Vestibular Exam cont Flashcards
List the components of the vestibular exam
- Auditory Screen
- Gaze Stability Assessment
- Cervical Dizziness tests
- Balance and Postural Control Assessment
what tests are performed during the auditory screen?
Weber and Rinne Test
What tests are included in the gaze stability assessment?
- Spontaneous Nystagmus
- Gaze-Evoked Nystagmus
- Optokinetic Nystagmus
- Pursuit
- Saccades
- VOR
- Dynamic Visual Acuity
- Head Impulse Test
- Post Head-Shaking Induced Nystagmus
- Skew Deviation
- VOR Cancellation
what is a spontaneous nystagmus?
onset of nystagmus without any cognitive, visual or vestibular stimulus
occurs in the absence of any purposeful eye or head motion
(you observe nystagmus at rest)
describe a spontaneous peripheral nystagmus
- mixed horizontal/torsional
- fast phases of the horizontal and torsional component move the eyes away from involved ear
- present w/acute lesions, rarely w/chronic stable lesions
- more prominent w/fixation removed
describe a central spontaneous nystagmus
- vertical or torsional
- acute or chronic
- more prominent with fixation present
how is a gaze-evoked nystagmus tested?
head remains still but eyes move side/side and up/down but only in a small range
performed with and w/o visual fixation
describe a gaze-evoked nystagmus that is indicative of a peripheral vestibular dysfunction
- uni-directional
- fast-phase away from involved side (ie it points to the good ear)
- present w/acute lesions, rarely w/chronic stable lesions
- decreases when fixation available
describe a gaze-evoked nystagmus that is indicative of a central vestibular dysfunction
- changes direction
- seen acutely or chronicaly
- increase or stays the same with fixation available
what is alexander’s law?
a peripheral vestibular nystagmus increases in intensity with the gaze directed towards the fast phase
what is a 1st degree nystagmus?
only present when gaze directed towards fast phase
what is a 2nd degree nystagmus?
- present in primary gaze and when gaze directed towards fast phase
- strongest when gaze is directed towards fast phase
what is a 3rd degree nystagmus?
- present in all gazes
- strongest when gaze directed towards fast phase
what is an optokinetic nystagmus?
an involuntary optic reflex for percieving motion in the visual field
normal to have nystagmus during this
what is an abnormal aysmmetrical response for the optokinetic nystagmus?
direction of reduced motion → non-compenstation vestibular condition
you will see a blunted or irregular beating response compared to the other side
define smooth pursuits
ability of eyes to follow a target at a slow pace
this is a voluntary movement
to test → sit with head still and target is brought at a slow pace from L to R
what are saccades? How do you test these?
rapid repositioning between visual targets (voluntary movement)
To Test:
- Pt sits w/head still and 2 targets are placed to R and L fields of vision
- Pt is instructed to move from center point (nose) to L to center then to R target
how is VOR tested?
- passively moving pt through horizontal canal’s plane (30 degrees below horizontal) while instructing pt to maintain gaze on target (nose)
- abnormal findings:
- corrective saccades or nystagmus
What is the gold standard for VOR testing?
Head Thrust and Head Impulse Test
what is an abnormal response to the Head Thrust test?
correct saccades and or post/thrust nystagmus → suggestive of peripheral vestibular hypofunction
what increases the sensitivity of the Head thrust test?
- unpredictable head thrusts
- frequency (>2Hz) and velocity (180 deg/sec)
- maintaining appropriate head positioning (30 deg below neutral)
what is the head shake test?
presence of post-headshake nystagmus = strong clinical indicator of non-compensated injury
what are the steps of the head shake test?
- fixation removed (eyes closed)
- 2Hz (120 bpm) head shaking horizontal for ~20 seconds
- keep eyes closed, therapist passively opens one eye and assesses for nystagmus
what are abnormal findings for the head shake test?
- Peripheral dysfunction
- >3 beats of post head shaking nystagmus considered clinically sig for unilateral vestibular dysfunction
- should see horizontal nystagmus beating away involved ear
- Central dysfunction
- vertical nystagmus
what is the dynamic visual acuity test?
a functional challenge to VOR
- better able to ID dysfunction in subacute and chronic vestibular disorder
- to perform obtain a static baseline and then use 2 cycles/second 120 bpm
- perform in both the horizontal and vertical fields
what is considered an abnormal finding for the dynamic visual acuity test?
>/= 3 line degradation considered significatn
what is the skew deviation test?
this assess for vertical dysconjugate gaze
predictor of central vestibular involvement (98% sensitivity)
describe the steps for the skew deviation tests and abnormal findings
- move your hand back and forth to each eye, blocking their vision, while observing the uncovered eye.
- instruct pt to keep eyes forward and on target (nose) during the test
- abnormal response:
- deviation of one eye while it is being convered, followed by correction after uncovering it
what does an abnormal result on the skew deviation test indicate?
central pathology
what is the purpose of the VOR cancellation test?
evaluate cerebellar control w/regards to modulation (inhibition) of VOR
describe the steps to the VOR cancellation test
- pt seated, with either target set directly in midline or pt’s arms outstretched w/thumbs up
- have pt move head and target in unision to L and R eye, observing eye movements
- abnormal results = + corrective saccades (ipsilateral)
T/F: the VOR cancellation test assists with determining the presence of a peripheral vestibular pathology
FALSE
central screen
this test is looking at the modulation of the VOR, if the VOR is alread broken (like in a perihperal pathology) its hard to test modulation of it
what is the HINTS test?
quick bedside, physical exam that can be performed on pts w/acute vestibular symptoms
has a very high sensitivity and specificity
what does the HINTS test include?
- Head Impulse test
- Nystagmus observation
- Test of Skew
what results on the HINTS test indicate concern for central dysfunction?
I.N.F.A.R.C.T
Impulse Normal
Fast phase Alteration
Refixiation on Cover Test
what is included in balance and postural control assessment during a vestibular exam?
- CTSIB
- Gans Sensory Organization Processing (SOP) Test
- Mini-BESTest
- BESS test
- Computerized Sensory Organization
what is the CTSIB test?
Clinical Test of Sensory Organization and Balance
assesses sensory contributions to postural control
Involves the observation of a patient’s attempts to maintain balance
list the 6 conditions included in the CTSIB
- firm surface
- eyes open
- eyes closed
- visual conflict
- foam surface
- eyes open
- eyes closed
- visual conflict
what is the Gans Sensory Organization Performance Test?
combines components of tests to better evaluate balance modality systems
- modified Romberg
- CTSIB
- Fakuda Step test
describe the Fakuda Step Test
Marching w/eyes closed for 50 steps
rotation greater than 30 degrees or displacement of 0.5m indicative of uncompensated peripheral vestibular dysfunction
describe the Mini-BESTest
14-item test observing anticipatory and reactive control, sensory organization and dynamic gait
MCID = 4 points
What is the BESS Test?
Balance Error Scoring System Test
- initially develoed for consussions and return-to-play
- fundamentally looking at vestibular dysfunction
- 6 conditions, eyes closed for all, 20 seconds each
- measuring #errors during each condition
- max 10 per condition
- MCID = 3 points (3 errors)
what is Computerized Posturography Sensory Organization Testing?
- This test manipulates difference balance inputs to ID how pt weighs each modality
- Can be used as assessment tool, as well as for intervention
- helps ID malingering pts
list the 6 conditions of the Computerized Posturography Sensory Organization Test
- Fixed Support
- normal vision
- absent vision
- sway-referenced vision
- Sway-Referenced Support
- normal vision
- absent vision
- sway-referenced vision
