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Practical Exam Flashcards

1
Q

Part 1: History

A

-listen to s/s and verbilize working diagnosis and why
-verbalize tests being done

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2
Q

Part 2: Exam

A

-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

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3
Q

Part 3: Intervention

A

-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

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4
Q

Part 4: HEP

A

-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

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5
Q

Benign Paroxysmal Positional Vertigo: Canalithiasis

A

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

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6
Q

Vesibular Hypofunction

A

-damage to inner ear or vestib n
-affects VOR and VSR

-unilateral: dizzy
-bilateral: moving images (oscillopsia); gradual onset; no dizziness

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7
Q

Benign Paroxysmal Positional Vertigo: BPPV

A

-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

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8
Q

Benign Paroxysmal Positional Vertigo: Cupulolithiasis

A

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

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9
Q

Subjective Assessment

A

-quality of s/s
-longevity of s/s
-frequency
-aggravating factors
-easing factors
-associated s/s

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10
Q

Nystagmus: PNS

A

Peripheral Vestib:
-Slow phase: VOR
-fast phase: corrective saccade
-usually horizontal
-moves in the same direction

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11
Q

Vertigo

A

-sensation of the room spinning

BPPV or non-BPPV (anything not canal related)

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12
Q

Quality: Vertigo

A

-Illusion of movement
-spinning, rocking, swaying, falling

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13
Q

Frequency and Duration: BPPV

A

Short Spells: Canal
Long Spells: Cup

-recurring

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14
Q

Aggs and Eases: BPPV

A

Ag: changing positions or lying or rolling
Eas: holding still for time

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15
Q

Cervical Screen

A
  1. Contraindications
  2. Cervical AROM
  3. Seated Ext/ROT Test
  4. Alar, Transverse leg and VBAI Test (acknowledge)
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16
Q

Cervical Screen: Contraindications

A

Ask about Hx of
-neck surgery
-recent trauma
-severe RA, AA or OA instability
-Cervical meylopathy/Radiculopathy
-Carotid sinus syncope
-Chiari malformation
-Vascular dissection

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17
Q

Cervical Screen: Cervical AROM

A

-flx/ext/SB/ROT (Ds and Ns)
-Rot head and ext head and count back from 10

no overpressure
check 5Ds and 3Ns

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18
Q

Cervical Lig and ABI Testing

A

-verbalize

“I have checked the transverse and alar ligaments as well as the vertebral basilar artery for insufficiency”

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19
Q

BPPV Exam Order

A
  1. Subjective
  2. Clear C-Spine
  3. Perform Dix-Hallpike (only if cleared)
  4. Roll Test (if -)
  5. Side-Lying Test (if - and symptomatic)
  6. Determine side and canal/cup
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20
Q

Canalithiasis

A

-free floating debris
-latent onset of s/s
-short term (<1 min)
-Geotropic

Tx: done slowly

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21
Q

Cupulolithiasis

A

-debris stuck on cupula and constantly firing
-immediate onset and long-lasting s/s in position
-Ageotropic

Tx: done quickly

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22
Q

Dix-Hallpike Test

A

-for PSSC
-test less affected side first
-Clears VBA first

  1. Use Frenzels
  2. Turn head to 45 deg
  3. Quickly bring their head down into ext
  4. Hold for 1 min or until dizziness subsides +30 and look at nystagmus

(+) PSC: upbeat
(+) ASC: downbeat

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23
Q

Horizontal Canal

A

-oriented 30 deg upwards and horizontal
-matched with opp HC
-pitch head down 30 to make it parallel to ground

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24
Q

Roll Test

A

-for HSC
-if DHP is (-), do it immediately after

  1. Use Frenzels
  2. Pt slides head down until it’s supported
  3. Flex head 30deg and support with pillow
  4. 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

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25
Sidelying Test
-for PSC/ASC as alternative to DHP or if DHP and RT are negative 1. Pt sitting at edge 2. Rotate head to less affected side 3. 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
26
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
27
Posterior Canal BPPV Treatments
-Canalith Repositioning Maneuver (CRM) (Canal) -Semont Maneuver (cup) HEP: Epley Self semont
28
Anterior Canal BPPV Treatments
-Reverse Semont Maneuver (Canal AND Cup) -Yacovino HEP: -Reverse Semont
29
Horizontal Canal BPPV Treatments
-BBQ Roll (Canal) -Gufoni/Casani (Cup) HEP: -Forced Prolonged Positioning + BBQ roll -Self-Casani
30
Canalith Repositioning Maneuver (CRM)
-PSC canalithiasis 1. Stay in DHP position until the nausea goes away +30s 2. Rotate head slowly to opp side and wait 30s 3. Have Pt move to sidelying and pitch head down in dump position while maintaining rotation, wait 30s 4. Pt slowly sits up maintaining head position, wait 30s 5. Bring head up to neutral, wait 30s
31
Epley Maneuver (Self-CRM)
-HEP for PSC Canal 1. Pt in long sitting 2. Rotate head slowly to same side of impairment and immediately Lay back maintaining rotation and have head off side of pillow, wait 30s 4. Slowly turn head to opposite side, wait 30s 5. Slowly turn body in direction and tuck head into dump position, wait 30s 6. Return to sitting, wait 30s *3x/day until s/s stop for 3 days straight*
32
Semont Maneuver
-PSC Cupulolithiasis -2 reps in one session 1. 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 3. 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 4. Slowly come up while maintaining head, wait 1 min 5. Head to neutral slowly, wait 1 min
33
Reverse Semont Maneuver
-ASC Canalithiasis OR Cupulolithiasis -2 reps in one session 1. Pt at edge of table, turn head 45 deg in SAME direction of affected side, wait 1 min 2. Quickly bring Pt down on affected side with head rotation maintained and head down into dump position, wait 1 min 3. 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 4. Slowly come up while maintaining head turn to affected side, wait 1 min 5. Head to neutral slowly, wait 1 min
34
HEP for ASC and PSC Cupulolithiasis
-Semont or Reverse Semont -3-5 reps until 3 days s/s free
35
BBQ Roll
-HSC Canalithiasis or Geotropic -wait for s/s to dec + 30s 1. Begin in roll test position w/ head turned towards affected and flexed 30 deg, hold for 30s 2. Slowly roll head in opposite direction maintaining flexion, wait 30s 3. Slowly roll body in direction of head into dump position, wait 30s 4. Slowly roll onto Pt stomach while maintaining head position, provide pillow under chest, wait 30s 5. Slowly roll patient onto other side maintaining head position, wait 30s 4. Slowly sit up maintaining position, wait 30s 5. Return to neutral, wait 30s
36
Casani Maneuver
-HSC Cupulolithiasis or Ageotropic -2 reps 1. Pt sitting at mat in neutral 2. Quickly bring patient down onto affected side (opp side of positive testing side), hold for 2 min 3. Quickly rotate head upward away from affected side, hold for 2 min 4. Slowly return to sitting w/ head position maintained, wait 2 min 5. Head to neutral, wait 2 min
37
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
38
HEP for HSC Cupulolithias
-Self-Casani -3-5 reps weeks x3 days
39
Forced Prolonged Position
-HEP for HSC Canalithiasis -3 days in a roll 1. Laying on affected ear for 1 min 2. Lie on back for 1 min 3. Quickly roll lying on unaffected ear and sleep in this position (explain way to prop up) 4. In the morning finish BBQ roll
40
non-BPPV Determinants
1. Vestibular or not 2. Central or peripheral 3. Acute or chronic 4. Unilateral or Bilateral
41
non-BPPV Exam Order
1. Oculomotor Tests (2) 2. VOR Tests 3. VOR treament 4. HEP (VOR progression)
42
Vestibulo-ocular Reflex (VOR) Tests
-Head Shake Nystagmus Test -Head Impulse Test -Dynamic Visual Activity -VOR 1 -VOR 2 -VORc
43
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
44
VOR: Head Shake Nystagmus Test
-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
45
Vestibulo-Ocular Reflex (VOR)
-driven at 2 Hz -120 bpm or 240 bpm -30 deg each side of movement or 60 deg total
46
VOR: Head Thrust/Impulse Test
-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
47
VOR: Dynamic Visual Acuity Test
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
48
VOR 1 Test
-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 -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*
49
VOR 2 Test
-active head movement while target moves opp 1. 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
50
VORc Test
-head and arms together -suppresses VOR -metronome -chronic unilateral treatment *ONLY as treatment in practical* 1. Pt seated w/ arms ext, start slow then fast 2. Passive or actively move head as target follows -Want s/s to last 5-10min after Abnormal: -saccdic intrusion -dizziness -imbalances
51
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
52
Substitution
-inc use of other strategies to replace lost vestibular function -Bilateral VOR or central dysfunction -Unilateral if complete loss
53
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*
54
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*
55
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'
56
VOR Exercises: Adaptation
1. VOR x1 -2 Hz for 1 minute (if not, ocular 3x/day) -progress to 2 after 2 mins 2. VOR x2 -2 mins (no metronome) 3. VORc - 50bpm for 2 mins *don't progress variables until all 3 completed*
57
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
58
VOR Substitution #1 Exercise: Head Movements Between 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 Progression: -more reps of 1 min at a time -posture -movement -speed -target size
59
VOR Substitution #2 Exercise: 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 Progression: -More reps of 1 minute at a time -posture -Movement -speed
60
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
61
HEP for Non-BPPV
-Use same as intervention used -Increase 2 variables
62
Oculomotor Tests
On practical: 1. Gaze Evoked Nystagmus (frenzels) 2. Vergence 3. Smooth Pursuit 4. Saccades
63
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
64
Vergence
1. Slowly bring target to nose and ask them to keep their eye on it 2. “ 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)
65
Smooth Pursuit
1. Follow target an arms length away slowly 2. 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)
66
Saccades
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 as you tell them 4. Up/down and diagonally too 5. Switch eyes Abnormal: -overshooting or undershooting -slow scan -central sign
67
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

Vestibular (5 decks)

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