Vestibular Examination Flashcards by Owen Honroth

explain the transition of signals from peripheral to central vestibular system

goes into vestibular nuclei in pons

divides and travels to 3 places
- oculomotor nuclei
- through thalamus to vestibular cortex
- distally from vestib nuclei to LVST and MVST tracts

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what does the information traveling to the vestibular cortex tell the body about

awareness of head and body in space

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what does LVST and MVST get information about

maintaining postural control

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what does a vestibular examination consist of

subjective
diagnostic tests
special test/measures
gait and balance exam

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when asking about symptoms what is important to get from the patient in relation to severity

an idea of how bad they think the symptoms are

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the questions that we ask about vestibular issues sound a lot like the ones we ask for ________

pain
ie - when, what makes it better, what makes it worse, previous treatments?

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specifically, we want to know what about one’s symptoms

Tempo
specific symptoms
circumstances of symptoms

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explain the differentiators of tempo in relation to symptoms

acute - <2 weeks
chronic - >3months
episodic

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when thinking of episodic symptoms, what does the timeline of:
- seconds to minutes
- minutes to hours
- lasting for days

suggest

short = BPPV
medium = Meniere’s
long = neuritis / migraine associated

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common symptoms reported

vertigo
disequilibrium
oscillopsia
light headed

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why are eye movements critical in an exam

defining and localizing vestibular pathologies

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what tests can we use to examine eye movements

nystagmus
head impulse test
– head shaking induced nystagmus
dynamic visual acuity
positioning tests

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explain peripheral vs central nystagmus in relation to room light suppression

peripheral = suppressed in room light

central = not surpressed

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in the oculomotor exam, what is looked for

nystagmus:
spontaneous vs gaze-evoked

visual tracking

VOR

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what is spontaneous nystagmus?

nystagmus at rest

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if there is spontaneous nystagmus in room light, what may that indicate

acute neuritis in the peripheral system

–> should resolve within 3-7 days

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how to test for gaze-evoked nystagmus

instruct patient to gaze approx 30°
- left and right
- up and down

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what is physiological nystagmus?

when gaze is taken to the end range of vision

– not gaze evoked nystagmus

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what system controls visual tracking

central

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what are the mechanisms involved in visual tracking

smooth pursuits
VOR cancellation
convergence
saccades

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what is VOR cancellation? how is that compared to VOR

moving eyes and head move in the same direction

normal VOR = head and eyes move opposite of each other

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what system does the VOR use

both central and peripheral

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how to test the VOR

Head impulse
head induced shaking
dynamic visual acuity

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what is saccadic intrusion

use of saccades when smooth movement should be produced

can be when testing for smooth pursuit or VOR

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protocol of head shaking induced nystagmus

oscillation of the head with infrared goggles - 20x at a frequency of 2 Hz --> 2 repetitions per second

protocol for dynamic visual acuity test

ask pt to take visual acuity test -- lowest line that can be read accurately is noted shake head at 2Hz (2 reps per sec) have patient do acuity test

what indicates a positive dynamic visual acuity test result

a difference of >3 lines

abnormal presentation associated with ocular ROM test indication?

saccadic intrusion abnormal alignment central sign

explain the fixation block testing component when observing gaze-evoked and spontaneous nystagmus

gaze = yes, darkness spontaneous = yes and no -- nystagmus in darkness = central -- nystagmus in light = peripheral

abnormal smooth pursuit test indication?

saccadic intrusion central

abnormal VOR cancellation indication

saccadic intrusion central

abnormal saccadic testing result indication

corrective saccades --> back and forth will miss the object and then saccade back to object central

abnormal result in convergence testing indication

if convergence occurs ≥ 6 cm from tip of nose central

abnormal head impulse test result indication?

corrective saccade peripheral

abnormal head shaking nystagmus result indication?

if ≥3 beats are present once head shaking has stopped peripheral

which oculomotor exam items are fixation blocked

spontaneous nystagmus gaze-evoked nystagmus head-shaking nystagmus

what is the MSQ

motion sensitivity quotient - subjective score of sensitivity to motion

what is the protocol of the MSQ

10 testing positions of head / body motions provocation of symptoms is noted (intensity and duration)

condition 1 of sensory organization test

normal vision fixed support

condition 2 of sensory organization test

vision taken away fixed support

condition 3 of sensory organization test

sway referenced vision fixed support

condition 4 of sensory organization test

normal vision sway referened support

condition 5 of sensory organization test

absent vision sway-referenced vision

condition 6 of sensory organization test

sway referenced vision sway referenced support

which conditions of the SOT isolate vestibular system the best

5 and 6

what is the ABC

activities specific balance confidence scale

how is the ABC scored?

individual rating of confidence in not losing balance with household and community activities 0-100%

how can the ABC be implemented clinically

goal writing for specific tasks that patient wants to improve confidence in

for those with vestibular disorders, what is a common psychological issue

anxiety and depression

what can be used to screen for anxiety/depression

hospital anxiety/depression scale geriatric depression/anxiety scale PHQ-4 --> 4 item Patient Health Questionnaire for Anxiety and Depression

if s/s point toward central pathology without a pre-existing pathology/diagnosis, what is necessary

referral back to MD

explain the FGA and DGI's relationship

DGI hit a ceiling and then the FGA was made from it

what are the item differences between the DGI and FGA

DGI: - change speed - walk with head turns - pivot turn FGA (^ with): - tandem gait - walking with EC

what tests/measures are applicable in vestibular disorder populations

mCTSIB Dynamic Visual Acuity (DVA) Modified Motion Sensitivity Test (mMST) Screening for anxiety/depression

what functional assessments are applicable in vestibular disorder populations

gait speed FGA/DGI

what are tests and measures versus assessments of function/mobility applicable for clinically

test/measures = interventions function/mobility = goal writing

if one has a positive HIT and DVA, what is indicated? what do we do as PTs

Unilateral Vestibular Hypofunction (UVH) treat

if one has positive Dix Hallpike or roll tests what is indicated? what do we do as PTs

BPPV treat

if one has changes in hearing or tinnitus, what do we do as PTs

refer to ENT

if one has abnormal smooth pursuits, saccades, or VOR cancellation what is indicated? what do we do as PTs

central signs refer to neuro physician

follow up interventions associated with patient confirmed by diagnosis of central pathology

fall prevention compensatory strategies for gaze stability habituation exercises gait/balance retraining

duration of treatment associated with: - UVH - BPPV - Central Patho

UVH = 5-7 wks BPPV = 1-3 visits Central = dependent, but much slower