Vestibular Flashcards
Name two common ototoxins that can cause dizzyness
Aspirin
Amino Glycosides: broad spectrum antibiotics
The best test for vestibular dysfunction is what?
pt hx
Name two red flags in a hx you would refer out for?
Sudden onset of hearing loss
Headaches
Other than PMH what do you want to know as part of a persons medical hx?
PSH: past surgical hx
PANAS is what?
screen for anxiety and depression
ABC is what
Activities of balance Confidence scale
DHI is what?
dizziness handicap index
Duration matches with what etiology
Seconds
Minutes
Hours/Days
Seconds: BPPV, perilymph fistula, orthostatic hypotension
Minutes: TIA, migraines
Hours/Days: Meniere’s Disease
8 components of occulomotor exam
Spontaneous nystagmus
Gaze evoked nystagmus
Saccades
Smooth pursuit
Optokinetic Nystagmus
Convergence
Skew Deviation
Extraocular ROM
4 tests for VOR
VOR
VORc
HTT
Dynamic Visual Acuity Test
What does abnormal VORc tell you?
Eyes are unable to keep up. Central sign!
+R HTT you’ll see what? what side it eh problem on?
Corrective saccade to get the eyes back on target
R side
Gaze evoked nystagmus, you see the nystagmus change direction when you move position, what does this mean?`
Central impairment!
How fast do you rotate the pts head for dynamic visual acuity?
What is a + test?
2Hz or 120 bpm
Jump of 3 or more lines and 4 or more dropped letters within a line
name the three tests performed with light fixation removed
spontaneous nystagmus
Gaze holding nystagmus
Head Shaking Nystagmus
What is normal head shake test
always done with goggles on, start w/ eyes closed
Normal would be no nystagmus when they open their eyes
Name three otolith function tests
Cover cross cover test (which is also the skew in the occulomotor screen)
Ocular tilt reaction
SVV/bucket test
What does an abnormal ocular tilt reaction look like?
both eyes will not roll away (no ocular counter rolling)
Dependent eye will not move up (this is the part you’ll see in room light)
What deviation on the bucket test is considered abnormal?
What does this tell you?
> 2.5 degrees from true vertical
Problem with the saccule on the same side as the deviation
Videonystagmography
different positions w/goggles on they measure amplitude, velocity and direction of nysagmus
What are some signs of central nystagmus
Resting, pure vertical or direciton changing nystagmus other UMN signs, CONSTANT vertigo
Differentiate between neuritis and labyrinthitis
central or peripheral?
Neuritis: no hearing loss
Labyrinthitis: hearing loss
Peripheral!
True or false antivert/meclizine is a treatment for BPPV?
False! its a vestibular supressant which should only be used in someone who cannot keep their eyes open cause they’re vomitting etc.
Labrynthitis and neuritis we want them taking or not taking vestibular supressants?
NOT TAKING
what is the most common thing to cause bilateral vestibular loss?
ototoxic antibiotics
Known risk factors for BPPV
old age, DM
What is the most common cause of otologic dizziness
BPPV
If someone has transient having loss do you think its Meniere’s disease?
no, hearing loss is constant.
Pt presentation for meniere’s
fullness in ear, decreased hearing, tinnitus (waves), rotational vertigo, postural imbalance, nystagmus, nausea and vomitting
Can you predict when attacks of meniere’s are going to occur?
No! they’re spontaneous
Pt may have an aura
Will you be able to trigger dizziness in a Menieres pt?
no! Its spontaneous
What is Betahistine drug therapy used for? When is it taken?
Meniere’s disease.
Taken when the feel one coming on to stop it before it comes on
Low salt diet, vestiublar suppressant during attack, intratympanic introduction of ototoxic antibiotics generally used for treatment of what kind of disorder?
Meniere’s disease
If Meniere’s Disease is stable is PT indicated?
NO
End stage Meniere’s or post treatment (surgically or intratympanic gentamycin) creates what?
Unilateral hypofunction
Dizziness/disequilibrium caused by abnormal afferent activity from the neck is what?
Cervicogenic dizziness
Diagnosis of cervicogenic dizziness is what?
dizziness associated w/neck movement
Time association btwn neck pain and onset of dizziness
What has a frequent association with traumatic injury and cervical arthritis?
Cervicogenic dizziness
subjective report of someone with CGD would be what?
“swimming”
“floating”
“detached”
“off”
NOT room spinning!
Dizziness inceased with cspine motion and no los of hearing is probably what?
Cervicogenic dizziness
Does someone with cervicogenic dizziness have nystagmus?
no!
Mismatch between vestibular, visual and cervical inputs, perceived as dizziness and disequilibrium is describing what etiology of neck pain?
cervicogenic dizziness
What reflex is exaggerated or abnormal in patients with CGD
COR: perpetuated by movements of the neck
Provoked room spinning dizziness is likely what?
BPPV
Onset of BPPV
sudden
W/ positional changes
> 60 seconds:
<60 seconds:
> 60 seconds: cupula
<60 seconds: canal
upbeating:
Downbeating:
Upbeating: posterior
Downbeating: anterior
Does cupula or canal have latency?
Does cupula or canal extinguish?
Canal
Canal: cupula persists it hasn’t settled anywhere its just chilling there
Explain the BBQ roll (write it)
start in supine, put head so affected ear is dependent (towards strong side)
Slowly rotate head to neutral (15 seconds)
Slowly rotate head to opposite side (15 seconds)
Pt body and head to prone
Tuck chin
Quadriped –> sitting –> standing
Casini explanation
Whole body to INVOLVED side (weak)
IMMEDIATELY head down (2min)
Sit up maintaining head turn
Appiani explanation
Whole body to UNINVOLVED side (weak) 2 min here
Then turn head down (2 more min)
Sit up maintaining head
Guffani explanation
whole body to INVOLVED side (weak) stay here until nystagmus stops +15 seconds
Head facing up 45 degrees stay here until stops + 15 sec
Maintain head turn and sit up
You perform a SRT and you see apogeotropic nystagmus that is not persistent what do you do? (ageotropic is cupula so it normally is persistent)
Gufoni Maneuver
When lateral canal BPPV occurs post treatment for PSCC BPPV, this tells you what?
the side you just treated is the involved side. there was canal conversion.
Post treatment instructions?
none
Recurrence rate of BPPV?
30% in a year
What may pt feel after tx?
lightheadedness for up to 2-3 days
Liberatory decreases or increases the risk of canal conversion?
Decreases risk! It’s more violent
Vestibular neuritis, do they experience hearing loss?
NO
onset of VN
sudden
What does the evidence say about the recovery of long term vestibular hyopfunction?
Recovery can occur treat them!
Early is better
What is the deficit in VN?
unilateral hypofunction
What tests would be positive for someone with vestibular neuritis?
Spontaneous nystagmus (acute in room light, chronic w/fixation removed), + head shaking, abnormal VOR, +Head shake
What is the most common cause of bilateral vestibular loss?
ototoxic drugs
How to treat bilateral vestibular loss
there is no VOR to recalibrate , work on balance, gait, and ensure they’re seeing someone for bilateral hearing loss
Vestibular migraine, central or peripheral?
central
Is dizziness w/o HA able to be classified as a vestibular migraine?
Yes, no HA necessary
Is vestibular migraine or Meniere’s higher incidence?
Vestibular Migraine
Tx for vestibular migraine
migraine diet
migraine pain medication: even if they don’t have a HA
stress reduction: good sleep, regular meals, PT (balance and decrease movement restrictions)
Unilateral vs. bilateral lesion for static problems
Unilateral
Gaze stability
Postural stability
Bilateral
Gaze stability
Postural stability
Unilateral
Gaze stability: spontaneous nystagmus
Postural stability: asymmetry in stance
Bilateral
Gaze stability: no nystagmus
Postural stability: symmetrical in stance
Dosage for movement of the head for someone with VN
no good evidence for it
tx with or w/o AD for someone with acute vestibular problem?
treat w/o but send them home w/one if they need it
is adaptation or compensation the original goal in individuals with acute vestibular problems
adaptation
What should tx be based on
individualized!
When does adaptation occur
when there is a retinal slip = an error signal
This is a slow process
Is adaptation context-specific
Yes! you want to get them back specific tasks.
Get them moving!
Graded activities
Gaze exercises are used to adapt what?
the VOR!
Tx for bilateral vestibular disorder
they don’t have a VOR but she gives it a shot anyway
compensatory or adaptive? After a large grade transitional movement, wait before moving
Compensatory
Compensatory or adaptive?
Eyes first then head?
Compensatory
name four things you can modify to progress gaze stabilization exercises
- time
- speed of head movement
- target
- position of the body
- surface
- stance
- background
Reliable outcome measures for vestibular specific?
none use balance
Dosing for VOR adaptation exercises
2 minutes tops for x1 and x2
5 minutes tops for all other
30-60 second rest between trials
start with 2-3x a day
Good documentation to support the necessary treatment time to make an impact on the vestibular system
functional impairments, changes in activity, rating of symptoms, develop fittness goals etc.
Progression of VOR habituation exercises
x1 horizontal x1 vertical Btwn two targets remebered targets x2 horizontal x2 vertical
MSQ is used for what population?
non-vestibular causes of dizziness, motion induced complaints
what is intensity ranked from on the MSQ
0-5
Dosing of MSQ
pick three positions, you want to do each position for three reps
What is the total score of MSQ?
All intensity ( minus if the baseline intensity was not zero) + duration
What is the motion sensitivity quotient equation?
of positions(total score) all divided by 20.48
What is the goal of the MSQ after therapy?
<10% of their quotient
What exercises should you be choosing for HEP from MSQ
middle of the line provoking exercises to ensure carryover at home
true or false, pts should be wearing glasses during occulomotor screening?
true!
What do we think about vertical spontaneous nystagmus?
red flag!
What about a gaze holding nystagmus would point you towards a central sign?
if the nystagmus changed direction
When are you not super worried about a smooth pursuit that is abnormal?
If it is not accompanied by other central signs
if the individual is over 65 yrs
When is normal convergence, where do you measure from?
<5cm
Measure from bridge of nose
How many skips is normal saccadic eye movement?
2 skips or less
What would be a central sign for optokinetic nystagmus?
if their eyes are moving smoothly
Abnormal VORc tells you what?
Central sign
cross cover cross test is for what two things
occulomotor scan as well as otolith function
