vertigo

Question 1

causes of vertigo

Answer 1

Otologic
Neurologic
general medical
psychiatric/undiagnosed

Question 2

what is the most common cause of vertigo???

Answer 2

) BPPV 49

2) Ménière’s disease 18.5
3) Unilateral Vestibular paresis 13.5
4) Bilateral Vestibular paresis 8
5) Middle Ear Dysfunction 6
6) Fistula

Question 3

CAUSES OF NEUROLOGICAL DIZZINESS

Answer 3

Stroke and TIA 35
Vertebrobasilar migraine 16
Nystagmus 8
Sensory ataxia 7
Basal ganglia dysfunction 4
Cerebellar ataxia 5
Seizure 3
Miscellaneous disorders 22

Question 4

medical causes of vertigo and what medicine typically is used to treat vertigo

Answer 4

Cardiovascular 23-43
Hypotension
Cardiac arrhythmia
Coronary artery disease
Infection 4-40
Medication 7-12
Hypoglycemia 4-5
mecolzine even though it can cause dizziness it typically inhibits the vestibular cochlear nerve

Question 5

what some other reasons for vertigo think about people that freak out??

Answer 5

“hyperventilation syndrome”, “post-traumatic vertigo,” and “nonspecific” dizziness. About 25% of dizziness or vertigo falls into this category.
Remember classic vs. non-classic presentation
Also there is a high correlation with anxiety disorders and dizziness

Question 6

BPPV what are its clinical signs that you might hear

Answer 6

only last for a few seconds, usally happens when I change positions

Question 7

vestibular neuritis signs

Answer 7

typically can last for 48-72 hours usually. motion sensitivity,

Question 8

meineres disease signs

Answer 8

last any where from 1-24 hours typically causes HEARING LOSS, fullness in ear, tinnitus and vomiting

Question 9

bilateral vestibular disorder signs

Answer 9

is permenant more serious of th of the disease gait ataxia, osclilopsia (in ability of the vestibular ocular reflex to hold an image on the retina)

Question 10

Fistula signs

Answer 10

last for a few seconds, loud tinnitus, usally cause of nose blowing, or sneezing.

Question 11

what is a big factor of when determining what is going on??

Answer 11

the duration of the symptoms

Question 12

Specific Questions to ask during the exam??? think like positioning vs. motion vs. environments

Answer 12

Oscillopsia
Headaches
Positioning Symptoms
Motion Sensitivity
Issues in Dark, busy environments
Exertion induced (vertigo with strain may suggest a fistula)
Coordination issues
Incontinence / memory loss (normal pressure hydrocephalus)

Question 13

Some commonly used tests during an examination!!!

Answer 13

Ocular Motility (simple ROM of eyes)
2)  Nystagmus
Spontaneous
Gaze evoked
Direction changing or follows Alexander’s Law
3)  Saccades
4)  Smooth Pursuit
5)  VOR
6) Head Thrust
7) VOR Cancellation
8)  Dynamic Visual Acuity (DVA)
9)  Head Shaking Nystagmus

Question 14

what is called when you look to the left real fast???

Answer 14

Above is Left beating nystagmus (fast phase to left) that worsens when looking to the Left and lessens when looking to the Right
CALL IT: 3rd degree left beating nystagmus that follows Alexander’s Law

Question 15

when eyes are looking down and you have a nystagmus what is this an indication of. What determines a tumor from a stroke indication

Answer 15

View eyes looking left, straight, and right. Observe for nystagmus

   RIGHT                                      LEFT

Above is Vertical nystagmus – this is a CENTRAL Finding until proved otherwise
the onset: so the tumor will be more of a insidious onset and a stroke will be more very acute onset like it just happens very rapidly and patient can typically pinpoint when it happens.

Question 16

eyes that have a left beating pattern are indication of what

Answer 16

View eyes looking left, straight, and right. Observe for nystagmus

   RIGHT                                      LEFT

Look to the right, right beating nystagmus – look to the left, left beating. This is a CENTRAL SIGN

Question 17

when a PT performs saccades on a patient what is this an indication of???

Answer 17

Look from target to target

Significant Overshooting is a Central Sign
Multiple movements is a Central Sign
1 undershoot is considered normal

Question 18

description of the headthurst test

Answer 18

Ask patient to focus on your nose, slowly move head side to side, observing for visual fixation
Patient focuses on your nose, then turn their head quickly in a random fashion (about 20 degrees)
Look at their eyes to see if they remain stationary on your nose
Highly specific (95%), not highly sensitive (38%) (misses many positives, but doesn’t falsely identify normals)
Can increase sensitivity by RANDOMIZING the direction of movement, but be careful not to exceed patient’s comfortable ROM
Direction of HEAD MOVEMENT = DIRECTION of Dysfunction ie:
Decrease in fixation with forced LEFT ROTATION = LEFT DYSFUNCTION, + L Head Thrust test

Question 19

VOR cancellation test what is this an indication of??? if the eyes move with the head??

Answer 19

The VOR must be suppressed during the head movement in order to keep focused on the target which is moving synchronously with the head.
Unilateral vestibular lesions do not impair VOR cancellation unless the spontaneous nystagmus from the lesion is so high that it prevents the eye tracking systems from functioning normally, therefore impaired VOR cancellation is almost always a sign of cerebellar pathology.
How to perform: Hold patient’s head, ask them to focus on your nose. As you step from side to side, keep your patient’s head facing you. Normal: patient’s eyes remain focused. If eyes cannot focus test is positive for cerebellar pathology.

Question 20

Dynamic visual acuity (DVA) explain procedure

Answer 20

Patient reads Snellen chart – assess score
Gently turn patient’s head as they try to read at 1 cycle/sec
Positive test is 3 or more line difference

Question 21

head shaking test explain and what does it indicate?/

Answer 21

Move head back and forth, 2 Hz, 20 cycles
Excursion is +/- 30 degrees, as tolerated
Nystagmus is often seen in patients with unilateral vestibular lesions
“normals” may show 1-2 seconds of nystagmus
Nystagmus usually beats away from the “bad” side
Kristindottir et al (2000) reported higher frequency of HSN in hip fracture subjects than healthy subjects
From Hain – www.dizziness-and-balance.com

Question 22

Which finding suggest a Central Lesion?

Answer 22

Which finding suggest a Central Lesion?
Vertical gaze nystagmus
Saccades (left gaze and vertical nsytamgus)
VOR Cancellation during head rotation test
Coordination deficits
Spasticity

Question 23

what are some reasons for a central lesion??

Answer 23

Epilepsy
Demyelinating diseases
Tumors
Vascular (including CVA, VBI)
Traumatic
Degenerative changes

Central findings in the examination may necessitate further diagnostic imaging

Question 24

what muscles if weak can be an indication of possible falls?? what else

Answer 24

Tib anterior and weak glute med, and lack of hip IR, and decreased ROM and strength in the hip

Question 25

description of Benign Postional vertigo

Answer 25

Benign Paroxysmal Positional Vertigo (BPPV)
Presentation: complaints of vertigo (room spinning) with static positioning
Initial episode can be with rolling for the snooze alarm or retrieving object from shelf.
Pt usually knows which positions are involved and avoids them!
Symptoms usually abate quickly with movement out of provoking positions.
Patient may also c/o disequilibria and have decreased balance secondary to poor use of vestibular (VT) cues for balance.

Question 26

Describe the hallpike manuever!! no this can’t have a false negative!!

Answer 26

Patient starts in long sit, with head rotated 45 degrees towards the side to test. Ask the patient to keep their eyes open as you quickly bring them into a supine position with their head extended 30 degrees

Question 27

difference between the Vestitubal artery insuffiecy test and the Hallpike manuever

always perform the halpike manuever on the unaffected side first

Answer 27

Hallpike vs. Vertebral Basilar Insufficiency
Hallpike – 45 degrees rotation, 10-20 extension
VBI – full extension and full rotation
Both usually done in supine, but can do VBI in sitting!
+ VBI: dizziness, nausea, tinnitus, headache, blurred vision, slurred speech, slowed responses – but according to New England Medical Center Posterior Circulation Registry (over 400 patients) < 1% of VBI patients present with only a single sign or symptom (not necessarily vertigo or dizziness

Question 28

Whats the Rebound Phenomenon??? think about when you return the patient to sitting??

Answer 28

Complaints upon return to sitting are also common. Make sure the therapist is supporting the patient from BEHIND for 60 seconds after a positive hallpike

Question 29

pathogenesis of BPPV

Answer 29

Posterior semi-circular canal (SSC) becomes gravity sensitive (SSCs normally respond to dynamic changes while otoliths respond to static positioning).
More common in the elderly, and usually idiopathic; with identifiable causes including head trauma, viral labyrinthitis, vestibular neuritis and perilymph fistula
Otoconia dislodge into the semi-circular canals (usually posterior) and become free floating in the endolymph of the canal. When the head is moved into provoking positions endolymph is moved by debris which pulls cupula out of position. In the hallpike expect latency and fatigue. Almost all cases of BPPV

Question 30

Cupulolithiasis remember this is cuplolithiasis

Answer 30

Otoconia become adhered to the cupula (end organ in the ampulla) making it gravity sensitive. Expect immediate nystagmus which may not fatigue

Question 31

posterior canal

horizontal canal

anterior canal??

how would you determine each one???

Answer 31

Rhythmic Oscillation of the eye
Defined by the FAST phase
Beats to side of HIGHER activity
As most lesions are paretic, this means that most Nystagmus beats AWAY from the lesion

Posterior Canal: Expect upgoing, rotary nystagmus to the affected ear
Horizontal Canal: Cupulolithiasis ageotropic; canalithiasis geotropic (up cup)
Anterior Canal: downgoing, rotary nystagmus to the affected ear

Question 32

description of the epley manuevers

Answer 32

Rotate the head 45 to the affected side and lie the patient back with manual contacts at the shoulder

Ease the head into 30 extension, support the head. Remain here for 30 seconds until the vertigo ceases.

Over a 30 second period rotate the head to the opposite side. Remain 30 seconds

Have the patient roll onto the unaffected side maintaining the head in rotation. Remain 30 seconds.

Assist the patient into sitting.

Patient flexes their neck 30. Support them at the shoulders for 1 minute to protect against a “rebound phenomenon

Question 33

when do you use the brandt exercise???

Answer 33

Generally used after symptoms have decreased by 50%-75% with Epley maneuvers
This is habituation for the vertigo, needs to be performed 3x per day x 5 cycles
Compliance is difficult as patient is making themselves dizzy multiple times per day but difficulty can be eased by having patient use pillows or by moving more slowly

Question 34

How to perform brandts exercise

Answer 34

) Start sitting up, head neutral. The faster the patient moves, the harder the exercise will be.

Lie down onto the affected side. The use of pillows makes the exercise easier.

) Keep shoulders square, head looking up at the ceiling. Stay 30 seconds beyond vertigo ceasing.

Return to sitting. Wait 30 seconds

Lie onto the opposite side. Wait 30 seconds beyond the vertigo ceasing

Perform the exercise 5 cycles per session, 3 sessions per day until symptoms have resolved for 2 consecutive days

Question 35

Liberatory Maneuverused for immediate nystagmus in the Hallpike which does not fatigue

Answer 35

Quickly lie the patient onto the affected side. Wait 2 minutesPlace your hands onto the lower trap near the mat and the superior zygomatic archQuickly move the patient onto the opposite side, instructing them to look into the mat. Patient remains in this position for 2 minutesQuickly return to sitting, support the shoulders for 1 minute

Question 36

Bar BBQ roll and what is it used for?? I don’t the postition is as important as what the manuever is used for!!!!

Answer 36

Barbeque RollUsed for horizontal canal canalithiasis
) Lie the patient in the hallpike position with the affected ear down. Wait 15 seconds. ) Turn the head to the opposite side. Wait 15 seconds
Roll the patient into prone. Support the head in slight extension. Wait 15 seconds
Continue to rotate the head in the same direction. Wait 15 seconds. Roll to supine. Assist the patient to sit as necessary

Question 37

precautions used after manuevers have been performed

Answer 37

After performing a maneuver on a patient many facilities have their patients abide by the following precautions:
a) patient must sit up for 48 hours including sleeping
b) should issue soft cervical collar in office for use over coming week
c) patient must not bring on symptoms for 1 week
d) patient must not lie on affected side for 1 week
e) no up or down movement of the head for 1 week
Most facilities are NOT using precautions as the need for them has been called into question

Question 38

Estimated recovery time with people with vertigo

Answer 38

generally patients respond quickly to a few treatments (generally 1x per week) with a decrease in symptoms greater than 75%.
Prognosis: excellent, 80% elimination of dizziness each successive maneuver

Question 39

Unilateral Vestibular Hypofunction: to define it!!

Answer 39

: Primarily difficulty with dizziness (motion sensitivity) and gaze instability as the patient receives conflicting information from each semi-circular canal. Patients may report visual complaints as with Bilateral Hypofunction and/or sensitivity to motion in the environment. Patients in more acute phases of unilateral vestibular hypofunction may present with decreased balance and gait disturbances, possible Positive Sharpened Romberg with Eyes Closed on Foam. Fukuda demonstrates greater than 30-degree turn to hypoactive side. Patient may also demonstrate difficulty with high-level ambulation: head rotations or on uneven surfaces
Neuronitis (no hearing loss), labyrinthitis (hearing loss), or weakness/damage to one vestibular organ, acoustic neuromas
These patient have “classic” dizziness, and balance deficits as only ½ of the vestibular system is working normally
Vertigo lasting days (up to 2 weeks), often related to a viral infection (sometimes patients decompensate by limiting input to the vestibular system)
May see spontaneous nystagmus for 2 weeks (will beat towards the higher activity side)

Question 40

Prognosis for Unilateral vestibular hypo function

Answer 40

Most patients should have full return to all pre-morbid activities as they can compensate through the intact 1/2 Vestibular system in addition to their visual/somatosensory systems.
Physical therapy length of stay ranges from 1 to 2 months on average.

Question 41

Bilateral vestibular hypofunction: think oscliposia

Answer 41

Classic symptom is oscillopsia (blurred vision with head movement - especially when driving in a car.) Balance and gait problems with feelings of disequilibria when standing and walking are also common.

Functionally, patients will have problems reading, driving (secondary to oscillopsia), and difficulty with visually stimulating situations

Question 42

What usally shows up on PT evaluation form.

Answer 42

decreased visual acuity with gentle head rotations (2 or more lines difference on the Snellen chart)

2) Patients with complete or severe vestibular loss may be unable to perform Romberg with Eyes Closed on foam. Patients may demonstrate increased sway when somatosensory or visual cues are removed and loss of balance (LOB) with both removed.
3) LOB with Fukuda’s stepping test (50 steps) with EC (worst) progressing to an anterior displacement greater than 2’
4) Gait analysis usually reveals increased BOS. With Head rotations (HR) gait slows and becomes ataxic with possible LOB

Question 43

Pathogenesis of bilateral vestibular hypofunction

Answer 43

ototoxic drugs (specifically Gentamicin and Streptomycin), inner-ear autoimmune disease, Paget’s disease, bilateral tumors, meningitis, endolymphatic hydrops

Question 44

Things to do once the vestibular system is shoot due to BVH

Answer 44

Compensation vs. adaptation:
Compensation:
a) train somatosensory and visual systems to take over for VT system
b) assistive devices to ensure patient safety initially then improve balance
c) strengthening, stretching of LE’s especially ankle and hip for strategies
d) use reachers
e) gait training to eliminate furniture walking
f) modify the home to minimize fall risks

Question 45

Bilateral Vestibular Hypofunction guidelines

Answer 45

. Patients need to (at least intermittently) be doing some exercises to maintain recovered function. Decrease from 3x per day to 2x one month later, to 1x two months later, and then maintain at 3x per week.

2) While ambulation may never be normal, patients may eventually ambulate without an assistive device (or at least with a straight cane) Keep in mind that patients with BVH may present quite differently, (some with only occasional visual complaints while playing Video Poker) to debilitating oscillopsia; so their outcomes will be quite different.
3) Patients will be at increased risk for falls when walking is low-vision situations, over uneven surfaces or when fatigued.
4) Patients with peripheral lesions are more likely to have hearing loss than those with central lesions.

Question 46

Prognosis for BVH

Answer 46

Prognosis: Patients with incomplete BVH are often able to return to night driving and some sports. Some severe cases may never return to driving, even during the day because of gaze instability.
Patients with either somatosensory or visual involvement (in addition to their vestibular involvement) will have more significant functional deficits.
Estimated length of stay: 2-3 months of therapy

Question 47

Ménière’s Disease: how does it present :

Answer 47

: episodic, often debilitating symptomatology including rotational vertigo, reduction in hearing (unilateral) tinnitus, postural imbalance, nystagmus, nausea, and often vomiting. Episodes typically last 30 minutes to 24 hours. Patient is generally ambulatory within 3 days. Some hearing will return, but there is often residual loss of hearing function. Later in the disease’s progression, the patient may experience drop attacks (Tumarkin’s otolithic crisis). Onset is typically between 30-50 yo.

Question 48

Pathogenesis of Ménière’s Disease

Answer 48

The fundamental phenomenon is the development of endolymphatic hydrops. The development of these hydrops is a function of malabsorption of endolymph in the endolymphatic duct and sac

Question 49

Treatment for Meineres disease

Answer 49

During the remission phase, treatment is aimed at reduction of episodes. Dietetic programs include restriction of salt, water, alcohol, and nicotine. Drugs include Betahistine (a histamine derivative). Those patients with disabling vertigo may be candidates for surgical intervention including intratympanic treatment with ototoxic antibiotics or a vestibular nerve section. Vestibular exercises are not appropriate unless there is permanent VT loss since between episodes the VT system returns to normal function. Sometimes, there is a permanent loss of Vestibular function (complaints of motion sensitivity, or increased complaints during ambulation with head rotations). Then, vestibular rehabilitation is appropriat

Question 50

Migraine presentation!!!!

Answer 50

High prevalence: 17.6% females, 5.7% males, 4% children have >= 1 migraine per year
Can have dizziness with or separate from periods with headache
Vestibular Migraine Aura: most have dizziness with personal movement, but some had vertigo while still in sitting or supine
Can also have Migraine with Aura which has transient neurological symptoms (sensory, motor or cognitive).

Question 51

Migrane vs. headache

Answer 51

Meineres 
Tinnitus:  Low pitched roar
\+ ear fullness
\+ hearing loss
Spontaneous vertigo is common, lasts HOURS
Naps don’t help
Motion sickness is uncommon 

Headache

Tinnitus:  High pitched
Maybe ear fullness
\+ phonophobia
\+ photophobia
Spontaneous vertigo is rare
Dizziness lasts for Minutes
Naps usually help
Motion sickness is common

Question 52

Perilymphatic Fistula

Answer 52

Episodic vertigo and sensorineural hearing loss
Most commonly occur at the round and oval windows of the middle ear
Usually a history of (minor) head injury, or vigorous straining precedes sudden onset vertigo, hearing loss and loud tinnitus
Patients often report hearing a “pop”
Later patients will report imbalance, positional vertigo, and nystagmus with hearing loss
Symptoms subside at rest, reoccur with activity
Symptoms can be recreated with sneezing and nose blowing, or valsalva maneuver

Question 53

Perilymphatic Fistula Treatment

Answer 53

Absolute bed rest for 5-10 days with the head elevated
Avoidance of straining, sneezing, coughing or head-hanging positions
Use of stool softeners
If symptoms last > 4 weeks or hearing loss worsens consider exploratory tympanotomy with surgical packing of the fistul

Question 54

Cervicogenic Dizziness: what symptoms does it usally present with??

Answer 54

New term for Cervical Vertigo
Altered afferent proprioceptive signals from upper cervical spine
Correlated with whiplash / neck pain?
Can see with balance / gait dysfunction
Neck movement usually aggravates symptoms

Question 55

Cervicogenic Dizziness treatment

Answer 55

Try cervical traction as both diagnostic test and treatment
Focus on upper cervical spine
Cervical kinesthesia exercises:
Glasses to restrict peripheral vision
Rotate trunk (on stool)
Patient tries to maintain gaze on fixed target while trunk is rotated

Question 56

VOR x 1

Answer 56

VOR x1 Viewing:
Start with your eyes focused on an object 1-2’ in front of you. Turn your head from side to side (total of 30 degree excursion) at the highest speed which allows you to keep the object in focus. Start in sitting, progress to standing, feet together, then one foot in front of the other.
Perform each of the below variations for 1.5-2 minutes, 3x/day
a) Head turning from side to side
b) Head moving up and down
c) with/without your glasses (if you have corrective lenses)
d) With a checkerboard or other complicated background
You should continue to increase the speed of head movement as long as the object is in focus. You can also perform this activity while walking focusing on an object across the room.
For the advanced client: Practice doing VOR as you perform a walking program. Focus on various objects at variable distances or try bouncing on a “Swiss Ball.”
10 minute rule: no worse for wear 10 minutes after exercises!!!!!!!

Question 57

VOR x 2 breakdown

Answer 57

VOR x2 Viewing:
Start with your eyes focused on an object 1-2’ in front of you. Turn your head from side to side (total of 30 degree excursion) at the highest speed which allows you to keep the object in focus while moving the object in the opposite direction. Start in sitting, progress to standing, feet together, then one foot in front of the other.
Perform each of the below variations for 1.5-2 minutes, 3x/day
a) Head turning from side to side
b) Head moving up and down
c) with/without your glasses (if you have corrective lenses)
d) With a checkerboard or other complicated background
You should continue to increase the speed of head movement as you practice as long as the object is in focus. You can also perform this activity while walking focusing on an object across the room. For the advanced client: Focus on various objects or try bouncing on a “Swiss Ball.”

Question 58

issues with HOR

Answer 58

Environment specific (background)
Frequency specific (need to vary speed) (up to 2Hz)
Can do with walking (forward, backward)
Can do with step ups / step downs
Can also incorporate with balance exercises
Start at 3x per day  max of 5x per day

Question 59

What is habituation

Answer 59

Habituation exercise reduce the intensity of dizziness by repetitive exposure to the specific movement that produces dizziness.
Can do Motion Sensitivity Quotient Test to help to quantify

Question 60

how to perform habituation exercises

Answer 60

Choose up to 4 activities that bring on mild to moderate dizziness
Client will perform these activities as quickly as results in mild to moderate dizziness
Then rest 30 seconds beyond the dizziness
3-5 sets per day; 1-2x per day
As motion sensitivity improves, can substitute more difficult activities
Practice performing activities which bring on your dizziness. Do only those activities which your therapist has selected for you. Keep in mind that the dizziness shouldn’t increase after the 10 minute mark.
rolling to the right
rolling to the left
go from lying on your back to a sitting position
go from sitting up straight, reach to the floor then reach toward the ceiling
spin in a circle

Question 61

how to focus on just vision or somatosensory training

Answer 61

Focus on vestibular system by “removing” other systems (vision, somatosensory)
Vision: eyes closed, complex background, moving background, incorporate head movement, dim lights
Somatosensory: foam, wobble board, trampoline, balance beam, grass, ramps, treadmill

Question 62

Cervico-Ocular Reflex

Answer 62

Parallels the VOR, contributes a slow-component eye rotation in the direction opposite to head movement in the place of a deficient vestibular system
Generated by joints in neck
Works at slower speeds than VOR

Question 63

Number board/ clock method of training for people with gaze nystagmus!!

Answer 63

Used for patients with gaze nystagmus when attempting to focus in a given direction.
Have the patient stand up close to a large “clock”, where the numbers are at the end of their visual fields when their neck is maintained in neutral.
Patient focusses from 1 number to another, 5 seconds at a time. As the patient progresses, have them focus at the “problem number” every other trial
Perform for 1 minute, 3x per day

Question 64

how to increase pursuit gain!!

Answer 64

As an exercise, hold a card with lettering at arm’s length. Move the card left and right across the visual field, tracking with eye movement and keeping the head still. Repeat the full cycle 20-30 times. Perform the test in the vertical and diagonal directions as well, increasing speed but being certain to keep the letters in focus. Progress from sitting to standing to a sharpened stance.

Question 65

how to improve saccades

Answer 65

Hold a card with lettering in each hand approximately 15 inches apart at arm’s length. Keeping the head still, move the eyes back and forth from card to card, 1 second per card. Repeat 20-30 times for the complete cycle. This test also can be performed in the vertical and diagonal planes. Progress from sitting to standing to a sharpened stance

Question 66

convergence exercise

Answer 66

With your head straight, start with the pen at arm’s length, straight ahead and at eye level or slightly below eye-level. Focus on the tip of the pen and make sure it is single and clear. Move the pen slowly towards your nose making sure that the pen stays single for as long as possible.
If the pen goes double (i.e. you see 2 pens) stop moving the pen immediately but continue to look at it and use your eye muscles to “pull” the images together to make one pen again. Do not do this by closing one eye, by blinking or by looking away from the pen, as this will not exercise the muscles. The sensation you will feel is one of going cross – eyed; do not worry, this is normal and is necessary to achieve results. If you can make the stationery pen single again by pulling your eyes in then start to slowly move the pen towards you until it doubles up again. Repeat the process of stopping, trying to use your eyes to make the pen single again and then proceeding as before.

Question 67

cardiovascular exercise

Answer 67

15-20 minutes (build up to 30 minutes) 3x per week