Vestibular Exam Flashcards
Reflex System - VOR is what
Gaze stabilization with head movement
Reflex System - Gain is measuring what
Movement of they eye relative to the movement of the head - it should be 1.0 (where eye magnitude equals head movement magnitude)
Relationship of eye velocity to head velocity
Reflex System - COR
Cervical Ocular Reflex
Signals head movement relative to body position - Body rotates on stool while head remains stationary - common with whiplash
Reflex System - OOR
Oto ocular reflex
Controls vertical and horizontal eye movement via the linear VOR
Gaze stabilization with head tilt
Reflex System - VSR
Input from otoliths and canals
Stabilizes head and erect stance - output to antigravity muscles
Peripheral vs. Central imbalance
Peripheral - moderate
Central - severe
Peripheral vs. Central nausea
Peripheral - severe
Central - minimal
Peripheral vs. Central auditory
Peripheral - auditory problems
Central - rare
Peripheral vs. Central neuro symptoms
Peripheral - rare (no problems with coordination)
Central - Common
Peripheral vs. Central compensation
Peripheral - rapid (good recovery time)
Central - slow (months to years)
Peripheral vs. Central onset of symptoms
Peripheral - sudden onset of vertigo
Central - gradual worsening of symptoms
Peripheral vs. Central oscillopsia
Peripheral - mild unless bilateral
Central - severe
Peripheral Nystagmus - Spontaneous
Occurring when just sitting there
Combined movements
Well attenuate
Peripheral Nystagmus - Positional
Change position of head
Torsional upbeat
Latency is common
It will fatigue
Central Nystagmus - Spontaneous
Purely unidirectional
Won’t decrease with fixation
It will not stop
Central Nystagmus - Positional
Vertical upbeat (immediate)
Latency is uncommon
Usually will not fatigue - it will just keep going
Things to consider in vertigo
Define dizzy
Medications
Things to consider in vertigo - Define dizziness
Symptoms
Tempo
Circumstances - how long does it last, what makes it better/worse
Things to consider in vertigo - Medications
Alcohol Tranquilizers Antihypertensives Anticonvulsants Amnoglycosides/Antibiotic
Acute unilateral vestibular loss - 9% of clinic visits with c/o dizziness are dx as ___ or ___
Neuritis
Labryinthitis
Acute unilateral vestibular loss - Neuritis
Sudden onset, vertigo, nausea, severe 3-4 days, worse in first 24 hours
Inflammation of the vestibular nerve
Acute unilateral vestibular loss - Labyrinthitis
Viral or bacterial infections
Inflammation of the SC canals
Linked to cochlea and hearing loss
Acute unilateral vestibular loss - head injury
Inner ear concussion
Fx to temporal bone
Increase in ICP leading to periplymph fistula
Episodic Unilateral Vestibular Loss - Meniere’s Disease
Increase in endolymph volume causing membranous labyrinthine distension and rupture
Episodic Unilateral Vestibular Loss - Perilymphatic Fistula
Caused by disruption of labyrinth membranes, creating a passage between perilymph and the middle ear
Episodic Unilateral Vestibular Loss - perilymphatic fistula - events
Head injury
Barotrauma
Penetrating injury to tympanic membrane
Progressive Unilateral Vestibular Loss - Acoustic Neuroma
Usually around CN 8 at cbm/pontne
Evident on MRI
Slow onset
Progessive Unilateral Vestibular Loss - Acoustic Neuroma S/S
Progressive unilateral hearing loss
Tinnitus
Mild disequilbrium
Peripheral Bilateral Vestibular loss - incidence
11%
Irreversible so not a healing or recovering process
Peripheral Bilateral Vestibular loss - causes
Meningitis Polyneuropathy (diabetes) Neurofibromatosis Acoustic neuroma Congenital malformation Ototoxic drugs
Peripheral Bilateral Vestibular loss - Impact
44% change their driving habits
55% limit social activities and have problems with ADLs
31% increase in fall risk
Central Vertigo - Causes
CVA, HI
Unable to retrain if cbm is involved
Long term rehab
Central Vertigo - Symptoms
Dizziness not related to activity or position Falls/Disequilibrium Lightheaded (full/foggy) Spontaneous nystagmus Directional nystagmus Poor smooth pursuit
Non vestibular - dizziness and imbalance - Vestibular balance and rehabilitation therapy (VBRT)
Beneficial to people with a non vestibular dysfunction
Non vestibular - dizziness and imbalance – people with symptoms that were provoked with head or visual motion (more of a motion sensitivity)
Improve with vestibular exercise/gaze stabilization and balance training
Non vestibular - dizziness and imbalance - Mal de Debarquement
Typically after cruise and they still feel like they are on boat
Some people can persist for weeks or months
Non vestibular - dizziness and imbalance - Migraine associated dizziness
Can be with migraine or can be atypical migraine where it is just the symptoms of the migraine without the headache
Non vestibular - dizziness and imbalance - Primary anxiety and panic
Can make symptoms worse
Examination
Hx Medications Orientation ROM Sensory Strength Coordination Balance Gait
Medications - Meclizine
Prevent and rx nausea and motion sickness
Side effects - drowsiness, hypotension
Medications - Diazepam
For anxiety
Side effects - drowsy, ataxia, confusion, fatigue, respiratory depression
Medications - Meds to control nausea and vomiting
Trimethobenzamide Prochlorperazine Scopalamine Droperidol Side effects - Drowsy, Parkinsonism, blurred vision, confusion, changes in BP
Medications - often given for what reason
Hopes of decreasing the symptoms or to stop the level of discomfort
Most of them will dampen the CNS system
Medical and Lab Examinations - Test for Labyrinthine, Vestibular Nerve
Caloric Test
Rotary Chair Testing
Quantified Dynamic Visual Activity
Medical and Lab Examinations - Test for Labyrinthine, Vestibular Nerve - Caloric Test
Hot/warm in the ear to test to identify which ear is impacted
Medical and Lab Examinations - Test for Labyrinthine, Vestibular Nerve - Rotary chair testing
Sit in a chair that spins n a dark room - measuring nystagmus to differentiate diagnosis
Medical and Lab Examinations - Test for Labyrinthine, Vestibular Nerve, Otolith
Vestibular evoked myogenic potential test (VEMP)
Subjective visual vertical test
Outcome measures - body structure
Dynamic visual acuity Sharpened romberg Sensory orientation test CTSIB Visual analog scale Motion sensitivity quotient
Outcome measures - activity and participation
5XSTS Functional reach Gait velocity Mini BESTest Berg DGI/FGA 4 square step test Single leg stance TUG
Outcome measures - questionnaires
Dizziness Handicap Inventory
Activities Specific Balance Confidence Scale
Vestibular Activities of Daily Living
Modified Fast Evaluation of Mobility, Balance, and Fear Baseline Questionnaire
Vestibular Exam
VOR deficiency: Spontaneous nystagmus Gaze holding nystagmus Smooth pursuit Saccadic eye movement VOR cancellation Slow VOR Rapid VOR Head thrust (Halmagyi) Optokinetic nystagmus Static dynamic visual acuity Post head shaking nystagmus
VOR 1
Eyes stationary
Head turning
VOR 2
Eyes and object turning in opposite directons focusing on an object
Vestibular exam - motion intolerance
Hallpike
Motion sensitivity test
Generally hallpike is gold standard for BPPV
Vestibular exam - disequilibrium
Motion specific
Sensory condition
Functional task specific
Differential Diagnosis/Red Flags - Lightheadedness
Can be from a lot of things
Differential Diagnosis/ Red Flags - Dysequilibrium without dizziness and no dx
Undiagnosed central cause
Need to refer
Differential/Red Flags - Sudden onset of hearing loss
Acoustic neuroma
Refer to neurologist
Differential/Red Flags- Drop attacks
Cardiopulm or neuro
Need to refer
Differential/Red Flags - Neck pain/instability
Cervical ligament instability
Differential/Red Flags - No tx effect after 30 days
Acoustic neuroma
Refer to neurologist or PCP
Differential/Red Flags - Facial numbness
Acoustic neuroma
Undx CNS disease
Differential/Red Flags - Vertigo with vertical nystagmus and downward gaze
Red flag to refer
Differential/Red Flags - Urgent referrals to physician
Unexplained unilateral hearing loss Orthostatic hypotension Unexplained drop attacks Suspected vertebrobasilar insufficency Unexplained neuro or CN dysfunction Vertigo with vertical nystagmus
Goals and interventions
Decrease dizziness symptoms during functional activities
Improve balance
Understanding HEP that they will do 3 or 4 times a day
Clinical practice guidelines for peripheral vestibular hypofunction - Vestibular PT is effective for
Acute, sub acute, and chronic unilateral vestibular hypofunction (UVH) Bilateral hypofunction (BVH)
Clinical practice guidelines for peripheral vestibular hypofunction - exercise is effective for improved
functional goals with dosage of minimum TID for total of 20 minutes - moderate evidence (min of three sessions per day)
Clinical practice guidelines for peripheral vestibular hypofunction - PT supervise vestibular rehab
Moderated evidence
Don’t necessarily have to see them ongoing - is more of supervision
Clinical practice guidelines for peripheral vestibular hypofunction - saccades and smooth pursuit alone for UVH or BVH
DO NOT DO SACCADES OR SMOOTH PURSUIT ALONE!!!
Four primary exercise components
Exercise to promote gaze stability
Habituation
Balance and Gait Training
Walking program
Four primary exercise components - Exercise to promote gaze stability
VOR adaptation VOR substitution VOR 1 VOR 2 Eyes to target and then head to target
Four primary exercise components - Habitutation exercises
Optokinetic stimuli (moving pattern)
Virtual reality
Bath address visual vertigo or motion difficulty
