Vestibular Part Two

Question 1

How would you test someone that potentially falls under the classification Sensation of Motion at Rest?

Answer 1

Patient sits unsupported with feet on floor, hands on lap and eyes closed.

Question 2

Classification Sensation of Motion at Rest: what are the possible responses when testing this individual?

Answer 2

A. No motion reported: symmetrical vestibular function
B. Rotation: unequal signals coming from each side of the vestibular system
C. Rocking: inability to find vertical position from gravity sensors i.e. otoliths
D. Lightheaded: mismatch of vestibular and somatosensory input

Question 3

Sensation of Motion at Rest: functional implications?

Answer 3

A. Lack of concentration because vestibular information is not integrated at subconscious level
B. Difficulty with routine mental tasks such as math, sequential tasking, memory lapses
C. Persistent dizziness, loss of balance especially with head rotation or tilt

Question 4

Sensation of Motion at Rest: what are some intervention techniques?

Answer 4

Settling- somatosensory input to decrease sway by putting weights on the individuals shoulders while they are seated with their eyes closed or using hands to create a compressive force through the spine.
Cognitive task while balancing or settling- have them perform a cognitive task such as counting backwards from 100 by 3s to allow them to use vestibular system on subconscious level.

Question 5

Head Righting Responses: How would you test for this classification and what would you look for?

Answer 5

Use a tilt board to tip patient side to side while observing their head position.
Normal response: head remains in vertical midline saggital plane orientation
Abnormal response: head remain in alignment with trunk -> otolith impairment or somatosensory dominance

Question 6

Which vestibular classification would you suspect if the patient reports symptoms with the following: when riding elevators, when on escalators or moving walkways, when walking in the dark, postural instability going from sit to stand, and inadequate stepping strategy?

Answer 6

Head Righting Responses

Question 7

Head Righting Responses: Interventions?

Answer 7

Side reaches
Sit on tilt board
Semi-tandem stance to tandem stance to tandem walking
Postural work on foam
SLS
Sit on ball (marching with eyes closed)
Head tilts
Sit to sand with eyes closed, step downs with eyes closed

Question 8

Head Motion Provoked Dizziness: Test position

Answer 8

Patient is seated unsupported on mat table or chair while turning their head back and forth at speed of 1-3 Hz.

Question 9

Head Motion Provoked Dizziness: Responses to testing procedure

Answer 9

Dizziness associated with lack of vestibular system calibration at the speed that the head is turning
Dizziness associated with abnormal interpretation of somatosensory inputs in the neck

Question 10

What vestibular classification would you suspect if the patient reports dizziness when reading, turning, walking and looking around?

Answer 10

Head Motion Provoked Dizziness

Question 11

Head Motion Provoked Dizziness: Interventions

Answer 11

Head turns, tilts and nods
Spin in chair
Walking turns
Rolling

Question 12

Somatosensory Integration: test position and expected response

Answer 12

Romberg
Normal-minimal sway using ankle strategy and arms relaxed at their sides
Abnormal-Excessive sway or hip strategy on firm surface, lightheaded sensation. Patient often will say they do not feel more stable when standing against the wall indicating poor somatosensory contribution to balance responses

Question 13

What classification would you suspect if the patient reports the following:
Difficulty walking up or down inclined surfaces, reliance on tactile cues by using walls, furniture or AD for balance, excessive use of hip strategy on firm surface, unable to stack joints to improve postural stability?

Answer 13

Somatosensory integration

Question 14

Somatosensory Integration: Interventions

Answer 14

weight shifts with feedback about position
Weighted extremities
Proprioception exercises
Perturbed surface at higher speeds

Question 15

What classification would you suspect if the patient reports the following: difficulty reading, dizziness with eyes open that resolves with eyes closed activities, headaches that get worse with visual activity such as computer use, loss of depth perception?

Answer 15

Oculomotor function

Question 16

How would you test for the classification Oculomotor function

Answer 16

Saccades, smooth pursuits, convergence/divergence

These can all be used as interventions as well.

Question 17

What classification would you suspect if the patient reports the following: they avoid head movement during typical activities, decreased speed of walking, difficulty driving AND reading street signs, headache and neck pain associated with attempts to decelerate head during typical activities

Answer 17

Gaze stability with head turns

Question 18

Gaze Stability with Head Turns: testing procedure

Answer 18

VOR
Normal: object stays in focus
Abnormal: image is blurred as head turns

Question 19

Gaze Stability with Head Turns: interventions

Answer 19

Patient moves head only so fast as they can to maintain visual focus
Progress this activity to perform with increasing speed, in more visually simulating environments and during more challenging surface conditions

Question 20

What classification would you suspect if the patient reports the following;
imbalance ind ark environments especially when surface is uneven
Loss of balance when visual environment moves around them
More fatigue than expected with daily activity, especially when in stimulating visual environments

Answer 20

Visual dependency or preference

Question 21

Visual Dependency: Test procedure and response

Answer 21

Patient stands with narrow BOS and follows target with their central visual field including diagonals and figure eights. Compare sway pattern during eyes open and eyes closed activities.
Abnormal: pt sways excessively as physiologic visual field moves away form vertical, or when vision is absent

Question 22

Visual Dependency: Intervention

Answer 22

Smooth pursuit in progression of environments
Progression from standing on firm surface to narrow BOS to SLS with eye or head movement etc.
Work on balance activity with eyes closed

Question 23

What classification would you suspect if the patient reports difficulty walking on unstable surfaces (grass, thick padded carpet, sand etc), inability to switch from ankle to hip strategy as surface becomes less stable (walking from sidewalk to grass)

Answer 23

Somatosensory Dependency

Question 24

Somatosensory Dependency: Testing procedure and response

Answer 24

Standing on compliant, narrow, unstable then perturbed surfaces.
Abnormal response; maintains persistent joint angles i.e. joints do not adapt to surface variability resulting in postural instability.
Intervention: will train on these surfaces giving verbal cues to prevent patient from maintaining persistent joint angles

Question 25

What classification would you suspect if the patient reports the following:
avoids environments that are visually stimulating such as grocery stores and airports
Dizziness and nausea when using computers, watching TV or movies, when riding in cars
Difficulty reading unless book is held steady

Answer 25

Visual motion Hypersensitivity

Question 26

Visual Motion Hypersensitivity: test procedure and response

Answer 26

Increased sensation of dizziness or nausea with eye movement testing

Question 27

Visual Motion Hypersensitivity: Interventions

Answer 27

Have patient perform eye movement with head still in progressively stimulating environments
Use of optokinetic stimulus with progressive surface challenges and with eye movement

Question 28

What classification would you suspect if the patient reports the following: difficulty going from sitting to standing, inability to adequately orient using somatosensory cues

Answer 28

Somatosensory hypersensitivity

Question 29

Somatosensory hypersensitivity: testing procedures and responses

Answer 29

Sitting or standing, increase somatosensory input via joint loading (standing against wall)
Abnormal: report of dizziness or nausea
Intervention: provide progressive somatosensory stimulus during settling and weight shifts

Question 30

What classification would you suspect if the patient reports the following:
Dizziness when getting out of bed, rolling over, bending over or looking up
Imbalance when looking up or bending forward
Dizziness when drivign due to head movement

Answer 30

Head position provoked dizziness

Question 31

Head position provoked dizziness: testing procedure and response

Answer 31

Dix-Hallpike

Abnormal response: reported change in level of dizziness related to head position changes and nystagmus

Question 32

Head position provoked dizziness: intervention

Answer 32

If nystagmus is present, perform repositioning procedures (horizontal nystagmus=horizontal roll; torsional nystagmus=repositioning procedure)
If there is dizziness without nystagmus, perform head position exercise to adapt system to provoking head position

Question 33

What classification would you suspect if the patient reported the following: modification of activity level, especially driving or recreational activity for fear that an episode would cause issues of safety or extreme discomfort

Answer 33

Episodic sensation of vertigo not induced by movement of head

Diziness not related to activity and symptoms come on without warning
Dizziness is prolonged and does not resolve with PT intervention

This needs to be further evaluated by an appropriate medical practitioner