Vestibular Part 3 Flashcards
What are symptoms of central vestibular dysfunction?
- Ataxia can be severe
- Abnormal smooth pursuits & saccades, diplopia
- Hearing loss would be sudden & permanent if AICA stroke
- Vertigo is mild
- Pendular or vertical nystagmus at equal rates
What are symptoms of peripheral vestibular dysfunction?
- Mild to no ataxia
- Normal smooth pursuits & saccades
- Tinnitus, fullness in ears
- Acute vertigo that is intense
- Slow & fast phase nystagmus
What is Canalith Repositioning Maneuver used for a diagnosis of?
BPPV
What specific CRM is used for Posterior Canal BPPV Canalithiasis?
Epley Maneuver
What specific CRM is used for Cupulolithiasis?
Liberatory Sermont
What specific CRM is used for Horizontal Canalithiasis?
BBQ Roll
What specific CRM is used for Horizontal cupulothiasis?
Gufoni Maneuver
What are adaption exercises?
Designed to promote gaze stability, induce long term changes in the neuronal response to head movements, & reduce symptoms
Adaption or Gaze Stabilization Exercises are used for primary and secondary treatment of what?
- Primary: Unilateral Vestibular Hypofunction
- Secondary: Bilateral Vestibular Hypofunction
What is the goal of Adaptation or Gaze Stabilization Exercises?
Improve neuronal firing rate (rebalance) of the vestibular system & reduce retinal slip
How is adaption or gaze stabilization exercises achieved and what do they result in?
- Achieved: Head movements while maintaining focus on a target
- Results: Reduced symptoms, normalized gaze stability during head movements & normalized postural stability
How is VOR x 1 Exercises performed?
- Patient looks at a point in front of them (their thumb, X on the wall)
- Start at distance of arms length
- Moves their head back & forth as fast as possible but slow down to keep target in focus
- Patient does as many reps as possible, working up to 1 minute or until their symptoms increase too much
How are VOR x 2 exercises performed?
- Patient looks at a point in front of them (their thumb, x on index card)
- As they move the point back & forth, they move their head & eyes in opposite direction but slow down to keep target in focus
- Patient does as many reps as possible working up to 1 minute
Describe how you can progress VOR Exercises?
- Progress by changing position (sit, stand, Romberg, tandem, SLS, walking forward/ back)
- Progress by changing distance away (1m-3m)
- Progress by changing background
- Progress to performing VOR x 2
How long will unilaterally hypofunction need adaptation exercises? And what is the HEP? How does the HEP dosage change for chronic vs acute/ subacute?
- Weekly supervised clinic visits 4-6 weeks
- HEP: Gaze stabilization exercises & progression
- HEP (acute): 3x per day for at least 12 minutes
- HEP (Chronic): 3-5x per day for at least 20 min (total)
How long will Bilateral hypofunction need adaptation exercises? And what is the HEP?
- Weekly supervised clinic visits 5-7 weeks
- HEP: Gaze stabilization exercises & progression
- HEP Dosage: 3-5x per day for a total of 20-40 minutes daily
When using adaptation exercises how long until symptoms should resolve?
15 minutes from completion of exercise
T/F: Balance Training and walking programs are other interventions for UVH
True
- Static & dynamic balance exercises for 20 min daily for 4-6 weeks
What diagnosis is substitution exercises used for the primary and secondary treatment of?
- Primary: Bilateral Vestibular Hypofunction
- Central Vestibular Disorders
T/F: Saccadic or smooth pursuit eye movement are recommended for treating UVH
False- No, b/c do not have ocular issues
What is the goal of substitution exercises?
- Promote alternative strategies to substitute for impaired or lost vestibular function to improve postural & gait stability
- Increase reliance on visual cues
- Increase reliance on somatosensory cues
- Increase reliance on cervical ocular reflex
What is the dosage for substitution exercises?
3-5x/day for 20-40 minutes
How is active eye head movement performed?
- Hold 2 target at arm’s length from your head. Look with your eyes for to one of the target (X) & make sure your nose is pointed to the “X” as well.
- Now look at the “Y” with your eyes only, followed by turning your head horizontally to point your nose to the “Y”
- Repeat this sequence
- Attempt to perform for 60 seconds
What type of exercise is Active Eye Head Movement and what does it treat?
- Substitution
- Treat BVH
What type of exercise is Imaginary Target and what does it treat?
- Substitution
- Treat BVH
How is Imaginary Targets performed?
- Hold one target at arm’s length
- Close your eyes & turn your head horizontally away from target, attempting to keep your eyes focused on target
- Open your eyes after turning your head
- Goal: Eyes remain on target
What is the progression of substitution exercises?
- Sitting
- Standing
- Change/Decrease BOS
- Use a busy background
Name some other substitution ideas beside imaginary targets & active head movements?
- Use of night lights in home
- Use of an AD
- Ensuring proper footwear
- Improving balance (ankle, hip & stepping strategies)
T/F: Vestibular Adaptation Exercises can be used to treat BVH
True, many patients have an asymmetrical BVH
- VORx2 will likely be too aggressive causing excessive retinal slip
T/F: Daily walking program, pool & Tai Chi are not good to perform when a patient has BVH.
False but some activities may be limited such as walking or driving in the dark, sports involving quick head movements
Habituation is the primary treat for what diagnosis?
Central Vestibular Dysfunction
What are habituation exercises?
- Exercises or movements that systematically expose the individual to a provocative stimulus that over time with repeated exposure leads to a reduction in symptoms
- Could be a movement based or situation based (busy environment)
- Balancing act of inducing symptoms (brain learns) & overwhelming the system
How are habituation exercises performed?
- Performs several reps of body or visual motions that cause mild to moderate symptoms
- Assume provoking position & wait 10 sec for symptoms to appear
- If dizziness occurs, remain in the position for an additional 20 sec (30 total) or until dizziness stops
- Return to starting position & wait 10 sec (or until symptoms subside)
- Repeat 5x
What is the HEP for habituation exercises?
- Perform 3-5x each & complete 2-3x/day
- Keep diary to track progress
When performing habituation exercises how long does it take for symptoms to improve?
Symptoms normally decrease within 2 weeks
What SOM can be used to guide habituation exercises?
Motion Sensitivity Quotient
Give some examples of habituation exercises
- Quickly move from sitting upright to bending at the trunk as if to touch your nose to you knee
- Quickly move from sitting at edge of the bed to lying flat
- Roll left & right
- Turning head left to right (VOR)
What should you do if a patient has a flare up with habituation?
- Use grounding techniques
- Sitting in stable chair: feet on floor, armrest, back against chair
- Staring at stationary object
- Controlled breathing
- Cold washcloth or peppermint oil
T/F: Both optokinetic stimulation and virtual reality are other habituation treatments.
- True
- Optokinetic Stimulation: Use of repetitive moving patterns provided by optokinetic discs, moving rooms, busy screen savers on computers, or video of busy visual environments
- Virtual Realty: Immerses patient in realistic, visually challenging environments
Ocular Muscle strengthening can be used for what disorder?
Central Dysfunction
- Pencil Push Up
- Brockstring
- Visual Tracking & Saccades
What is the dosage of balance & gait training for:
- UVH:
- BVH:
- Central Vestibular Dysfunction:
- UVH: 4-6 weeks
- BVH: 6-9 weeks
- Central Vestibular Dysfunction: 6 months & beyond
Balance and gait training is good for everyone what should the prescription include and for how long?
- Prescribe 20 minutes daily
- Include: steady, anticipatory & reactive
- Steady: eyes open; eyes closed compliant surface
- Anticipatory (w/ head turns): walking & turning, walking with head turns, dual task
What is the average rehab time for UVH?
6-8 wks (acute may require less if VR is started early, wishing 2 wks
What is the average rehab time for BVH?
Up to 2 years for full recovery
What is the average rehab time for BPPV?
1 - 2 treatments
What is the average rehab time for central?
6 month or more & may be incomplete
