vestibular 1/16 Flashcards
test central or peripheral vestibular issue?
sponatenous nystagmus
both
peripheral - acute
test central or peripheral vestibular issue?
gaze evoked nystagmus
peripheral
test central or peripheral vestibular issue?
head shaking
head thrust
peripheral
test central or peripheral vestibular issue?
dynamic visual acuity DVA
both
test central or peripheral vestibular issue?
valsalva
peripheral
test central or peripheral vestibular issue?
dix hallpike
roll test for BPPV
peripheral
test central or peripheral vestibular issue?
saccadic eye movement
central
test central or peripheral vestibular issue?
convergence
central
test central or peripheral vestibular issue?
VOR cancellation
central
what test is this?
- look for abnormal eye beating in ambient room light
- test with goggles (to remove visual fixation, suppresses nystagmus)
- try to identify direction of fast phase
- nystagmus can be up beating, down beating, left beating, right beating, torsional
spontaneous nystagmus
central or peripheral? what next? \+ spontaneous nystagmus \+ abnormal smooth pursuit \+ saccadic eye motion \+ abnormal VOR cancellation
known neurologic condition clinician knows
OR central vestibular signs > refer to MD
central or peripheral?
nystagmus with goggles on (to remove visual fixation, suppresses nystagmus)
either
- patient may have acute, not compensated by CNS, peripheral hypofunction
- OR central vestibular sign and needs to be referred to MD
central or peripheral?
during smooth pursuit and convergence eye exam
+ delay or saccadic intrusions during eye movement
+ abnormal double vision when >3-4 inches from nose
possible central vestibular dysfunction
central or peripheral?
saccadic eye movements
+ abnormal multiple >2 movements to get to target, under or overshoots target
possible central vestibular dysfunction
what test?
patient sits 18 inches away
ask patient look back and forth between 2 targets - R/L, up/down
- observe if hits target in 1-2 movments or multiple movement, under or overshoots target
saccadic eye movement
what test?
patient sits with arm extended in front of nose and eyes on thumb nail
rotate trunk R/L, head rotates with trunk,
- nose and eyes remain aligned on thumbnail
- perform R/L, and up/down
VOR cancellation
tests ability to cancel VOR and move eyes together with head
central or peripheral?
VOR cancellation
head moves together with minimal to no symptoms
normal
central or peripheral?
VOR cancellation
+ abnormal, unable to keey eyes on target, dizziness, or other symptoms reported by patient
possible central vestibular dysfunction
what test is this?
wear goggles (prevent visual fixation)
ask patient move eyes L, R, up, down, and back to center (only 30 degrees, not end range)
- observe for nystagmus when hold each direction
gaze evoked nystagmus
central or peripheral?
gaze evoked nystagmus test
+ nystagmus direction fixed, always beat in same direction no matter which way patient looks
peripheral lesion follows alexander’s law
central or peripheral?
gaze evoked nystagmus test
+ nystagmus direction changes based on direction patient looks (upbeat when look up, downbeat when look down)
central lesion
what test?
wear goggles (prevent visual fixation)
head in 30deg cervical flexion
patient closes eyes
turn head R/L 20reps, ask patient open eyes at 18 reps
after 20, hold head stable observe if nystagmus present
head shaking nystagmus
central or peripheral? head shaking nystagmus test \+ nystagmus fast phase direction toward active or hypofunction side? what other test aligns with?
peripheral
- fast phase toward intact, more active neural side
- contralateral side has vestibular hypofunction
= coincides with + head thrust test
what test?
ambient room light, fixate eyes on target like therapist’s nose
- hold head 30 deg cervical flexion
- quickly rotate head 30deg R/L while eyes remain fixated on target
- repeat R/L in random order, pause after each rep
- observe any delay, eye move off target and delay return to target
head thrust test
central or peripheral?
head thrust test
+ eye move off target and delay return to target
what side is delay on active or impaired side?
peripheral - unilateral or bilateral hypofunction
delay occurs on impaired side
what test?
patient sits 4 ft from eye chart
- read down to lowest line they are able to easily read
- manually move patient head side to side 120bpm (tik tok by kesha) as patient reads chart top to bottom
- notice different between what is read at the bottom line while static vs moving
dynamic visual acuity DVA
tests VOR vestibulocular reflex, ability eyes stabilize target while head moves
central or peripheral?
DVA
2 lines different when reading eye chart between static vs moving
normal
<=2 lines different
central or peripheral?
DVA
3 lines or less different when reading eye chart between static vs moving
either
decreased VOR reflex
possible peripheral hypofunction or underlying central dysfunction
how to perform vertebral artery test? purpose of test?
goal compress vertebral arteries and observe cranial nerve involvement
- helps clear the neck before positional testing or cervical mob/manip
- safety first!
1. supine/sit neck in full extension and rotation
2. hold 30 seconds
3. repeat opposite side
what positional test for BPPV posterior and anterior canals?
dix hallpike
what positional test for BPPV horizontal canal?
horizontal roll test
nystagmus as a horizontal beat towards the ground
Geotropic beat toward Ground, indicates canalithiasis
eg. if test R side, beat to Right
horizontal canal
nystagmus as a horizontal beat towards the ceiling
Apogeotropic, beat Away from ground, indicates cupulolithiasis
eg. if test R side, beat to Left/ceiling
horizontal canal
what to look for during positional tests for BPPV?
- tell patient keep eyes open to look for nystagmus
- note direction (canal) and time (cupulo vs canalithiasis) of nystagmus
- assess nystagmus and vertigo
note: keep wastebasket nearby for vomit
what does this mean?
perform dix hallpike on Right side
see nystagmus- Up and Right torsion
BPPV
Right posterior canal
Otoconia migrate from the utricle, most commonly settling in WHICH semicircular canal?
posterior semicircular canal
what does this mean?
perform dix hallpike on Right side
see nystagmus- Down and Left torsion
BPPV
Left anterior canal
how long does nystagmus last if canalithiasis?
<60 sec
crystals are free, takes less than a minute for the crystals to stop moving after a particular change in head position has triggered a spin
how long does nystagmus last if cupulolithiasis?
> 60 sec
crystals stuck on the bundle of sensory nerves in semicircular canal will make the nystagmus and vertigo last longer, until the head is moved out of the offending
position.
- need to use liberatory movement before canalith repositioning
What test?
- Position patient in long sitting
- Rotate had 45° cervical rotation
- Quickly guide patient back on mat with 20 to 30° of cervical extension
- Patient must keep eyes open
- Observe for vertigo and nystagmus, note direction and time (<>60sec) of nystagmus
dix hallpike for BPPV in posterior and anterior canals
- nystagmus down = anterior canal
- nystagmus up = posterior canal
What test?
- Patient in supine, head and 20 to 30° of flexion
- Roll patient head to right or left
- Repeat on the opposite side
- Patient must keep eyes open
- Observe for both vertigo and nystagmus, note direction and time (<>60sec) of nystagmus
Roll test for BPPV in horizontal canal
- nystagmus toward ground - geotropic, canalithiasis, affected side MORE active
- nystagmus away from ground - ageotropic, cupulolithiasis, affected side LESS active
What rehab category? Mech for recovery?
Postacute vestibular neuritis or Labrinthitis
Inactive Ménière’s
Stable unilateral deficit
Unilateral vestibular hypofunction
- adaptation
What rehab category? Mech for recovery?
Post surgery on the vestibular system, neuromas
Stable unilateral deficit
Unilateral vestibular hypofunction
- adaptation
What rehab category? Mech for recovery?
exposure to medication
stable bilateral deficit
bilateral vestibular hypofunction
- substitution, adaptation
What rehab category? Mech for recovery?
acute vestibular neuritis or labyrinthitis
unstable unilateral or bilateral deficit
- not good candidate for PT until stable
What rehab category? Mech for recovery?
acoustic neuroma
chemotherapy
unstable unilateral or bilateral deficit
- not good candidate for PT until stable
What rehab category? Mech for recovery?
stroke
motion sensitivity
central vestibular deficit
-habituation
What rehab category? Mech for recovery?
migraines
concussion
central vestibular deficit
-habituation
What rehab category? Mech for recovery?
psychological anxiety
non vestibular deficit
- substitution
What rehab category? Mech for recovery?
peripheral neuropathy
non vestibular deficit
- substitution, strengthening, postural stability training, compensation, manual therapy
What rehab category? Mech for recovery?
postural instability, fall risk
cervicogenic disorder
non vestibular deficit
- substitution, strengthening, postural stability training, compensation, manual therapy
what rehab category use gaze stability exercises for adaptation of VOR? what is adaptation?
stable peripheral vestibular pathology
- change vestibular system response to accommodate for lost ability
- goal to improve gaze stability
what rehab category use habituation? what is habituation?
stable bilateral OR central vestibular
- expose individual to provoking stimuli to reduce symptoms be reducing sensitivity
- nondescript dizziness to positional change or visual stimuli
what rehab category use substitution? what is substitution?
- all diagnoses; mostly stable bilateral vestibular deficits and non-vestibular deficits
- replace or compensate lost and/or impaired function
- eg. use AD, activity modification, increase strength/ROM/prop
Dix hallpike test to the Right - Upbeat and Right nystagmus >60 sec. What next?
Right posterior cupulolithiasis
- Semont liberatory
- retest Dix hallpik, if canalithiasis Eply canalith repositioning maneuver
Dix hallpike test to the Left- Upbeat and Left nystagmus <60 sec. What next?
Left posterior canalithiasis
- Eply canalith repositioning
Dix hallpike test to Right and Left. Both negative. What next?
select new positional test, try horizontal roll test
Horizontal Roll test, nystagmus on both eyes but more active
on Right side - Right side beating toward ground <60 seconds
Right horizontal geotropic canalithiasis (more active side)
- Treat BBQ Roll
Horizontal Roll test, nystagmus in both eyes beating away from ground, more active on Right side (nystagmus toward Left)
>60 seconds
Left horizontal ageotropic cupulolithiasis (less active side)
- liberate with Gufoni/Casani maneuver
- repeat Roll test, if canalithiasis (geotropic), treat with BBQ Roll
Dix hallpike test to the Right - Downbeat and Right nystagmus >60 sec. What next?
Right anterior cupulolithiasis
- semont liberatory, eply canalith repositioning
what describes cupulolithiasis in horizontal canal?
- ageotropic nystagmus - beating away from the ground
- side affected has LESS active ageotropic nystagmus
- test with Horizontal roll test
- liberate with Gufoni/Casani
what describes canalithiasis in horizontal canal?
- geotropic nystagmus - beating toward ground
- side affected has MORE active geotropic nystagmus
- test with Horizontal roll test
- reposition canalith with BBQ Roll
treatment for anterior or posterior canalithiasis
what was observed in Dix hallpike?
epley manuever
nystagmus <60sec
treatment for left or right horizontal canalithiasis
what was observed in Horizontal roll?
BBQ roll
geotropic nystagmus (toward ground)
affected side MORE nystagmus
liberatory maneuver for anterior/posterior cupulolithiasis
what was observed in Dix hallpike?
semont (then retest Dix Hallpike > epley)
nystagmus >60sec
liberatory maneuver for horizontal cupulolithiasis
what was observed in Horizontal roll?
gufoni, casani (retest horzontal roll > BBQ roll)
ageotropic nystagmus (away from ground)
affected side LESS nystagmus
what test/maneuver? what for?
- pt long‐sitting, turn head to clinician, hold clinicians arm, Clinician holds patient’s upper body. Patient lies back until their head is in 20 to 30 degrees of extension. Hold 60 sec.
- Rotate pt head 45deg opp side, maintain cervical extension. Hold 60 sec.
- Ask pt roll onto side and tuck chin. Clinician turn pt head so forehead on mat. Hold 60 sec.
- Have pt return to sitting. Head in 20-30deg flexion. Wait 30 sec.
Epley maneuver
for ant/post canal canalithiasis
what test/maneuver? what for?
- pt supine. place head 20-30deg flexion (whole treatment). Rotate head so affected side is down. Hold 60 sec.
- Rotate head to neutral position. Hold 60 sec.
- rotate head so unaffected side is down. Hold 60 sec.
- Rotate head so looking at ground. Have patient roll onto stomach for comfort. hold 60 sec.
- Rotate pt head so affected side down. Have pt roll onto side for comfort (now in starting position). Hold 60 sec.
- pt slowly sit up from sidelying. wait 60 sec.
BBQ roll
for horizontal canal BPPV canalithiasis
what test/maneuver? what for?
- Pt sit EOB facing clinician. Turns head away from suspected side (45 degrees rotation). Hold 1 minute
- Patient moves sit‐to‐sidelying opposite side of head turn, maintaining head position. Hold 1 minute
- SMOOTH and QUICK motion to sidelying on opposite side, maintaining head position. Clinician block head from hitting the mat.
- Pt return to sitting. Head flexed 20-30deg.
semont liberatory maneuver for ant/post cupulolithiasis
what test/maneuver? what for?
- pt move sitting to side‐lying with AFFECTED ear DOWN
- pt quickly rotates head, nose is angled at 45 degrees
- Hold 2‐3 minutes
- Return to sitting
gufoni, casani liberatory maneuver for horiz cupulolithiasis
