Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Neuro Eval > Vestibular Lecture part 2 > Flashcards

Vestibular Lecture part 2 Flashcards

1
Q

Episodic vestibular conditions

A

– Benign Paroxysmal Positional Vertigo (BPPV)
– Vestibular migraine
– Meniere’s Disease
– Anxiety (? Situational)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Sudden/acute onset vestibular conditions

A

– Vestibular neuritis/labyrinthitis
– Vascular (TIA, CVA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Persistent/Chronic vestibular conditions

A

– Chronic concussion/mTBI
– Persistent Postural-Perceptual Dizziness (PPPD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

physical therapy assessment of vestibular system

A
  • subjective history
  • functional mobility assess
  • oculomotor exam
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

subjective description of “dizziness”

A
  • onset
  • quality (lightheaded, spinning, imbalance)
  • severity (verbal rating sale or visual analog scale)
  • frequency
  • duration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

blurred vision can be a result of what two things?

A
  • VOR impairment or visual activity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is double vision typically a sign of?

A

central involvement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

hearing impairment

A
  • Often accompanies peripheral vestibular involvement
  • Patients are not always aware of changes in hearing unless they are sudden and significant
  • Audiogram can identify impairment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Good questionnaires to use

A
  • dizziness handicap inventory
  • activity specific balance confidence scale
  • visual vertigo analog scale
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Modified Motion Sensitivity test

A
  • Systematically monitor subjective dizziness and
    presence of nystagmus to assess sensitivity to
    motion
  • Used as a tool to monitor progress in subjective
    dizziness over time
  • Items on test that cause dizziness can be used as starting points for treatment
  • 10 items, all movements are in standing
  • monitor symptom intensity and duration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what 10 items are on the modified motion sensitivity test

A

– Horizontal, vertical, diagonal head turns
– Standing trunk bends (reach to floor)
– Turns- trunk rotation and 360 degree
– VOR cancellation- visual motion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Balance assessment

A

– Romberg
– mCTSIB
– Berg Balance Scale
– Weight shifting
– Balance reactions (stepping strategy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

oculomotor exam provides information on:

A

ocular alignment and motility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

central oculomotor control

A

– Vergence
– Smooth Pursuit
– Saccades
– VOR Suppression/cancellation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Vestibular Function in the Oculomotor exam

A

– Presence of Nystagmus
* Spontaneous or Gaze-evoked
– Head Impulse/Thrust
– Clinical DVA test
– Head Shaking Nystagmus test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Ocular ROM

A
  • Ensure that patient’s eyes are moving
    conjugately and in all directions
  • Full ROM
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Near point of convergence

A
  • Slowly bring discrete target in toward bridge of nose
  • Have pt. identify when object blurs, then doubles
  • Measure distance for target doubling
  • < 6 cm = WNL
  • Note any symptom provocation
  • Often caused by fatigue
  • Use reading glasses if pt. needs them for near vision
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

convergence

A
  • Gold standard is performed by observing retinal fusion via otoscope
  • Patients may have subjective blurring or diplopia that is not consistent with retinal fusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

smooth pursuit deficit is indicative of what?

A

a central deficit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

smooth pursuit

A
  • Patient follows pen with head still in vertical and horizontal directions
  • Look for quality of movement or “jumping –> Documented as “corrective saccades”or
    “saccadic intrusions”
  • Degrades with inattention, age, sedatives and speed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what structures are smooth pursuit primarily a function of?

A

parieto-occipital cortex, pons and cerebellum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

VOR Cancellation issues is typically indicative of what?

A

Central deficit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

VOR Cancellation

A
  • Sit in front of pt. and instruct patient to focus on your nose
  • Rotate patient’s head left/right as you move with
    him/her
  • Eyes and head stay together
  • Look for saccadic movements, which are a sign of an inability to fixate
  • Even if normal, may have increased symptoms due to visual motion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What should you do before performing a Head Thrust (AKA Head Impulse Test)

A

check cervical ROM and tolerance to quick motion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Head Thrust Procedure

A
  • Sit in front of pt, instruct them to relax neck
    and focus on your nose
  • Thrust head rapidly over a small amplitude
  • Look for pt ability to stay focused on your
    nose
  • Look for corrective saccades to catch up to your nose after their gaze slipped off
  • Note head thrust direction when it occurs
  • Too fast to involve the cerebellum so primarily
    VOR test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is a good differentiator between peripheral and central lesions?

A

head thrust

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

a positive head thrust indicates what?

A

a peripheral sign

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

a successfully performed head thrust test should be…

A
  1. FAST
  2. Unpredictable
  3. Small amplitude
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Dynamic Visual Acuity Test

A
  • Have pt. sit at appropriate distance from chart and read the lowest line possible
  • Stand behind pt and turn head at 2 Hz while
    he/she reads lowest line possible
  • Use Metronome to ensure correct speed
  • Drive pt. to make at least one mistake- don’t let them quit early
  • A degradation of 3 or more lines indicates an impaired VOR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

does dynamic visual acuity test indicate a central or peripheral deficit?

A

can be either

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

DVA differential diagnosis:

A

– Central- concussion, migraine, central vestibular
– UVH or BVH
– Low tolerance to movement due to highly symptomatic
– Anxiety
– Decreased effort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is good for test-retest to determine if a pt is progressing, or has compensated for a hypo function?

A

DVA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

what is the primary intervention strategy for a positive DVA

A

VOR x 1
Gaze Shifting

34
Q

When checking spontaneous nystagmus, what will a patient with a peripheral lesion present with?

A
  • spontaneous nystagmus only in the acute phase
  • will be suppressed by smooth pursuit
35
Q

When checking spontaneous nystagmus, what will a patient with a central lesion present with?

A
  • may have nystagmus in a variety of directions in acute and chronic phases
  • will see corrective saccades during smooth pursuits
36
Q

how is gaze evoked nystagmus test performed

A
  • with the fancy goggles
  • ask pt to look to the left, right, up and down,
    approximately 30 degrees, for at least 15 sec.
    each
  • observe for nystagmus and direction
37
Q

during gaze evoked nystagmus test, what finding would be indicative of a central sign?

A

Nystagmus in the direction of gaze or that
changes directions

38
Q

during gaze evoked nystagmus test, what finding would be indicative of a peripheral sign?

A

Nystagmus that is in the same direction (left
beating w/left gaze and upward gaze, none
with right gaze)

39
Q

How is head shaking nystagmus test performed?

A
  • Ask pt. to close eyes and turn head 30-45º
    bilaterally 20 repetitions at speed sufficient to
    stimulate the vestibular system
  • Before stopping, ask pt. to open eyes
  • Observe any nystagmus
  • More than 3 beats is considered abnormal
40
Q

a positive head shaking nystagmus test is indicative of what?

A

non-specific peripheral sign

41
Q

What are your intervention options

A
  • habituation: motion sensitivity
  • sensory organization
  • gaze stabilization
  • habituation: visual motion intolerance
42
Q

what is the primary recovery strategy to improve function of the VOR?

A

gaze stabilization

43
Q

what should you use gaze stabilization?

A

-if DNA is impaired
- pt may or may not have a positive head thrust test
- best with intact CNS

44
Q

what 2 processes does gaze stabilization use?

A
  • change in gain of VOR using adaptation
  • use of compensatory saccades to supplement VOR
45
Q

gaze stabilization flow chart

A

using exercise, create a controlled retinal slip with head movement –> results in creation of an error signal –> brain makes a long term change in response to the error signal –> retinal slip decreases and there is better vision and less dizziness

46
Q

principles of VOR exercises

A
  • Target at least 3-5 ft away
  • Horizontal and vertical directions
  • Goal is 1 minute each direction
  • 3-5x/day
  • Move head as fast as able maintaining a stable target
  • TARGET MUST STAY CLEAR
47
Q

Gaze shifting at slower velocities:

A

combined smooth pursuit and saccades

48
Q

gaze shifting at faster velocities:

A

combines saccades and VOR

49
Q

what is the primary mechanism for visual scanning of environment

A

gaze shifts

50
Q

when should you use gaze shift interventions

A

when VOR x 1 is too difficult or symptoms are too elevated

51
Q

what should gaze shifts be used in combination with?

A

gaze stabilization training

52
Q

how to perform gaze shift intervention:

A

Two targets: Start with eyes and head on one target, move eyes to next target but keep head still, then move head to the next target once eyes are stable –> works on eye/head coordinated movement

53
Q

how to progress gaze shifts

A

process to eyes and head moving together to each target

54
Q

CPG recommendations for peripheral vestibular hypofunction

A

– 12 min of gaze stability exercises per day
– Can be a combo of gaze shifting, VOR x 1, etc.
– No evidence for smooth pursuit or saccade exs

55
Q

what is the goal of habituation

A

Used to relieve motion induced dizziness or vision motion intolerance

56
Q

How does habituation decrease symptoms?

A

by systematically provoking symptoms through repeated exposure to specific provoking motor or visual task

57
Q

2 important things to remember with habituation:

A
  • PACING: only need to drive symptoms up enough to induce moderate symptoms to get results
  • PATIENT EDUCATION is a MUST
58
Q

what in your assessment leads you to do habituation?

A
  • Modified Motion Sensitivity Test
    – Motion sensitivity- patient’s own motion
    – Visual motion intolerance- motion in the
    environment, even when pt. is still
  • Patient report of dizziness with specific exacerbating conditions
59
Q

habituation exercise design

A
  • identify provoking movement OR visual motion task
  • performs movement or is exposed to visual motion –> symptoms go up no more than 5/10 –> rest and allow symptoms to return to baseline
60
Q

habituation: motion sensitivity interventions

A

– Head turns in standing/gait
– Turning quickly
– Bending to pick up objects

61
Q

habituation: visual motion intolerance interventions

A

Optokinetic Stimulation:
– VOR cancellation
– Ball toss
– Reading while walking (visual flow)
– Busy background
– Twirling Umbrellas

62
Q

Habituation summary

A

– Habituation is used a primary intervention
– Use repeated exposure to provoking stimulus
– Progress as patient tolerates
– More is not always better!
– Patient must understand why you are provoking their symptoms and the goal of intervention

63
Q

Sensory Re-weighting training things to remember:

A
  1. Identify patients that are visually dependent
    – Developed ineffective compensatory strategies
    – Postural instability or increased symptoms in complex visual environments
  2. Important for patients to be proficient at
    somatosensory tasks prior to progression to vestibular re-weighting
    – Static and dynamic, with head movement
64
Q

Sensory Re-weighting Training to enhance vestibular feedback:

A

disadvantage both somatosensory and visual feedback

65
Q

Balance interventions for sensory re-weighting

A
  • Important to challenge balance
    without UE support (Should include only postural support used in function)
  • Not too much challenge- too large of an “error
    signal” and the CNS will not induce change
  • Important to challenge static and dynamic systems
  • Reactive and anticipatory postural responses
66
Q

Sensory Re-Weighting Summary

A

– Important to identify those that are visually dependent
– Proficient at somatosensory before training vestibular feedback
– Don’t use UE support during balance tasks
– Static and dynamic training- include variety

67
Q

Static Compensation

A

Initial spontaneous nystagmus resolves after
unilateral peripheral loss with or without any
visual input

68
Q

Dynamic Compensation

A

VOR won’t recover without an error signal created
by visual input, to drive a change in the system

69
Q

what is “compensation” used to define?

A

when someone has achieved adaptation- VOR is working due to changes in the central system to accommodate for peripheral loss

**it is not used to describe substitution

70
Q

Medications

A
  • Meclazine (AKA Dramamine)
    – Over the counter
    – Vestibular suppressant
71
Q

Patient education - pacing

A
  • Symptoms no higher than 5/10
  • Rest between activities
  • After therapy exercises, symptoms should
    not last longer than 15-30 minutes
72
Q

Intervention for Chronic Dizziness/PPPD

A
  • Validate pt’s experience and symptoms
  • objectively describe pathophysiology and path to recovery
  • discourage hypervigilence and catastrophic thinking
  • sensory re-weighting
  • posture control and balance confidence- “grounding”
  • core stabilization
  • fitness/endurance
  • participation in community activities, work, volunteering as tolerated
  • habituation
  • lower autonomic nervous system reactivity
73
Q

problem list

A
  • Gaze instability
  • Motion sensitivity
  • Visual motion intolerance
  • Postural stability impairment
    – Gait
    – Static/dynamic balance
  • Musculoskeletal impairment
  • Exercise intolerance
74
Q

gaze instability and dizziness - intervention

A

gaze stabilization

75
Q

motion sensitivity - intervention

A

habituation

76
Q

visual motion intolerance - intervention

A

Optokinetic, habituation

77
Q

postural imbalance - intervention

A
  • sensory organization
  • reactive and APA control
78
Q

complete bilateral loss - intervention

A
  • gaze stabilization
  • sensory organization (visual and somatosensory)
  • postural control
79
Q

prognosis

A
  • Age does not matter
  • Migraine makes recovery harder, even if not Migraine-related vestibulopathy
  • Good recovery for BPPV
  • Central Vestibular disorders get better, but take
    longer and have more guarded outcomes
  • Bilateral Vestibular disorders have a similar result
80
Q

factors affecting PT recovery

A
  • sleep
  • emotional issues
  • headache/migraine
  • social support, social roles

Neuro Eval (18 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions