Vestibular Examination Flashcards
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
what does the information traveling to the vestibular cortex tell the body about
awareness of head and body in space
what does LVST and MVST get information about
maintaining postural control
what does a vestibular examination consist of
subjective
diagnostic tests
special test/measures
gait and balance exam
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
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?
specifically, we want to know what about one’s symptoms
Tempo
specific symptoms
circumstances of symptoms
explain the differentiators of tempo in relation to symptoms
acute - <2 weeks
chronic - >3months
episodic
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
common symptoms reported
vertigo
disequilibrium
oscillopsia
light headed
why are eye movements critical in an exam
defining and localizing vestibular pathologies
what tests can we use to examine eye movements
nystagmus
head impulse test
– head shaking induced nystagmus
dynamic visual acuity
positioning tests
explain peripheral vs central nystagmus in relation to room light suppression
peripheral = suppressed in room light
central = not surpressed
in the oculomotor exam, what is looked for
nystagmus:
spontaneous vs gaze-evoked
visual tracking
VOR
what is spontaneous nystagmus?
nystagmus at rest
if there is spontaneous nystagmus in room light, what may that indicate
acute neuritis in the peripheral system
–> should resolve within 3-7 days
how to test for gaze-evoked nystagmus
instruct patient to gaze approx 30°
- left and right
- up and down
what is physiological nystagmus?
when gaze is taken to the end range of vision
– not gaze evoked nystagmus
what system controls visual tracking
central
what are the mechanisms involved in visual tracking
smooth pursuits
VOR cancellation
convergence
saccades
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
what system does the VOR use
both central and peripheral
how to test the VOR
Head impulse
head induced shaking
dynamic visual acuity
what is saccadic intrusion
use of saccades when smooth movement should be produced
- can be when testing for smooth pursuit or VOR
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
