Practical Material Flashcards
FABS test
≥25 points = high fall risk
high sensitivity and specificity
MiniBEST
16/28 indicates high fall risk
high specificity and sensitivity
Berg Balance Test
Cutoff score ≤ 50 points
ceiling effect, patients can score a high score but still be at a fall risk
low sensitivity, high specificity
TUG
cuttoff score ≥ 12 sec
low sensitivity, high specificity
Combining TUG, gait speed, and miniBEST
if all 3 tests are + = 89% chance or ID person at risk of falling
if all 3 tests are - = 3% chance of obtaining a false negative result
Gait Speed
no clear cut off score identified
SPIN/SNOUT not reported
Most promise in identifying fall risk
previous history of falling
modified functional reach test
gait speed
balance tests that assess multiple balance resources
Using Knees to get off the floor
- turn onto back
- roll onto side
- push onto hands
- push up onto hands and knees
- kneel, using stable furniture to steady
- place strongest leg forward
- stand up
- Turn slowly
- Sit down, rest, notify someone of fall
Using arms to get up from fall
- turn onto back
- roll onto side
- push onto hands
- prop self up with both arms behind
- use cusion as a low seat
- lift bottom back onto cushion
- push as far back as possible
- lift bottom back onto chair
- sit down, rest and tell someone of fall
Ocular ROM
- Ask pt if they have noticed difficulty with eye movement of gaze
- ask the patient if they experienced blurry or double vision with any movements performed
- instruct patient that you’ll be testing strength and coordination of eye muscles
- Demonstrate the H movement
- Pause briefly at the end of each movement
- Assess conjugate eye movements, observe to ensure the eyes move together
Neuroanatomy of ocular ROM
CN 3, 4, 6 (motor)
CN 3 = m. rectus, s. rectus, i. rectus, i. oblique
CN 4 = s. oblique
CN 6 = l. rectus
Documentation of Ocular ROM
describe any asymmetry in resting eye position and any observed inability to move the eye and in which direction
Smooth Pursuit
- Inform the patient you will be assessing the coordination of their eye movements
- PT holds target with point perpendicular to pts eyes
- ask the pt to maintain focus on the target with their head still as target slowly moves
- Target should be about 20 in from pts’ face
- Move your pen tip slowly in + pattern across a distance of approx 18 in to the left, right, above, below midline over 2 seconds
- observe for skips, jumps, etc
Neuroanatomy of smooth pursuit
Cerebellum – flocculonodular lobe, vermis
Documentation of smooth pursuit
describe the eye movements as normal or saccadic
describe the direction of saccadic intrusions
Saccades
- Ensure pts have intact oculomotor innervation
- Inform that you will be testing coordination of their eye movements
- Demonstrate saccades by placing a pen adjacent to your ear and instructing the pt you will be asking them to shift gaze between the pen and your nose several times
- Hold pen adjacent to your ear with the tip in the same plane as your nose
- ask the pt to shift gaze from your nose to your pen when you say nose/pen
- continue testing moving from ear to top of had to opposite ear, to below chin in midline
Neuroanatomy of saccades
cerebral cortex = frontal eye fields, purposeful eye movements
basal ganglia = impaired initiation or suppression
cerebellar vermis = dysmetria (overshoot/undershoot)
Documentation of saccades
describe the movement as normal, hypermetric, or hypometric including direction of saccade
normal gaze shift requires only 1-2 saccades
Gaze Holding Nystagmus
- ask the pt to hold their gaze on targets
- target should be approximately 20” from face
- observe for nystagmus at rest
- move target through + sign
- Set the target 30°from midline in all quadrants
6 Have pt maintain their gaze for 10s on each target
Neuroanatomy for Gaze holding nystagmus
vestibular system
cerebellum
Documentation of gaze holding nystagmus
document as intact or impaired
document the direction of impaired fization, in which eye it is noted, and associated S/S
it is normal for pts to have nystagmus present at end range gaze so its important that the target isn’t at end range
VOR Test
- ask the patient to hold their gaze on target
- move the patient’s head passively 30° to each side at a rate of 60° per second (120 bpm)
- Monitor closely for provocation of vertigo or loss of gaze stability
Neuroanatomy for VOR
vestibular system
Documentation of VOR
document intact VOR or inability to maintain stable gaze on target
Head Thrust Test/Head Impulse Test
- let the pt know that you will be moving their head from side to side with some progressively faster head turns
- Firmly hold the sides of the pts head while tilting it forward to 30°
- Ask the pt to maintain their gaze fixed on your nose
- Gently move the pts head from side to side to make sure they are relaxed
- Progress to moving the pts head quickly at a rate of 2 Hz/s through a small arc of motion and add in a quick thrust of the pts head 10° to one side
Neuroanatomy of head thrust
vestibular system
a positive test is indicative of peripheral vestibular dysfunction on the side rotated to during the corrective saccade
Documentation of Head thrust test
document the presence of a corrective saccade with head impulse test and the direction of the head movement that produced a corrective saccade
positive = sudden corrective movement back to the examiner’s nose when the head stops moving to refix gaze on the target
Head Shaking Test
- assess fr resting nystagmus prior to initiating the exam
- inform the patient that you will be moving their head rapidly from side to side
- Tilt pts head forward into 30° flexion
- ask pt to close their eyes
- Shake the head in lateral rotation vigorously at a speed of 2 hz through a range of 30-45° for 20 rotations
- After 20 rotations ask the patient to open their eyes
Neuroanatomy of head shaking test
vestibular system
Documentation of head shaking test
document the presence or absence of nystagmus and the direction of nystagmus if present
the presence of nystagmus indicates a unilateral peripheral hypofunction, and will beat away from impaired side
VOR Cancellation
- Tilt the head forward 30°
- Instruct the pt to hold their hands out in front of them at full elbow extension and focus on one thumb nail
- Ask the patient to maintain gaze fixed on thumb while rotating head and arms as a unit 30° to the right and 30° to left
Neuroanatomy of VOR cancellation
vestibular system
ability of central nervous system to override the peripheral vestibulo-ocular reflex to maintain gaze fixed on a target
Documentation of VOR cancellation
document the presence of intact smooth pursuit OR the presence of saccadic intrusions/corrections as the patient tracks the target
Static and Dynamic Visual Acuity Test
- Have patient wear eye glasses to determine the smallest line of text that can be accurately read at baseline before initiating movement
- patient should be a distance of 6m from eye chart
- Stand behind the patient with a firm grasps on their head and rotate the head side to side at a speed of 2Hz, then repeat in vertical direction
- Instruct the patient to read the chart starting from the largest type to the line with the smallest type that can be read accurately
- A difference of 3 lines or more between the static and dynamic DVA is an indicator of gaze instability
Neuroanatomy of static and dynamic visual acuity test
vestibular system
not a clear indicator of what component of the vestibular system in experiencing dysfunction but often related to UVH
Documentation of Static/Dynamic Visual Acuity Test
document the line differential between static and dynamic DVA in the horizontal and vertical directions
VOR x 1 Viewing Exercises
- patient is given a stable target and is instructed to move their head while keeping their eyes focused on the target
- Target speed is 2 Hz through small 30° arc of motion
- Start by writing a letter A on a post it note the size of the patient’s thumb and placing it on the wall and an arm’s length away
- Instruct the patient to complete 30 s to 2 min intervals a min of 3 to 5 times per day
- Exercises can be progressed once they can complete these without S/S exacerbation
VOR x2 Viewing Exercises
- Same set up as VOR 1x
- Patient is given stable target and is instructed to move their head and arm in opposite directions while keeping their eyes focused on target
Remembered Targets
Substitution
1. Using a stationary target, have the patient focus on it
2. They have them close their eyes and move their head for 1-2 min.
3. Once the patient stops the head turns, instruct them to open their eyes to see if they have focused on the target
Active eye-head movements between two targets
Substitution
1. Place two targets on a neutral wall at nose level, and should be placed close enough that the patient is not using peripheral vision
2. Instruct the patient to move eyes towards second target without head movement, and then move head to the second target
3. Eyes are never moving at the same time as the head
Dix Hallpike Test
Assessing the posterior canal
- patient begins in long sitting
- head is rotated 45° towards the side being tested
- patient is assisted to supine with neck extended, 20-30° beyond horizon
- Hold position for 30-60 s
- Observe eyes and note which direction they beat
Modified Epley Maneuver
Treating the posterior canal
1. begin with patient long sitting and head rotated towards the involved side
2. Quickly move the patinet into supine with neck in extension, hold position for duration of S/S + 30s
3. Rotate the pts head to the other side, maintaining extension. Hold this position for duration S?S + 30 s
4. Help patient to roll onto side, chin tucked, on univolved side. Hold for S/S duration + 30s
5. Assist the pt back into seated, chin tucked.
Roll Test
Assessing the horizontal canal
1. Begin with patient in supine and cervical spine flexed 30°
2. Turn the head to the side you are assessing and hold for 30-60s
3. Assess bilaterally, starting with the side that produces less S/S
Canalithiasis and Roll test
side of the stronger symptoms is the affected side
Cupulothiasis and Roll test
side of weaker symptoms is the affected side
BBQ Roll
Treating the horizontal canal
1. Begin with pt supine in 30° of flexion
2. Turn the head to the side you are treating and hold this for S/S duration + 30s
3. Thrn the head to supine and keep flexion, hold here for S/S duration + 30s
4. Turn the had away from affected side, keeping flexion, hold here S/S duration +30s
5. Have patient roll onto their belly, then prop on elbows maintaining flexion of neck. Hold for S/S duration + 30s
Right Posterior BPPV Results
up-beating right torsional
Left Posterior BPPV Results
Up-beating left torsional
Right anterior BPPV Results
down-beating right torsional
Left anterior BPPV Results
down-beating left torsional
Horizontal canalithiasis BPPV Results
Geotropic/towards the ground and <60 seconds
side with the more profound symptoms
Horizontal cupulolithiasis BPPV Results
ageotropic/away from ground and > 60s
Roll Test provokes
both canals during test
R head turn –> excites R/Inhibit L
L head turn –> Excite L/Inhibit R
places the horizontal canals in the most provocative position
