Practical Exam Flashcards
Part 1: History
-listen to s/s and verbilize working diagnosis and why
-verbalize tests being done
Part 2: Exam
-Set up environment
-Safety tests for BPPV
-Verbalize precautions
-Explain to Pt in layman’s terms
-Communicate with Pt during and ask about s/s
-Verbalize diagnosis and rationale
-State intervention
Part 3: Intervention
-Set up environment
-Explain to patient what you found and what exercise they’ll be doing, and what they should expect
-Talk to the patient while performing exercise
-Verbalize holding positions for certain amounts of time
Part 4: HEP
-Explain HEP, rationale, and do it for the patient
-Have Pt do it infront of you
-Correct their mistakes
-Inform them about how long to do it
Benign Paroxysmal Positional Vertigo: Canalithiasis
Canalithiasis (MC):
-otoconia fall off and free float in PSCC
-latent onset of vertico and nystagmus after provoking
-disappears in 1 min
s/s:
-short spells, recurring
-holding still makes it better
Vesibular Hypofunction
-damage to inner ear or vestib n
-affects VOR and VSR
-unilateral: dizzy
-bilateral: moving images (oscillopsia); gradual onset; no dizziness
Benign Paroxysmal Positional Vertigo: BPPV
-BPPV
-most common; age, trauma
-crystals from utricle or saccule (MC) fall from utricle into SCC (PSCC MC)
-heavy crystals cause change in endolymph viscosity and fire nerve signals
-top shelf vertigo
-brief vertigo and nystagmus
s/s:
-short spells, recurring
-holding still makes it better
Benign Paroxysmal Positional Vertigo: Cupulolithiasis
Cupulolithiasis:
-otoconia fall off and adhere to cupula of PSCC making cupula denser around endolymph
-immediate vertigo is persistent until head moved
-nystagmus
s/s:
-ling spell
-persistent
Subjective Assessment
-quality of s/s
-longevity of s/s
-frequency
-aggravating factors
-easing factors
-associated s/s
Nystagmus: PNS
Peripheral Vestib:
-Slow phase: VOR
-fast phase: corrective saccade
-usually horizontal
-moves in the same direction
Vertigo
-sensation of the room spinning
BPPV or non-BPPV (anything not canal related)
Quality: Vertigo
-Illusion of movement
-spinning, rocking, swaying, falling
Frequency and Duration: BPPV
Short Spells: Canal
Long Spells: Cup
-recurring
Aggs and Eases: BPPV
Ag: changing positions or lying or rolling
Eas: holding still for time
Cervical Screen
- Contraindications
- Cervical AROM
- Seated Ext/ROT Test
- Alar, Transverse leg and VBAI Test (acknowledge)
Cervical Screen: Contraindications
Ask about Hx of
-neck surgery
-recent trauma
-severe RA, AA or OA instability
-Cervical meylopathy/Radiculopathy
-Carotid sinus syncope
-Chiari malformation
-Vascular dissection
Cervical Screen: Cervical AROM
-flx/ext/SB/ROT (Ds and Ns)
-Rot head and ext head and count back from 10
no overpressure
check 5Ds and 3Ns
Cervical Lig and ABI Testing
-verbalize
“I have checked the transverse and alar ligaments as well as the vertebral basilar artery for insufficiency”
BPPV Exam Order
- Subjective
- Clear C-Spine
- Perform Dix-Hallpike (only if cleared)
- Roll Test (if -)
- Side-Lying Test (if - and symptomatic)
- Determine side and canal/cup
Canalithiasis
-free floating debris
-latent onset of s/s
-short term (<1 min)
-Geotropic
Tx: done slowly
Cupulolithiasis
-debris stuck on cupula and constantly firing
-immediate onset and long-lasting s/s in position
-Ageotropic
Tx: done quickly
Dix-Hallpike Test
-for PSSC
-test less affected side first
-Clears VBA first
- Use Frenzels
- Turn head to 45 deg
- Quickly bring their head down into ext
- Hold for 1 min or until dizziness subsides +30 and look at nystagmus
(+) PSC: upbeat
(+) ASC: downbeat
Horizontal Canal
-oriented 30 deg upwards and horizontal
-matched with opp HC
-pitch head down 30 to make it parallel to ground
Roll Test
-for HSC
-if DHP is (-), do it immediately after
- Use Frenzels
- Pt slides head down until it’s supported
- Flex head 30deg and support with pillow
- Quickly rotate head to unaffected side first and observe
(+): Geotropic/Canal: ground beating, stronger/faster to affected ear
(+): Ageotropic/Cup: sky beating; stronger/faster to affected ear
Sidelying Test
-for PSC/ASC as alternative to DHP or if DHP and RT are negative
- Pt sitting at edge
- Rotate head to less affected side
- Quickly bring pt’s head down on affected side with nose up, hold until s/s ease + 30s
(+) PSC: upbeat, same side of testing side
(+) ASC: Downbeat, opp side of testing side
Precautions to Treatment of Vestibular Disorders
-sudden loss of hearing
-increase in pressure to the point of discomfort
-discharge or fluid from the ear
-severe ringing in ear
Posterior Canal BPPV Treatments
-Canalith Repositioning Maneuver (CRM) (Canal)
-Semont Maneuver (cup)
HEP:
Epley
Self semont
Anterior Canal BPPV Treatments
-Reverse Semont Maneuver (Canal AND Cup)
-Yacovino
HEP:
-Reverse Semont
Horizontal Canal BPPV Treatments
-BBQ Roll (Canal)
-Gufoni/Casani (Cup)
HEP:
-Forced Prolonged Positioning + BBQ roll
-Self-Casani
Canalith Repositioning Maneuver (CRM)
-PSC canalithiasis
- Stay in DHP position until the nausea goes away +30s
- Rotate head slowly to opp side and wait 30s
- Have Pt move to sidelying and pitch head down in dump position while maintaining rotation, wait 30s
- Pt slowly sits up maintaining head position, wait 30s
- Bring head up to neutral, wait 30s
Epley Maneuver (Self-CRM)
-HEP for PSC Canal
- Pt in long sitting
- Rotate head slowly to same side of impairment and immediately Lay back maintaining rotation and have head off side of pillow, wait 30s
- Slowly turn head to opposite side, wait 30s
- Slowly turn body in direction and tuck head into dump position, wait 30s
- Return to sitting, wait 30s
3x/day until s/s stop for 3 days straight
Semont Maneuver
-PSC Cupulolithiasis
-2 reps in one session
- Pt at edge of table, turn head 45 deg in opp direction of affected side and Quickly bring Pt down on affected side with head rotation maintained, wait 1 min
- Quickly move onto opposite side maintaining rotation and flexing head into dump position, wait 1 min
-shake head if no s/s appears and wait 1 min - Slowly come up while maintaining head, wait 1 min
- Head to neutral slowly, wait 1 min
Reverse Semont Maneuver
-ASC Canalithiasis OR Cupulolithiasis
-2 reps in one session
- Pt at edge of table, turn head 45 deg in SAME direction of affected side, wait 1 min
- Quickly bring Pt down on affected side with head rotation maintained and head down into dump position, wait 1 min
- Quickly move onto opposite side maintaining rotation and tilting head up, wait 1 min
-shake head if no s/s appears and wait 1 min - Slowly come up while maintaining head turn to affected side, wait 1 min
- Head to neutral slowly, wait 1 min
HEP for ASC and PSC Cupulolithiasis
-Semont or Reverse Semont
-3-5 reps until 3 days s/s free
BBQ Roll
-HSC Canalithiasis or Geotropic
-wait for s/s to dec + 30s
- Begin in roll test position w/ head turned towards affected and flexed 30 deg, hold for 30s
- Slowly roll head in opposite direction maintaining flexion, wait 30s
- Slowly roll body in direction of head into dump position, wait 30s
- Slowly roll onto Pt stomach while maintaining head position, provide pillow under chest, wait 30s
- Slowly roll patient onto other side maintaining head position, wait 30s
- Slowly sit up maintaining position, wait 30s
- Return to neutral, wait 30s
Casani Maneuver
-HSC Cupulolithiasis or Ageotropic
-2 reps
- Pt sitting at mat in neutral
- Quickly bring patient down onto affected side (opp side of positive testing side), hold for 2 min
- Quickly rotate head upward away from affected side, hold for 2 min
- Slowly return to sitting w/ head position maintained, wait 2 min
- Head to neutral, wait 2 min
HEP for HSC Canalithiasis
-Forced Prolonged Positioning for that night followed by BBQ roll in the morning
-1x/night and bbq roll in morning, 3 days in a row w/o s/s
HEP for HSC Cupulolithias
-Self-Casani
-3-5 reps weeks x3 days
Forced Prolonged Position
-HEP for HSC Canalithiasis
-3 days in a roll
- Laying on affected ear for 1 min
- Lie on back for 1 min
- Quickly roll lying on unaffected ear and sleep in this position (explain way to prop up)
- In the morning finish BBQ roll
non-BPPV Determinants
- Vestibular or not
- Central or peripheral
- Acute or chronic
- Unilateral or Bilateral
non-BPPV Exam Order
- Oculomotor Tests (2)
- VOR Tests
- VOR treament
- HEP (VOR progression)
Vestibulo-ocular Reflex (VOR) Tests
-Head Shake Nystagmus Test
-Head Impulse Test
-Dynamic Visual Activity
-VOR 1
-VOR 2
-VORc
Alexander’s Law
-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
VOR: Head Shake Nystagmus Test
-stimulates Horizontal canal
-can be treatment
- Use Frenzels
- Pt close eyes and PT pitches head 30deg down (puts HC parallel)
- Passively shake head to metronome fr 20 s
- 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
Vestibulo-Ocular Reflex (VOR)
-driven at 2 Hz
-120 bpm or 240 bpm
-30 deg each side of movement or 60 deg total
VOR: Head Thrust/Impulse Test
-stimulates Horizontal canal
- Sit at eyes level and an arm away and Pt looks at PTs nose
- PT holds head 30deg down (puts HC parallel)
- Passively rotates head slowly and unexpectedly thrusts 10-20 degs
- 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
VOR: Dynamic Visual Acuity Test
- Chart at eye level 4m away
- Test vision at lowest level
- 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
VOR 1 Test
-active head movements while moving
- Pt moves head 30 deg at 120 bpm (2 Hz) while keeping eyes and arm length away
- Keep going until blurry
-Want s/s to last 5-10min after
Abnormal:
-target gets blurry or jumping before 2 Hz and 2 mins
document and determine speed they can do
VOR 2 Test
-active head movement while target moves opp
- Pt moves head opp of target as fast as they can (don’t need metronome)
-Want s/s to last 5-10min after
Abnormal:
-target becomes blurry or jumping or dizziness
VORc Test
-head and arms together
-suppresses VOR
-metronome
-chronic unilateral treatment
ONLY as treatment in practical
- Pt seated w/ arms ext, start slow then fast
- Passive or actively move head as target follows
-Want s/s to last 5-10min after
Abnormal:
-saccdic intrusion
-dizziness
-imbalances
Adaptation
-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
-Want s/s to last 5-10min after
Substitution
-inc use of other strategies to replace lost vestibular function
-Bilateral VOR or central dysfunction
-Unilateral if complete loss
Unilateral Hypofunction
-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 (if s/s while moving eyes)
-VOR1 AND VOR 2 AND VOR C*
HEP (Progression):
–Oculomotor (if s/s while moving eyes)
-VOR1 AND VOR 2 AND VOR C*
Bilateral Hypofunction
-dec function of both sides
-harder to recover
-S/s: Jumping/oscillopsia
Tx:
-Substitution (Mainly)
-Adaptation (if some function remains)
-Oculomotor
-VOR 1 AND VOR C*
- Remembered/Imagined targets*
-Active head-eye movement btwn target*
HEP (progressed):
-Oculomotor
-VOR 1 AND VOR C*
- Remembered/Imagined targets*
-Active head-eye movement btwn target*
VOR Exercises Progressions
-for VOR adaptation OR Substitution
Changes:
-postural supports
-Visuals
-Directions
-Speed
-Cognitive
-Multi-tasking
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
Bilateral Hypofunction:
-1 min ea for 3x day
-should feel dizzy for 5-10 mins post
-target must remain ‘not blurry’
VOR Exercises: Adaptation
- VOR x1
-2 Hz for 1 minute (if not, ocular 3x/day)
-progress to 2 after 2 mins - VOR x2
-2 mins (no metronome) - VORc
- 50bpm for 2 mins
don’t progress variables until all 3 completed
VOR Exercises Adaptation: HEP
-VOR 1, VOR 2, VOR C
Acute:
-12 min throughout day
-1-2 mins intervals
Chronic:
-20 min throughout day
-1-2 min intervals
VOR Substitution #1 Exercise: Head Movements Between 2 Targets
-bilat hypo
-must do adaptation and both substitution exercises
-provides oculomotor substitute
- Place 2 targets on wall a nose level
- Pt looks at one target then turn head towards other target and maintain vision
- Look at other target
- Move head
- Repeat for 1 min, 3x/day
Progression:
-more reps of 1 min at a time
-posture
-movement
-speed
-target size
VOR Substitution #2 Exercise: Remembered or Imagined Target
-bilat hypo
-must do adaptation and both substitution exercises
-provides cervical substitute
- Place 1 target on wall a nose level
- Pt closes eyes and turns head away and maintain eye motion
- Open eyes and see if you remembered
- Repeat for 1 min, 3x/day
Progression:
-More reps of 1 minute at a time
-posture
-Movement
-speed
VOR Cancellation Exercise
-chronic unilateral hypo
50 bpm
-treatment on practical for both
-start VORc slowly, then progress to faster
-s/s should last 5-10 mins
Progression: Posture, background, direction (vertical and diagonal)
-speed
-larger amplitude, up to 60deg
HEP for Non-BPPV
-Use same as intervention used
-Increase 2 variables
Oculomotor Tests
On practical:
1. Gaze Evoked Nystagmus (frenzels)
2. Vergence
3. Smooth Pursuit
4. Saccades
Gaze Evoked Nystagmus (GEN)
-non-BPPV
-have target arm arm away from patient
-move L/R and U/D slowly
(+): nystagmus increases when looking in direction of HEALTHY EAR (contra ear is issue)
-repeat with frenzels
-determine acute/chronic
Vergence
- Slowly bring target to nose and ask them to keep their eye on it
- “ i’m going to bring this closer to your face slowly, I want you to tell me when you see two”
Normal: target is at least 6cm before Pt sees double
Abnormal: dis conjugate eye movement before 6 cm OR aversion reaction (SNS)
Smooth Pursuit
- Follow target an arms length away slowly
- Move to 30deg on each side (side to side, up/down, diagonal)
“ follow the target with your eyes, but don’t move your head, let me know if this causes any symptoms”
Abnormal:
-saccadic intrusions (central sign)
Saccades
- Hold target an arms length away
- Move to 30deg on each side
- Tell Pt to look quickly btwn PT nose and target as you tell them
- Up/down and diagonally too
- Switch eyes
Abnormal:
-overshooting or undershooting
-slow scan
-central sign
VOR Exercises Substitution : HEP
-bilateral hypofunction
-1 min ea exercise 3x a day
HEP (Progressed):
-VOR 1 (if some function remains)
-Active Between 2 Targets
-Remembered Targets
-VOR C
