades

A
  1. Hold target an arms length away
  2. Move to 30deg on each side
  3. Tell Pt to look quickly btwn PT nose and target

Abnormal:
-overshooting or undershooting
-slow scan
-central sign

23
Q

Vestibulo-Ocular Reflex (VOR)

A

-driven at 2 Hz
-120 bpm or 240 bpm
-30 deg each side of movement or 60 deg total

24
Q

Ewald’s 2nd Law

A

-horizonal canal BPPV and VOR
-excitation creates a greater response than inhibition
-flow towards ampulla creates a stronger response

25
Q

VOR: Head Shake Nystagmus Test

A

-stimulates Horizontal canal
-can be treatment

  1. Use Frenzels
  2. Pt close eyes and PT pitches head 30deg down (puts HC parallel)
  3. Passively shake head to metronome fr 20 s
  4. Stop then have them open their eyes and check for nystagmus
    -assess for degree

Abnormal:
-Peripheral dysfunction with direction-fixed beating toward INTACT side
-acute vs chronic

26
Q

VOR: Head Thrust/Impulse Test

A

-stimulates Horizontal canal

  1. Sit at eyes level and an arm away and Pt looks at PTs nose
  2. PT holds head 30deg down (puts HC parallel)
  3. Passively rotates head slowly and unexpectedly thrusts 10-20 degs
  4. Check to see if their eyes remain on your nose or jump

Abnormal:
-Pts eyes jump to the side of thrust then re-fixate
-Hypofunction to the SAME side of head thrust

27
Q

VOR: Dynamic Visual Acuity Test

A
  1. Chart at eye level 4m away
  2. Test vision at lowest level
  3. PT flexes head to 30deg and rotate 20-30deg to metronome 120 bpm WHILE reading lowest level available

(+): Unilateral: >3 line dif or dizziness
(+): Bilateral: >3 line dif, no dizziness, oscillopsia, postural instability

28
Q

VOR 1 Test

A

-active head movements while moving

  1. Pt moves head 30 deg at 120 bpm (2 Hz) while keeping eyes and arm length away
  2. Keep going until blurry

Abnormal:
-target gets blurry or jumping before 2 Hz

document and determine speed they can do

29
Q

VOR 2 Test

A

-active head movement while target moves opp

  1. Pt moves head opp of target as fast as they can (don’t need metronome)

Abnormal:
-target becomes blurry or jumping or dizziness

30
Q

VORc Test

A

-head and arms together
-suppresses VOR
ONLY as treatment in practical

  1. Pt seated w/ arms ext, head pitched down 30 deg
  2. Passive or actively move head as target follows

Abnormal:
-saccdic intrusion
-dizziness
-imbalances

31
Q

Fukuda’s Stepping Test

A

-NOT on practical
-tests vestib function

  1. Pt marches in places for 50 steps with UE parallel and eyes closed
  2. Watch their progression and turns

Normal: move less and than 50cm and 30 deg
Abnormal: often turn towards INVOLVED side

32
Q

Deficits in VOR Function

A

Static:
-seen at rest with acute unilateral dysfunction
-resolves within a few days

Dynamic:
-abnormality in VOR gain or timing of eye movements in relation to head motion

33
Q

Mechanisms of Vestibular Recovery: Neuroplasticity

A

-varies according to the severity of vestibular dysfunction

34
Q

Mechanisms of Vestibular Recovery: Spontaneous

A

-resolve spontaneously in 4-7 days
-if not, CNS is unable to adapt

35
Q

Mechanisms of Vestibular Recovery: Compensation

A

-when recovery is not possible
-may be required to dec s/s

36
Q

Mechanisms of Vestibular Recovery: Vestibular Rehabilitation

A

-Adaptation
-Substitution
-Habituation

37
Q

Adaptation

A

-recovery mechanism for VOR to make long term changes
-modifies VOR gain; requires error signal to initial adaptation
-Unilateral Hypofunction (NOT FOR BILAT unless hypofunction)
-can be induced 1-2 min at a time
-must work through s/s for 1 min
-if blurry, dec use then progress to 2 Hz

38
Q

Adaptation: Gain

A

-ratio used to describe the relationship of eye movement to head movement or eye movement to target

Normal VOR gain: 1
Abnormal VOR gain: retinal slip causing images to become blurry

39
Q

Substitution

A

-inc use of other strategies to replace lost vestibular function
-Bilateral VOR or central dysfunction
-Unilateral if complete loss

40
Q

Habituation

A

-repeated exposure to a stimulus dec brain’s pathological response to that stimulus
-for motion sensitivity or mixed dysfunction
-repeated provoking position/stimulus until s/s dec
-last ditch effort
-Ex: Brandt-Daroff

Immediate: reduced sensitivity of Ca
Long-Term: change in size and number of synapses

41
Q

Unilateral Hypofunction

A

-dec function of one side
-easier to recover
-S/s: dizziness

Tx:
-Adaptation if hypo
-Substitution if complete loss
-Habituation to dec s/s

-Oculomotor
-VOR1/2/c

42
Q

Bilateral Hypofunction

A

-dec function of both sides
-harder to recover
-S/s: Jumping

Tx:
-Substitution (Mainly)
-Adaptation (if some function remains)

-Oculomotor
-VOR 1/c
-Remembered/Imagined targets
-Active head-eye movement btwn target

43
Q

Gaze Stabilization VOR Exercises

A

-for VOR adaptation OR Substitution

Changes:
-postural supports
-Visuals
-Directions
-Speed
-Cognitive
-Multi-tasking

-for Unilateral hypofunction
-Perform 3x a day
-should feel dizzy for 5-10 mins post
-target must remain ‘not blurry’
-speed of head should inc as needed

44
Q

VOR Exercises: Adaptation

A
  1. VOR x1
    -2 Hz for 1 minute (if not, ocular 3x/day)
    -progress to 2 after 2 mins
  2. VOR x2
    -2 mins
  3. VORc
    - 50bpm for 2 mins

don’t progress variables until all 3 completed

45
Q

VOR Exercises Adaptation: HEP

A

Acute:
-12 min throughout day
-1-2 mins intervals

Chronic:
-20 min throughout day
-1-2 min intervals

46
Q

VOR Exercise: Substitution #1

A

-active eye-head movements btwn 2 targets
-bilat hypo
-must do adaptation and both substitution exercises
-provides oculomotor substitute

  1. Place 2 targets on wall a nose level
  2. Pt looks at one target then turn head towards other target and maintain vision
  3. Look at other target
  4. Move head
  5. Repeat for 1 min, 3x/day
47
Q

VOR Exercise: Substitution #2

A

-Remembered or imagined target
-bilat hypo
-must do adaptation and both substitution exercises
-provides cervical substitute

  1. Place 1 target on wall a nose level
  2. Pt closes eyes and turns head away and maintain eye motion
  3. Open eyes and see if you remembered
  4. Repeat for 1 min, 3x/day
48
Q

VOR Cancellation Exercise

A

-chronic unilateral hypo
-treat for practical
-1 minute, 3x/day
-start VORc slowly, then progress to faster
-s/s should last 5-10 mins

49
Q

Grounding Exercise

A

-for all vestib patients
-during symptom recovery or increased anxiety
-focus somatosensory
-Box breathing

50
Q

Central Vestibular Dysfunction: Rehab

A

-occulomotor exercises
-habituation

Vestibular (5 decks)

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