Vestibular Examination

Question 1

Some

Answer 1

How/when did it START - acute/chronic

Question 2

Funny

Answer 2

What does it FEEL like - w/o using dizzy/vertigo, true room spinning or person spinning

Question 3

Dude

Answer 3

How long do episode(s) last DURATION - episodic/constant

Question 4

Taught

Answer 4

What are your triggers - movement, sound, observation of movement

Question 5

Me

Answer 5

History of migraine - universal complicator, makes things more sensitive

Question 6

About

Answer 6

Aural symptoms - tinnitus, fullness/pressure, hearing changes/fluctuations

Question 7

Falls

Answer 7

History of falls?

Question 8

Musculoskeletal assessment associated with vestibular

Answer 8

• Posture/trunk strength: static & dynamic sitting/standing, righting reactions when balance challenged, head/neck position
• Extremity strength - MMT

Question 9

Somatosensory assessment associated with vestibular

Answer 9

• Eyes closed -
  -Proprioception: extremities or cervical
• Localization: where am I touching you
• Vibration: bony prominences

Question 10

Pathway of cervical proprioceptive system

Answer 10

• Mechanoreceptors of cervical intervertebral joints and cervical musculature (muscle spindle fibers)
• Receptors then carry info to vestibular nucleus

Question 11

Reasons for dysfunction within cervical proprioceptive system

Answer 11

• A functional blockage of joints irritates mechanoreceptors
• Abnormal muscle tone skews muscle spindle function

Question 12

Results due to dysfunction within the cervical proprioceptive system

Answer 12

• Increased or aberrant activity of end organs leads to confusion of vestibular system
• Impulses from cervical proprioceptors do not match incoming info from vestibular system or other senses ie. Vision/somatosensation

Question 13

Presentation associated with cervical proprioceptive system dysfunction

Answer 13

Symptoms are vague sometimes experience nystagmus

Question 14

Test of Joint Position Error

Answer 14

A test for cervical proprioception using a Rob Landel JPE chart (pt needs to be 90 cm from tip of laser pointer to chart)
- Error < 4.5 degrees is normal
- At least 3 attempts at bilateral rotation

Question 15

Goal/purpose of oculomotor testing

Answer 15

Assess range and control of ocular movement and determine integrity/function of several pathways/elements of CNS/PNS
- Should be done in sitting

Question 16

Spontaneous nystagmus testing

Answer 16

Patient asked to stare at blank background, examiner observes for any movement/beating of eyes (direction) or ocular misalignment

Question 17

Down-beating spontaneous nystagmus indicative of

Answer 17

CNS lesion

Question 18

Gaze holding or evoked nystagmus testing

Answer 18

Patient asked to hold focus on examiners finger in midline, and at 20-30 degrees horizontally and vertically in both directions, looking for nystagmus

Question 19

Direction changing gaze holding nystagmus indicative of

Answer 19

Sign of CNS lesion, nystagmus occurs in the direction the gaze is held

Question 20

Direction fixed gaze holding nystagmus indicative of

Answer 20

Sign of peripheral vestibular issue

Question 21

Smooth pursuit testing

Answer 21

Patient follows examiners finger with eyes, head still typically in H pattern, looking for eyes to move smoothly and conjugately

Question 22

Saccade testing

Answer 22

Patient moves eyes quickly between two points, assessing velocity and accuracy of movement and ability to move eyes together

Question 23

Convergence testing

Answer 23

Patient follows examiners finger as it moves towards pts nose, ask pt if they see target as blurred or double, examine ability of eyes to adduct
- Double vision (not blurred) around 6-10 cm from nose can use tool to measure distance

Question 24

May be indicative of central or peripheral lesion

Answer 24

• Abnormal spontaneous nystagmus
• Gaze holding nystagmus

Question 25

May be indicative of (CNS) cerebellar or brain stem lesions

Answer 25

Abnormal smooth pursuits

Question 26

May be indicative of (CNS) brain stem, cerebellar, basal ganglia, or frontal cortex lesions

Answer 26

Abnormal saccades

Question 27

May be indicative of brain stem or occipital lobe lesions (CNS)

Answer 27

Abnormal convergence

Question 28

Elements to oculomotor assessment

Answer 28

- Spontaneous nystagmus - Gaze holding nystagmus - Smooth pursuits - Saccades - Convergence

Question 29

Components to vestibular ocular assessment

Answer 29

- VOR - Head impulse test - Dynamic visual acuity test - VOR cancellation

Question 30

VOR testing

Answer 30

Pt asked to focus on pointer finger while moving head side to side followed by up and down at a speed of 2 Hz - Looking for pt ability to maintain gaze and reports of blurred/double vision/dizziness

Question 31

Head impulse test

Answer 31

Pt seated and asked to focus on examiners nose, examiner moves pt head side to side slowly followed by quick thrust 30 deg from midline - Looking for gaze stability during thrust without corrective saccade

Question 32

Positive head impulse test

Answer 32

Corrective saccade indicative of peripheral issue in horizontal semicircular canal - Low gain: eye movement/head movement

Question 33

Dynamic visual acuity test

Answer 33

Uses Snellan eye chart, pt asked to read lowest line able with head still, examiner shakes pt’s head at 2 Hz and asked to read lowest line - Should be within 2 lines

Question 34

Positive dynamic visual acuity test

Answer 34

Difference of 3 lines or greater between static and dynamic visual acuity - Indicative of peripheral issue, more lines lost = more severe issue is

Question 35

VOR cancellation

Answer 35

Cue pt to extend arm and focus on thumb, pt attempts to maintain focus on thumb while rotating trunk back and forth

Question 36

Positive VOR cancellation

Answer 36

Pt unable to maintain fixation on thumb while rotating trunk - May indicate cerebellar lesion - May reproduce motion sickness symptoms

Question 37

Responsible for cancelling vestibular ocular reflex

Answer 37

Cerebellum

Question 38

Benign Paroxysmal Positional Vertigo

Answer 38

Occurs when otoconia from utricle fall into semicircular canal - Most often into posterior canal (sometimes horizontal, almost never anterior canal)

Question 39

Hallpike-Dix Test

Answer 39

- Pt on table in long sitting - Turn pt head 45 degrees - Bring pt into supine with head extended off table - Looking for upbeat, torsional nystagmus lasting short duration

Question 40

Documenting spontaneous nystagmus

Answer 40

Note direction of nystagmus and whether visual fixation suppresses nystagmus ie. finger = less symptomatic

Question 41

Documenting gaze-evoked nystagmus

Answer 41

Note presence AND direction of nystagmus in each position comment if direction changing or direction fixed

Question 42

Documenting smooth pursuits

Answer 42

Abnormal described as saccadic pursuits or loss of fixation, comment if occurring in specific direction as well as symptoms

Question 43

Documenting saccades

Answer 43

Note any inaccuracies ie. dysmetric, comment where undershooting or overshooting is present and if symptoms present

Question 44

Documenting convergence

Answer 44

Describe if both eyes adduct together, comment if unable to hold adducted position, measure distance of target from bridge of nose when diplopia reported

Question 45

Documenting VOR

Answer 45

Note loss of fixation or gaze stability and when occurring (horizontal or vertical) report any symptoms

Question 46

Documenting VOR cancellation

Answer 46

Note any loss of fixation or inability to move eyes with head report any symptoms

Question 47

Documenting BPPV testing

Answer 47

Note presence and direction of nystagmus, delay between assuming position and nystagmus/symptom onset, duration of nystagmus, complaints of dizziness (room spinning)