Vestibular Disorders And Anatomy Flashcards
What are the different categories of “imbalance” causes?
Non-vestibular
Peripheral vestibular
Central vestibular
Non-organic
Why is it difficult to diagnose “dizziness”?
Bc pts present with varying, cross-system symptoms and complaints
What symptoms/complaints might someone with dizziness complain of?
Instability
Visual issues
Cognitive issues (brain fog)
Vestibulo-sympathetic
Cervical
Anxiety/mood
What are the various “root causes” of dizziness?
Medical
Pharmacological or toxins
Vestibular
Non-vestibular
Aphysiologic
T/f: dizziness and balance issues can be from a variety of origins
True
What are medical root causes of dizziness?
CV issues
Neurological issues
What are pharmacological or toxin root causes of dizziness?
Prescriptions drugs
Polypharmacy
Illicit drugs
Alcohol
What are aphysiologic root causes of dizziness?
Psychological or fxnal overlay
Secondary gain
T/f: when there is a toxic or pharmacological root cause of dizziness, the damage can sometimes be fixed by removing the toxin
True
Why should we pay special attention to a pts past hx of medications?
Bc if they had CA or an infection at some point in their life, it may have caused ototoxic effects
What meds are known for being ototoxic?
-mycin drugs
What classes of drugs can cause dizziness?
Aminoglycoside antibiotics
Antineoplastics
Diuretics
Environmental toxins
Antidepressants
Sedative hypnotics
Anti-anxiety meds
Muscle relaxers
Pain meds
Alcohol
Vestibular suppressants
Anti-hypertensives
What are the vestibular suppressants (don’t know if we actually need to know this)?
Bonine
Antivert
Meclizine
Scopolamine
What meds do physicians often prescribe when pts are dizzy and off balance?
Vestibular suppressants
T/f: pts should avoid LT use of vestibular suppressants
True
T/f: vestibular suppressants can make the problem worse in any situation where the vestibular system is needed
True
If a pt gets dizzy when lying down and sitting down, should we use vestibular suppressants?
NO!!!
If a patient is on dosed vestibular suppressant but we are trying to strengthening the vestibular system, what should we do?
Call their physician to try and get them off it
If a pt is on vestibular suppressants PRN and we are trying to strengthen the vestibular system, what should we do?
Educate them on the meds and that if they feel up to it, they can try not taking them before PT
Who are vestibular suppressants supposed to be used for?
Those with spinning symptoms
What are the parts of the diagnostic process with vestibular disorders?
Excellent hx taking
Medical diagnostics to date
Medical/rehab management to date
Hypothesizing the diagnostic group and probable disorder and testing the hypothesis based on the above
T/f: pts with dizziness may not have had any medical diagnostics done bc their physician just thinks it’s aging
True
When a patient with dizziness has been mismanaged, what it’s important for us to do as PTs?
Understand what has been done and how effective it was
Assure the to that you are taking a different approach
What is the most critical part of hx taking with a pt with dizziness?
LISTENING
A diagnosis begins with a clear description of ______ and ______ _______
Symptoms, symptom characteristics
What symptoms descriptions and characteristics do we want to gather in a pts history?
Chronicity
Onset and duration
Triggering factors
Associated symptoms like nausea, vomiting, and brain fog
T/f: “dizziness” is a subjective term with multiple potential meanings and causes
True
When a pt tells us they are “dizzy” what MUST we do next?
Don’t accept the complaint of “dizziness”
Ask the pt to “describe your symptoms w/o using the word “dizzy” or “tell me more about your symptoms”
When a pt tells us they have “vertigo” or “meneire’s”, what MUST we do next?
Don’t accept the statement “vertigo” or “Meneire’s”
Ask the pt to “describe your symptoms for me”
What are the potential causes of “lightheaddness”?
Pre-syncope
CV issues
What are the potential causes of “vertigo” (rotatory, true spinning)?
Peripheral or central vestibular issues
What are the potential causes of “disequilibrium” or “imbalance”?
So many causes…
What are the potential causes of “visual symptoms”?
Peripheral or central vestibular issues
What are the potential causes of “associated symptoms” (nausea, vomiting)?
Acute vestibular, psychogenic issues
What are the potential causes of “floating/swimming”?
Emotional component or anxiety
What are the potential causes of peri-oral or extremity tingling?
Psychogenic
MS
Stroke
What will direct our examination of a pt with “dizziness”?
The potential cause we hypothesize from their history and presentation
When a pt has vertigo, we must immediately decide if the vertigo is ____ ____ or _____ bc it could be a stroke.
Inner ear, brain
What is the #1 cause of dizziness?
Lightheadedness from CV cause
What is the #1 cause of lightheadedness?
CV issues (medical)
What is the #2 cause of dizziness?
Vertigo (true rotary spinning)
What is the #1 cause of vertigo?
Vestibular origins
T/f: vestibular problems become central once they enter the brain
True
T/f: retraining the brain and how info is processed is not an area we can do much about with vestibular disorders
False, this may be where we can make the biggest difference
What are the three semicircular canals?
Horizontal
Anterior
Posterior
What do the semicircular canals control?
Specific eye movts
ROTATIONAL movt
What are the pairs of vertical semicircular canals?
RALP (right anterior and left posterior)
LARP (left anterior and right posterior)
What are the 2 otoliths?
Saccule and utricle
What is the fxn of the otolithic organs?
To detect linear movt
Which otolith detects more vertical movt?
Saccule
What otolith detects more horizontal movt?
Utricle
Which otolith senses cars moving?
Utricle
What otolith senses elevator motion?
Saccule
T/f: With infection in the inner ear, nerves will swell and impair transmission
True
What are the vestibular nerve disorders?
Vestibular neuritis
Vestibular schwannoma
Neurovascular cross-compression
Is there hearing loss with vestibular disorders?
No
Vestibular Schwannoma typically affects what nerves?
Always the vestibular nerve and often the facial nerve too
When a vestibular schwannoma is removed, the ____ nerve is always gone, and the ____nerve is sometimes gone too
Vestibular, facial
What vestibular nerve disorder is a global problem causing hearing, balance, and vision issues?
Neurovascular cross-compression
What are the labyrinth disorders?
Endolymphatic hydrops
Dislodged otocones
Labyrinthine ischemia
Superior canal dehiscence (SCD)
Cupulolithiasis
Canalolithiasis
Vestibular migraine? (I might be making this up tbh)
Does labyrinth disorder cause hearing loss?
Yes
What labyrinth disorder is a chemical imbalance in the ear that causes swelling from too much Na+?
Endolymphatic hydrops
What artery is involved in labyrinth ischemia?
The labyrinthine artery
What is the only artery supplying the labyrinth?
The labyrinthine artery
T/f: labyrinthine ischemia can cause migraines associated dizziness/vertigo
True I think?
What are the roles of the vestibular system?
Coordination of eye and head movt and posture
Steadies the eyes as the head and body moves (via VOR)
Influences the muscle tone and makes postural adjustments (via VSR)
Interprets input, plays a role in motion perception and spatial orientation
What is balance?
A multidimensional, complex, and highly integrated postural system
An interaction bw postural control and gaze control
T/f: the vestibular system may or may not be involved in balance
True
What are the dimensions that balance depends on?
Sensory system inputs (vis, vest, som)
Sensory integration and organization
Multiple motor system outputs
Influence of other systems
What are the sensory inputs for balance?
Visual (vis)
Vestibular (vest)
Somatosensory (som)
Motor systems outputs can be …
Voluntary
Automatic
Adaptive
What are the three parts that affect posture?
The task
The individual
The environment
What are the individual postural system influences?
MSK
Cognitive resources
Muscle synergies
Sensory systems
Sensory organization
Cognitive strategies
What are the 3 postural tasks that contribute to balance ?
Steady state vs reactive vs proactive
What are the 3 individual components that affect balance?
Motor, sensory, and cognitive inputs
What are the 3 environment components that affect balance?
Support surfaces
Sensory context
Cognitive load
Can we change the environmental components of balance?
Yes!
Motor control of the postural system flows through what brain structures?
Frontal lobe—> supplemental cortex—>premotor cortex—>primary motor cortex
What part of the brain is responsible for the motor plan?
The pre-motor cortex
What part of the brain is responsible for the motor output?
The primary motor cortex
What brain structures modulate motor control?
The BG and cerebellum
What are the various motor output involved in balance?
Modulation of movt
Reflexes
Anticipatory postural set
Reactive postural responses
Voluntary movts
At first, when a sensory system is knocked out, do we want to substitute with the other two systems or force use of the impaired system?
Use substitution from the intact systems then move towards forced use
T/f: without one sensory input for balance, the others have to upweight or the system will be off balance
True
Can we teach pts how to upweight damaged sensory inputs?
Yes!
Normal individuals ____ the accurate sensory system(s) for a given task for normal balance
Choose
T/f: normal individuals will weight and re-weight based upon the sensory environment
True
We can teach the system through the ____ to listen to the more accurate systems
PIVC
Can we upweight an impaired system to do its job?
Yes!
During weighting on a stable surface, what is the contribution of each sensory system to balance?
70% som
20% vest
10% vis
During re-weighting on an unstable surface, what is the contribution of each sensory system to balance?
60% vest
30% vis
10% som
When on a stable surface, we rely most heavily on ____ input
Somatosensory
When on an unstable surface, we rely most heavily on the ___ input
Vestibular
Are the somatosensory inputs reliable on unstable surfaces?
No, so the brain will literally ignore it
T/f: vestibular dysfunction will have significant issues with both stable and unstable surfaces
False, they will usually do well with stable surfaces, but have much more difficulties with unstable surfaces
What are personal and environmental factors that can affect generation of body movt for balance?
Cognitive control
Cardiopulmon control
GI/GU systems
Emotion
Pain
Non-physiologic factors
What cognitive factors affect balance?
Learning, memory, judgement, attention, and divided attention
What cardiopulmonary factors affect balance?
Competition for muscular resources
Oxygenation
What GU/GI factors influence balance?
Laryngeal control
Pelvic floor control
(Like the top and bottom of a soda can)
What emotional factors can influence balance?
Anxiety
Depression
Fear
What non-physiologic factors can influence balance?
Motivation
Secondary gain
T/f: there is no single causative factor for disequilibrium of aging
True
What is disequilibrium of aging?
Disequilibrium on the basis of multiple small summating factors with age
What are the small summating factors that cause disequilibrium of aging?
Declining sensory input(s)
Declining sensory processing by the CNS
Aging MSK system
Gaining neural system
Decreased motor control
What’s a disorder caused by declining sensory inputs?
Presbyastasis (couch potato disease)
What are the affects of an aging MSK system?
Dec ROM, strength, power
Sacropenia
Fraility
T/f: there is a gradual worsening of s/s with disequilibrium of aging
True
What is the most common symptoms in disequilibrium of aging?
Dizziness when walking
What is a great measure to use for disequilibrium of aging?
The miniBEST
What is the prognosis for disequilibrium of aging?
Good within 2-4 weeks of “tune ups” for forced use of the weakened systems
____ weeks can make substantial difference in balance and unsteadiness in disequilibrium of aging
2-4
What is presbyastasis?
Age/activity dependent vestibular hypofunctioning (not loss) that is lesion based
T/f: If we can make changes in lifestyle with presbyastasis, the prognosis is good
True
What can we work on in presbyastasis?
Upweighting and forcing the system to work together
What is multi-sensory disequilibrium?
Combined dysfunction within the vestibular, visual, and/or somatosensory system
T/f: multi sensory disequilibrium occurs only with aging
False, it is an actual pathology in multiple systems
What is a disease that involves any combo of disorders that impair all 3 sensory systems?
Multi sensory disequilibrium
What are the symptoms of multi sensory disequilibrium?
Disequilibrium when walking, especially in dim lighting and uneven surfaces
Sensory complaints (numbness and tingling)
Poor proprioception/vibratory sensation (som)
Poor use of vestibular system (vest)
Poor use of vision (vis)
What is the prognosis for multi sensory disequilibrium?
Can be good, but involved more than just a “tune up” like in disequilibrium of aging
Are falls a normal part of aging?
NO!!!
T/f: there are differences bw people who fall and people who don’t fall
True
What are the risk factors for falls?
Intrinsic factors (changes in physical conditions)
Extrinsic factors (environmental situations)
Fear of falls
Hx of falls
Most falls occur where?
In the home during normal ADLs
When we are seeing a pt for balance, what should we ask them every session?
If they have had a fall since the last time we saw them
What is a good measure to use for pts we are seeing for balance?
The ABC scale
<50% on the ABC indicates …
Low confidence
50-80% on the ABC indicates ….
Moderate confidence
> 80% on the ABC indicates…
High confidence
<67% on the ABC indicates …
Increased risk for falling and can accurately classify people who fall 84% of the time
T/f: there is a ceiling effect of the ABC for pts that score over 80%
True
If a pt doesnt do an activity on the ABC scale, what should we tell them to do?
Imagine they do that activity and grade it that way
_____ behavior is a strong factor influencing the health of aging individuals and it also has an impact on the risk of falls
Sedentary
T/f: physically active adults are less likely to fall than sedentary older adults
True
T/f: physically active adults are less at risk for falls injuries
True
What can help reduce fall rates in older pts by 17%?
An exercise program
Sedentary activity with what other factors increases risk of falls?
LE weakness
Balance impairments
Substantial depressive symptoms in older adults can be defined by what outcome?
The Geriatric Depressive Scale (GDS) (15 items) score of greater than or equal to 5
What symptom is a significant independent predictor of falls
Depressive symptoms
What population of older adults is particularly at increased risk of recurrent falls?
Older community dwelling adults with pain
T/f: pain is associated with about 100% increased odds of recurrent falls in older adults
True
Elderly individuals with what diseases have a 57% increased risk of falls?
Cardiovascular diseases
The most consistent CV diseases associated with falls in older adults were what?
Low BP
HF
cardiac arrhythmias
______ and ______ ______ compete for resources in balance
Breathing, postural control
When breathing and postural control compete for musculature, what will always win?
Breathing
T/f: glottal control influences balance
True
EMG studies have confirmed what about pelvic floor musculature and postural/respiratory fxns?
That pelvic floor musculature contributes to both postural and respiratory fxns
What chronic CV condition has the highest prevalence of falls (~23-46%)?
COPD
What are some signs of Ramsey Hunt syndrome?
CN 7 and 8 symptoms
Rash
Facial droop
Hx of spinning
What are some signs of BPPV.
Spinning with position changes
Influence of wine and salty foods
What is vertigo?
An illusion of movt, typically rotary that occurs with nystagmus
Vertigo is associated with what?
Asymmetrical vestibular system firing from a unilateral vestibular hypofunctioning
True vertigo only occurs with what?
Nystagmus
What are the 2 causes of vertigo?
Central and peripheral vestibular dysnfxn
Central causes of vertigo involve what vestibular structures?
The central vestibular structures
Peripheral causes of vertigo involve acute or paroxysmal involvement of what vestibular structures?
The vestibular nerve and or apparatus
The fast phase of nystagmus beats towards the _____ side
Strong (more neurally active side)
What question should we ask EVERY balance impaired patient during hx taking?
If they EVER had vertigo in their lifetime
Why should we ask all balance impaired patient if they EVER had vertigo?
Bc inner ear function doesn’t tend to really come back fully and can be contributing to the current issue
If a balance impaired patient has had a hx of vertigo in their lifetime, what should we ask?
We should ask for a description of the event and their symptoms at that time
When characterizing symptoms of imbalance,what is one of the first things we should determine? Why?
If the symptoms are chronic or acute bc it could be a stroke
If the onset of symptoms is acute, we should as decide if the symptoms are _____/______ and _____/_______
Episodic/continuous
Spontaneous/triggered
If acute symptoms are triggered episodic, what should we ask?
What triggers it
If acute symptoms are spontaneous episodic, what should we ask?
How often they occur
If dizziness is chronic, we should decide if the symptoms are _____/_____
Triggered/spontaneous
If symptoms are acute continuous vertigo, what could it be?
Acute spontaneous continuous
Acute traumatic/ototoxic
What are the acute spontaneous continuous disorders?
Stroke (posterior circulation)
Vestibular neuritis/labyrinthitis
Meneire’s
How can we differentiate a posterior circulation stroke from vestibular neuritis/labyrinthitis and Meneire’s?
By the direction of the nystagmus
Stroke with have central nystagmus (vertical or direction changing)
Peripheral causes will have horizontal or torsional nystagmus
What can cause acute traumatic/ototoxic vertigo?
Meds
If symptoms are acute episodic vertigo, what could it be?
Acute triggered episodic vertigo
Acute spontaneous episodic vertigo
What can cause acute triggered episodic vertigo?
BPPV (positional)
Communicating disorders like SCD or fistula (pressure)
If “dizziness”=OH
If a pt with acute triggered episodic vertigo complains of “dizziness”, what is likely the cause?
OH
What can cause acute spontaneous episodic vertigo?
Vestibular migraine
If symptoms are chronic vertigo, what could it be?
Triggered chronic vertigo
Spontaneous chronic vertigo
What can cause triggered chronic vertigo?
Uncompensated unilateral or bilateral loss
Presbyastasis
PPPD
Central or sensory integrative disorders (processing issue)
What can cause spontaneous chronic vertigo?
MS
Migraines (MAV)-labyrinthine artery involvement
What are the potential causes of vertigo that is always present?
Acute vestibular neuritis/labyrinthitis
Psychogenic causes
Non-organic causes
If vertigo that is always present is associated with hypoventilation, what is likely the cause?
Anxiety
If ACUTE vertigo is present spontaneously and when sitting still, what is a potential cause?
vestibular migraine
If CHRONIC vertigo is present spontaneously and when sitting still, what is a potential cause?
MS
If a pt reports that their vertigo happens spontaneously, what should we ask them? Why?
We should ask them what was happening right before the attack bc they often don’t realize there was a trigger
When vertigo is present with movt or movt of the head and eyes, what are some potential causes?
Vestibular sensory integrative issues
Vestibular/VOR issues
When vertigo is present in moving visual environments or with self movt, what are some potential causes?
PPPD
Vestibular/VOR issues
When vertigo is present with head position movt, what are some potential causes?
Vestibular, BPPV/otolith dysfunction
Movt sensitivity
When vertigo is induced with pressure, what is a potential cause?
Fistula/SCD
When vertigo is induced by specific foods/drinks, what are potential causes?
Meneire’s
Endolymphatic hydrops
When vertigo is triggered by elevators, escalators, or riding in a car (linear acceleration), what is the implicated structure?
Otoliths (saccule/utricle)
When vertigo is triggered by bending forward/backward, rolling over, quick head movt (angular acceleration), what structure is implicated?
Vestibular semicircular canals
When vertigo is triggered by poor stability of gaze, particularly with movt, walking, reading, what structure is implicated?
VOR dysnfxn
When vertigo is triggered by reading, tracking targets, looking from one object to another, converging/diverging (saccadic movt), what structure is inmplicated?
Occulomotor dysnfxn
When vertigo is triggered by imbalance in visual environments or activity (esp faster activities), what structure is implicated?
Visual dependence for balance (problem with the vestibular system at higher speeds)
What symptom characteristics are important for differentiating different types of causes?
Duration, type, and trigger of symptoms
If the latency of symptoms (time from start of symptoms to their worst) is immediate, what may be the cause?
BPPV
If the latency of symptoms (time from start of symptoms to their worst) is delayed, what might be the cause?
Canalithiasis or cupulolithiasis
If symptoms duration is <1 minute, what is a likely cause?
BPPV or non-vestibular causes
How long do symptoms typically last in BPPV
<1 minute
If symptoms are permanent in duration, what is a likely cause?
Psychogenic factors
With nonvestibular causes, what is the symptoms duration?
Minutes
With meneire’s, what is the typical symptom duration?
Minutes to hours
With vestibular migraines, how long do symptoms typically last?
Hours to days
If symptoms are chronic and the pt is symptomatic 4or more than half the day, can it be BPPV?
No bc BPPV pts would not be symptomatic more than half the day, it would be seconds to minutes
What are the symptoms of PPPD?
Chronic (>90 days) unsteadiness, dizziness, non-vertiginous
Symptomatic more than half the day
What are the triggers of PPPD?
Complex visual stimuli
Motion of self
Visual flow
Environmental vigilance
Dependence on visual-somatosensory cues
What is visual flow?
The movement of the environment in relation to the person causes symptoms of moving with the environment
Pts with PPPD are often heavily dependent on what cues?
Visual and somatosensory cues
Why are pts with PPPD sometimes literally “bug eyed”?
Bc they over rely on their visual cues
T/f: PPPD is a mismatch bw hardware and software where they show normal vestibular output but their perceptions are impaired
True
What is the etiology of PPPD?
Symptoms occur after a “normal” vestibular insult
Thought to be a cortical disruption to normal recovery mechanisms
PPPD is more common in ppl with a hx of….
Migraines, anxiety, depression
Are more men or women affected by PPPD?
Women
What age range is most affected by PPPD?
Those bw 30-50yo
What are the multimodal interventions for PPPD?
Cognitive behavioral therapy
PT
seronergic meds
What is involved in PT for PPPD?
Visual desensitization
Graded balance
Habituation
T/f: pts with PPPD are exclusively treated in the PT clinic
False
How do we differentiate PPPD from anxiety/fear?
Anxiety is fear based while PPPD is a fear of how the activity will make them FEEL not a fear of the event itself
What are the medical diagnostic tests for central vestibular disorders?
Traditional imaging (CT/MRI/BOLD MRI)
BAER (BS auditory evoked response
What are the medical diagnostic tests for peripheral vestibular disorders?
ENG/VNG
Rotational testing (autorotation and rotary chair testing)
VEMP
Subjective visual vertical (SVV)
What is the gold standard test for peripheral vestibular disorders?
ENG/VNG
What are the ENG/VNG tests for peripheral vestibular disorders?
Spontaneous and gaze evoked nystagmus
Electronystagmography (calorics)
“Positionals”
What are the rotational tests for peripheral vestibular disorders?
Auto rotational testing
Rotary chair testing
What does the SVV test tell us about?
The otoliths
T/f: most pts do not have vestibular fxn testing completed before coming to PT
True
T/f: we cannot treat a vestibular pt if they have not had vestibular fxn testing done
False
T/f: vestibular fxn testing results correlate well with fxnal deficits of balance and/or gaze
False, they do not correlate well
