Vestibular Flashcards
Central Vestibular System
CN 8 > vestib nuclei > cerebellum/vestibulospinal/abducens/oculomotor
Vestibular Apparatus
Semicircular Canals: ant, pos, horizontal
-each with an ampulla
Otolithic Organs: utricle, Saccule
Membranous Labyrinth
-separated by perilymph fluid
-filled with endolymph
-hair receptor cells bend with mmt
Semicircular Canals
-Ampulla that contains a crista with a cupula (gelatanous structure containing hair)
-hairs constanly fire AP when the rate of fluid changes when at rest and with head mmts to give information about the body in space
-only actively move during rotation of head in the opposite direction
-Only angular or rotational movement
Horizontal: head rotation (no)
Ant and Post: pitch and roll (yes)
-R and L Posterior and anterior work in same plane
Ex: Turn to the L, L endolymph shifts toward kinocilium (activating), R endolymph shifts away from kinocilium (inhibiting)
Otolith Organs
Urtricle and Saccule: membranous sac that responds to linear acceleration/decceleration
-have a macula that contains hair cells embedded in a gelatinous mass with microscopic cristals (otoliths) on top
-displacement of otoliths stimulate neurons
-linear movement of the head
Uricle: Horizontal mmt
Saccule: vertical mmt
Vestibulo Occular Reflex
-head and eyes move in diff direction to maintain view
-opp lateral rectus activate to move eyes in same direction
Activation of hair cells
-movement that bends hair toward kinocilium causes depolarization and activation
-movement that bends hair away from kinocilium causes hyperpolarization and deactiviation
Otolith Ocular Reflex
-input from otoliths
-output to eye muscles
-controls horizontal and vertical eye mmts
-via linear VOR
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
Nystagmus: CNS
CNS:
-smooth pursuit and saccades (cerebellum and brainstem)
-often follows gaze
-typically vertical, constant (not changed by fixation)
-changes direction when looking changes
Neuritis/Labyrinthitis
Neuritis: no hearing loss
Labryrinthitis: hearing loss and tinitis
-infection/inflammation causing hyperexcitation
-damage causes hypofunction
-fireing rate affected
-long lasting 3-7d
-nystagmus fixed on good side in all 3 degrees of gaze
s/s:
-sudden, lasting days, single event
-spontaneous, exacerbating by movement
Acoustic Neuroma
-benign tumor on cochlear n that places pressure
-can cause dizziness and balance issues
-no true vertigo s/s
Endolymphatic Hydrops/Meniere’s Disease
-chronic condition of inner ear
-fluid accumulation building up pressure in inner ear, leads to hyperstimulation
-causes vertigo/hearing loss/hypofunction
Causes:
-Meniere’s Disease (idiopathic)
-Sodium/potassium imbalance
s/s:
-sudden, recurring
-exacerbated by head movements
Fistula/Dehiscence
-structural hole from trauma
-makes it hard to manage endolymph and pressure
-causes vertigo
Vesibular Hypofunction
-damage to inner ear or vestib n
-affects VOR and VSR
-unilateral: dizzy
-bilateral: moving images (oscillopsia); gradual onset; no dizziness
Spontaneous Nystagmus
-cns or pns vestib problem
Positional Nystagmus
-paroxysmal or static
-Torsional: BPPV or brainstem
-Down/upbeat: cerebellar dysfunction
Gaze evoked Nystagmus
-eyes drift toward center, contantly corrective
Congenital Nystagmus
-birth
Peripheral Vestibular System
-Vestibular Apparatus
-Semicircular Canals
-Otolithic Organs
Vestibular Pathway
CN 8 > Vestibular nuceli/ Cerebellum/Vestibulospinal tract/Vestibuloocular/
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:
-short spells, recurring
-holding still makes it better
Vestibular Migraine
-sensory-perceptual disorder in vestibular
-can cause vertigo/tinnitus
Persistent Postural Positional Dizziness (PPPD)
-chronic functional dizziness
-autonomic and emotion hyperresponsiveness to vestib stimuli
-after vestibular trauma, s/s becomes persistent after brain fails to adapt
Mal de Debarquement (MDDS)
-mal adaptation following getting off a moving vehicle
-s/s persistent of rocking or swaying that
Subjective Assessment
-quality of s/s
-longevity of s/s
-frequency
-aggravating factors
-easing factors
-associated s/s
Symptom Quality
Vertigo: illusion of self movement or room spinning
Disequilibrium: sense of being off balance
Gaze-instability: foggy headed, blurry vision (decreased of VOR)
Oscillopia: illusion of excessive motion of object (no dizziness; Bilateral non-BPPV)
Nystagmus
-non voluntary rhythmic oscillation of eyes
-named by fast phase
-can be suppressed by fixation
-viewed with frenzel or infared goggles
-increases toward fast phase (Alexander’s law)
Physiologic: normal stimuli
Pathologic: abnormal; 4 types
Caused by vestib:
-slow phase caused by VOR
-fast corrective by cerebellum
Caused by CNS:
-smooth pursuit and saccades
Nystagmus: PNS
Peripheral Vestib:
-Slow phase: VOR
-fast phase: corrective saccade
-usually horizontal
-moves in the same direction
Nystagmus: BPPV
BPPV:
-named by torsion (canal) and rotary component toward the lesion
-Upbeat and rotary for PSCC
-direction fixed
Cause:
-canal stimulation and mixed matched
Vertigo
-sensation of the room spinning
BPPV or non-BPPV (anything not canal related)
Subjective Exam
-Quality of s/s
-Frequency
-Duration
-Agg/Eas
-Other s/s
Quality: Vertigo
-Illusion of movement
-spinning, rocking, swaying, falling
Quality: Disequibrium
-sense of being off balance
-unsteady, wobbly, drunk, tilted
Quality: Gaze-Instability
-foggy headed
-heady-headed
-light headed
-motion sickness
Quality: Cardiovascular
-dec bloodflow
-light headed
-pre-syncope
-tunnel vision
Quality: Anxiety
-floating
-swimming
-rocking
Quality: Visual
-diplopia
-oscillopsia (visual jumping)
Frequency and Duration: Vestibular Neuritis
-Sudden onset
-lasts days
Frequency and Duration: BPPV
Short Spells: Canal
Long Spells: Cup
-recurring
Frequency and Duration: Bilateral Hypofunction
-gradual onse
-constant/chronic
Frequency and Duration: Mennniere’s or Vestib Migraine
-Sudden
-Recurrent spells (hours/days)
Frequency and Duration: Orthostatic Hypotension
-short spells
-Recurring
Frequency and Duration: PPPD of MDDS
-Constant
-Chronic
Aggs and Eases: BPPV
Ag: changing positions or lying or rolling
Eas: holding still for time
Aggs and Eases: Gaze Instability
Ag: head movement
Eas: holding still and closing eyes
Aggs and Eases: Vestibular Neuritis
Ag: Spontaneous made worse by head movement
Eas: Holding still, closing eyes, meds
Aggs and Eases: Vestibular Migraine or Meniere’s
Ag: Spontanous made worse by head movement
Eas: Holding still, closing eyes, meds
Other Associated S/s
-Illness
-Allergies
-Headache
-Syncope
-N/t
Components of a Vestibular Screen
- Subjective
- Systems Review
- Observe for Nystagmus
- Oculomotor Tests (CNS)
- VOR Screen (Peripheral)
- HINTS
- Postural Control (Balance)
- Position Provocation Testing
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
Vertigo
-sensation of the room spinning
BPPV or non-BPPV (anything not canal related)
Determine Canal Involvement
-nystagmus present in provoking positions and gone when return to sitting
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 ipsi 45 deg
- Quickly bring their head down into ext
- Hold for 1 min or until dizziness subsides and look at nystagmus
(+) PSC: upbeat
(+) ASC: downbeat
Ewald’s 1st Law
-for vertical canal BPPV
-eye movements are in the plane of canal stimulated
-opp reaction shown in reversal phase
Posterior Canal: Upbeat
Anterior Canal: Downbeat
Left: Left torsional
Right: Right torsional
Ewald’s 3rd Law
-for vertical canal BPPV
-deflection of the cupula towards the canal affected creates a stronger excitatory response than away
-positional tests move cupula toward canal
Ewald’s 2nd Law
-horizonal canal BPPV and VOR
-excitation creates a greater response than inhibition
-flow towards ampulla creates a stronger response than away
Free floating (canal): turning head towards affected side brings cupula away from canal (stronger)
Stuck (cup): turning head towards non-affecred brigns cupula toward canal (strogner)
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
(+) 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
Anterior Canal BPPV Treatments
-Reverse Semont Maneuver (Canal AND Cup)
-Yacovino
Horizontal Canal BPPV Treatments
-BBQ Roll (Canal)
-Gufoni (Cup)
HEP:
-Forced Prolonged Positioning + BBQ roll
-Self-Casani
Brandt-Daroff Habituation
-non specific when maneuvers ineffective BPV
-given as an HEP
not on practical
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 or Cup
- Pt in long sitting
- Rotate head slowly to same side of impairment, wait 30s
- 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 inttot 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, wait 1 min
- 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
Oculomotor Tests
On practical:
1. Gaze Evoked Nystagmus (frenzels)
2. Vergence
3. Smooth Pursuit
4. Saccades
Not on Practical:
-spontaneous nystagmus
-ocular ROM
-Skew-eye deviation
Spontaneous Nystagmus
-not on practical
-non-BPPV
-test with frenzels and observe eyes
Central:
-nystagmus doesn’t change with fixation
-direction of beating changes
-not fatiguable
Peripheral:
-nystagmus dec with fixation
-unidirectional
-Direction doesn’t change (Alex law)
-fatiguable
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
Gaze Evoked Nystagmus (GEN): Central
-intinsity of nystagmus changes direction
-doesn’t improve with fixation
-not fatiguable
-vertical nystagmus
Gaze Evoked Nystagmus (GEN): Peripheral
-nystagmus dec with fixation
-unidirectional
-Direction doesn’t change (Alex law)
-fatiguable
Vergence
- Slowly bring target to nose and ask them to keep their eye on it
Normal: target is att least 6cm before Pt sees double
Abnormal: disconjugate eye movement before 6 cm OR aversion reaction (SNS)
Skew Deviation
not on practical
- Cover one eye to determine if there’s a compensation
-Skewed eye will jump back with uncover
-Non-skewed eye will cause skewed eye to jump back with cover
Smooth Pursuit
- Follow target an arms length away slowly
- Move to 30deg on each side
Abnormal:
-saccadic intrusions
Saccades
- Hold target an arms length away
- Move to 30deg on each side
- Tell Pt to look quickly btwn PT nose and target
Abnormal:
-overshooting or undershooting
-slow scan
-central sign
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
Abnormal:
-target gets blurry or jumping before 2 Hz
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)
Abnormal:
-target becomes blurry or jumping or dizziness
VORc Test
-head and arms together
-suppresses VOR
ONLY as treatment in practical
- Pt seated w/ arms ext, head pitched down 30 deg
- Passive or actively move head as target follows
Abnormal:
-saccdic intrusion
-dizziness
-imbalances
Fukuda’s Stepping Test
-NOT on practical
-tests vestib function
- Pt marches in places for 50 steps with UE parallel and eyes closed
- Watch their progression and turns
Normal: move less and than 50cm and 30 deg
Abnormal: often turn towards INVOLVED side
Deficits in VOR Function
Static:
-seen at rest with acute unilateral dysfunction
-resolves within a few days
Dynamic:
-abnormality in VOR gain or timing of eye movements in relation to head motion
Mechanisms of Vestibular Recovery: Neuroplasticity
-varies according to the severity of vestibular dysfunction
Mechanisms of Vestibular Recovery: Spontaneous
-resolve spontaneously in 4-7 days
-if not, CNS is unable to adapt
Mechanisms of Vestibular Recovery: Compensation
-when recovery is not possible
-may be required to dec s/s
Mechanisms of Vestibular Recovery: Vestibular Rehabilitation
-Adaptation
-Substitution
-Habituation
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
Adaptation: Gain
-ratio used to describe the relationship of eye movement to head movement or eye movement to target
Normal VOR gain: 1
Abnormal VOR gain: retinal slip causing images to become blurry
Substitution
-inc use of other strategies to replace lost vestibular function
-Bilateral VOR or central dysfunction
-Unilateral if complete loss
Habituation
-repeated exposure to a stimulus dec brain’s pathological response to that stimulus
-for motion sensitivity or mixed dysfunction
-repeated provoking position/stimulus until s/s dec
-last ditch effort
-Ex: Brandt-Daroff
Immediate: reduced sensitivity of Ca
Long-Term: change in size and number of synapses
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
-VOR1/2/c
Bilateral Hypofunction
-dec function of both sides
-harder to recover
-S/s: Jumping
Tx:
-Substitution (Mainly)
-Adaptation (if some function remains)
-Oculomotor
-VOR 1/c
-Remembered/Imagined targets
-Active head-eye movement btwn target
Gaze Stabilization VOR Exercises
-for VOR adaptation OR Substitution
Changes:
-postural supports
-Visuals
-Directions
-Speed
-Cognitive
-Multi-tasking
-for 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
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 - VORc
- 50bpm for 2 mins
don’t progress variables until all 3 completed
VOR Exercises Adaptation: HEP Acute vs Chronic
Acute:
-12 min throughout day
-1-2 mins intervals
Chronic:
-20 min throughout day
-1-2 min intervals
VOR Exercise: Substitution #1
-active eye-head movements btwn 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
VOR Exercise: Substitution #2
-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
VOR Cancellation Exercise
-chronic unilateral hypo
-treat for practical
-1 minute, 3x/day
-start VORc slowly, then progress to faster
-s/s should last 5-10 mins
Grounding Exercise
-for all vestib patients
-during symptom recovery or increased anxiety
-focus somatosensory
-Box breathing
Central Vestibular Dysfunction: Rehab
-occulomotor exercises
-habituation
