Vestibular

Question 1

What are clinical presentations of dizziness for cardiopulmonary/metabolic?

Answer 1

Syncope
Orthostatic hypotension 
Cardiac arrhythmia
COPD
Anemia
Hypoglycemia

Question 2

What are clinical presentations of dizziness for Neuromuscular?

Answer 2

TBI/Concussion
TIA/CVA
Labyrinthits
Neuritis
Basilar migraine 
BPPV
Multi-sensory 
Acoustic Neuroma
Miners Disease
MS
Cerebellar atrophy

Question 3

What are clinical presentations of dizziness for Musculoskeletal?

Answer 3

Cervical Dizziness

Temporomandibular Joint Dysfunction

Question 4

Discuss signs, symptoms, and impairments of UVH, BVH, and BPPV. (5 general answers)

Answer 4

Disorientation to gravity 
Self motion intolerance 
Postural instability 
Gaze instability 
Sensory Conflict

Question 5

What is exercise progression for UVH? (7 general answers)

Answer 5

Slow to fast movement
Wide to narrow base of support
Reaching outside BOS
Eyes open to eyes closed
Stable surface to complaint surface
Eye movement only to eye movement with coordinated head movement.
Walking with head stable on trunk to head moving on trunk.

Question 6

Discuss signs, symptoms and impairments of Bilateral Vestibular Hypofunction

Answer 6

Presence of vertigo (depends on asymmetry)
Difficulty orienting to gravitational reference without vision
Motion discomfort; Slow head moving
Postural instability
Oscillopsia (Marced gaze instability)
Unsteadiness in complex motion environments

Question 7

Intervention for Bilateral hypofunction?

Answer 7

Permanent use of visual
Cautious head movement
Safety
Encourage motion of individual in environment

Highly structured; individualized program
Target Postural and gaze instability

Question 8

What is BPPV presentation?

Answer 8

Brief spells of dizziness
Nausea
Provoked by specific changes of head position
Consistent
Initial spell is not necessarily the worst

Question 9

What are the impairments for BPPV?

Answer 9

Distorted response to specific head positions 
No space/ motion discomfort 
Mild postural instability 
Normal VOR
Normal resolution of sensory conflict

Question 10

What are interventions for BPPV?

Answer 10

Epley Maneuver (Ant & Post canal)
CRM (Horizontal canal)
Brandt-Daroff Exercise
Balance retraining

Question 11

What examination tests are available for BPPV?

Answer 11

Dix Hallpike test (Ant & Post)
Roll test (Horizontal)
Balance 
Gait
Fall risk

Question 12

What are the Brandt-Daroff exercise guidelines?

Answer 12

5-10 repetitions; each rep 8-10 seconds.
2-3 times/ Day until symptom free
Symptoms resolve within 1-2 weeks
Symptoms should fatigue over reps and diminish over days.

Usually given has home exercise program; Specifically in session 2 of Clinical algorithm

Question 13

What are the vestibular rehabilitation indications and contraindications for distortion (BPPV)?

Answer 13

Indications: Consistently provoked symptoms
Contraindications: Inconsistent symptoms

Question 14

What are the vestibular rehabilitation intervention and goals for deficiency?

Answer 14

Intervention: Targeted exercise designed to promote Adaptation, substitution, and habituation.
Goal: Minimize symptoms, prevent or reverse maladaptive movement patterns, optimal function.

Question 15

What is the difference between adaptation, substitution, and habituation?

Answer 15

Adaptation - recovery/restoration (use errors to change symptom; force brain to change)

Substitution - compensation (using alternative means to achieve therapeutic goals)

Habituation - desensitizing the body to symptoms; repeated exposure to a provocative (noxious) stimulus results in a pathological response over time

Question 16

What are the vestibular rehabilitation indications and contraindications for deficiency?

Answer 16

Indications: Stable Pathology, provoked symptoms, and pre & post op

Contraindications: progressive, spontaneous symptoms, inconsistent symptoms

Question 17

What are the 5 Fundamental Impairments of Vestibular Rehabilitation?

Answer 17

1. Position tolerance: Perceptual disorientation relative to gravity (and position intolerance)
2. Motion tolerance: Self-Motion discomfort (and intolerance)
3. Postural Instability (VSR)
4. Gaze instability (VOR)
5. Sensory conflicts: Self vs Environmental Motion Conflicts - motion in the world around you can provoke symptoms

Question 18

What are Vestibular Hypofunction Interventions? (3 general answers)

Answer 18

VOR Training
Habituation of head motion and position
Orientation and postural stability training

Question 19

What are the 4 general rehab principles for UVH?

Answer 19

1. Encourage movement
2. Promote substitution in the short-term, adaptation in the long-term
3. Gradually promote movement that minimizes compensatory patterns and is continuous and repetitive
4. Be safe and compassionate.

Question 20

How long does it take one with UVH to recover?

Answer 20

6 weeks to 6 months under normal conditions

Question 21

Modifiers of UVH?

Answer 21

Willingness or ability to provoke symptoms (or low tolerance)

• High anxiety, agoraphobia, depressive disorder
• Fear of falling
• Other Cognitive / Behavioral impairments

Multiple vestibular diagnoses
CNS Pathology
Visual / somatosensory impairment
Pre-existing eye movement disorder
Cervical pathology / neck movement dysfunction
Multiple medications
Advanced age
Progressive bifocal / trifocal glasses (may interfere with vision and vestibular adaptation)

Question 22

What is the Dizziness Handicap Inventory (DHI)?

Answer 22

The patient is asked to answer each question as it pertains to dizziness or unsteadiness problems, specifically considering their condition during the last month.
Questions are designed to incorporate functional (F), physical (P), and emotional (E) impacts on disability.

To each item, the following scores can be assigned:
No=0 Sometimes=2 Yes=4

Scores:
Scores greater than 10 points should be referred to balance specialists for further evaluation.

16-34 Points (mild handicap)
36-52 Points (moderate handicap)
54+ Points (severe handicap)

Question 23

When should you use Vestibular Adaptations for rehab?

Answer 23

UVH = Yes!
BVH = Yes, but possibly due to a limited extent - focus more on substitution with BVH
BPPV = No.