Vestibular Practical Flashcards
Screen your patient (as appropriate) before running through the BPPV Test Sequence.
Ruling Out Contras: Ask about history of neck surgery / recent neck trauma / severe RA / OA or AA instability / cervical myelopathy or radiculopathy / carotid sinus syncope / chiari malformation / vascular dissection syndrome (in the head, neck)
In Sitting: Cervical AROM (ask about 5 Ds and 3 Ns as they perform this) - if no symptoms have patient ACTIVELY rotate head to one side and extend neck before counting back from 10 out loud - ask about 5 Ds and 3 Ns during this procedure as well and have them repeat on the other side if negative
Cervical Ligament + VBI Testing: If no symptoms in previous sequence, check Alar Ligament (Supine) / Transverse Ligament (sitting) / and screen for VBAI (Pt’s hands at pt’s temples and have patient fully rotate body to 1 side - count backwards from 10 and observe / ask about 5 Ds and 3 Ns - both sides)
5 Ds and 3 Ns
Dizziness / Diplopia / Dysarthria / Dysphagia / Drop Attacks
Nausea / Nystagmus / Numbness, Tingling (facial)
In BPPV testing, which side should you test first?
Less affected / suspected side
In BPPV testing, what should you do if a patient has a history of severe n/v?
Perform test slowly and have trashcan handy
What characteristics of a patient’s symptoms would make you think Canalithiasis (free floating debris)?
Latent onset of Vertigo / Nystagmus
Symptoms gradually intensify then subside (episodic) - symptoms subside when endolymph stops moving
Lasts for a few seconds to less than 1 minute
What characteristics of a patient’s symptoms would make you think Cupulolithiasis (adherent to Cupula)?
Immediate onset of Vertigo / Nystagmus
Symptom intensity remains constant (Posterior Canal) as long as that canal is provoked OR varies (Horizontal Canal) depending on side of movement
Lasts as long as head is held in provoking position
Provide a general breakdown of BPPV Test Sequence.
1: Dix-Hallpike Test - Less suspected side first / (if no vertigo or nystagmus) slowly bring pt up to sitting and perform the test on suspected side / if (+) determine Canal vs. Cup and go into PSCC treatment
IF DHT (-)
IF ROLL TEST (-)
Appearance of Nystagmus in Diagnosis Related to Posterior Canal Issue
Up-beating and rotary nystagmus towards undermost or down ear in DHT position
R: Upbeat, R torsional
L: Upbeat, L torsional
Appearance of Nystagmus in Diagnosis Related to Anterior Canal Issue
Down-beating and rotary nystagmus
R: Downbeat, R torsional
L: Downbeat, L torsional
Perform the Dix-Hallpike Test.
PUT FRENZELS ON / pt starts in long sitting position with head turned 45 degrees to less affected side / rapidly bring pt into supine with head hanging ~30 degrees into extension / hold for 1 minute OR until dizziness subsides + 30 seconds
Perform on affected side if first test is (-)
Observe for nystagmus / vertigo and determine Canal vs. Cup
(+) PSC Test = Up beating / rotary nystagmus towards undermost ear
(+) ASC Test = Down beating / rotary nystagmus
Perform the Roll Test.
KEEP FRENZELS ON / From DHT position, have pt slide down on the mat til head is supported on the mat / flex neck to 30 degrees (puts HC in neutral) and support in that position / quickly turn head 90 degrees to less affected side first and hold position for 1 minute / roll head slowly back to midline and quickly roll it to other side (same procedure)
(+) Test: Bilateral Symptoms
Geotropic Nystagmus = Beating towards ground / earth (Canal - side involved has worse nystagmus)
Apogeotropic Nystagmus = Beating away from ground (Cup - side involved has less nystagmus)
Perform the Side-Lying Test (PSC / ASC BPV).
KEEP FRENZELS ON / pt assisted to sitting at edge of plinth from Roll Test position / turn head 45 degrees to less suspected side / have pt QUICKLY lay down in side-lying position on suspected side (maintain 45 degree rotation in SL and when sitting position up initially) / test repeated to other side
(+) Test = Upbeat and rotary nystagmus towards down ear (BPV of downside PSC) / downbeat and rotary nystagmus (BPV of downside ASC)
Why would we perform the Side-Lying Test (PSC / ASC BPV)?
Alternative for pts that cannot tolerate DHT due to postural restrictions / medical precautions / pain, discomfort / (+) screen for VBI or cervical ligament instability
OR
DHT / Roll Test is negative but patient is still symptomatic
What red flags should you advise your patient to be aware of as they are performing their HEP?
If the pt experiences any of the following: sudden loss of hearing or fluctuations in hearing / increased pressure or fullness / discharge of fluid from the ear / severe ringing in the ear
STOP exercise immediately and contact PCP
If both BPPV and Non-BPPV findings are present, what should you treat first?
BPPV
What is a key distinction between treating Canalithiasis vs. Cupulolithiasis?
Repositioning maneuvers are done slowly for Canal / fast for Cup
What is the Canalith Repositioning Maneuver (CRM) used to treat?
Canalithiasis PSC
Take the pt through this treatment immediately if vertigo / nystagmus elicited during DHT or Side-Lying Test
Perform the CRM for Canalithiasis PSC.
KEEP FRENZELS ON
Remain in DHT position on affected side until symptoms cease + 30 seconds / slowly rotate patient’s head (maintaining neck extension) to opposite DHT position / remain in this position until symptoms cease + 30 seconds (30 seconds only if no symptoms) / have pt roll into SL on unaffected slide while maintaining 45 degree rotation (no extension) / tuck pt chin so nose pointed to the mat (“dump” position) / remain here until symptoms cease + 30 seconds (30 seconds only if no symptoms) / maintain 45 degree rotation as pt slowly sits up and remain in sitting position until symptoms cease + 30 seconds (30 seconds only if no symptoms) / return head slowly to neutral
If a patient ultimately presents with Canalithiasis in the PSC, what HEP could you provide them with?
Self-CRM (Home Epley Maneuver)
Demonstrate this to the patient first!
Sit in bed with pillows behind middle of back / turn head towards affected side / lay down with head turned towards affected side and ensure extension of the head (over the pillows) / turn head slowly towards unaffected side / turn body towards unaffected side and tuck chin + point your nose into the bed / return slowly to sitting
Stay in each position for 30 seconds or until symptoms subside + 30 seconds
Perform 1 rep every morning (starting day after treatment) until there are no symptoms 3 days in a row - record symptom intensity / duration AND schedule F/U visit in 1 week
What is the Semont (Liberatory) Maneuver used to treat?
Cupulolithiasis PSC
Perform the Semont (Liberatory) Maneuver.
Pt sits at edge of plinth with head turned 45 degrees toward unaffected side / pt quickly moved to SL on affected side while maintaining 45 degree rotation (looking up) / hold for 1 minute / quickly move in upward arc through sitting to opposite SL position while maintaining 45 degree rotation and facilitating 30 degrees of flexion (“dump” position) - nystagmus and vertigo should appear (if not, shake head 1-2x to free debris) / hold for 1 minute / slowly move pt to original sitting position while maintaining 30 degree flexion / wait 1 minute / return head to neutral / wait 1 minute
Repeat 2-5x in one session (2 on practical, symptoms should lessen in intensity with reps)
What is the Reverse Semont (Liberatory) Maneuver used to treat?
ASC Canlithiasis or Cupulolithiasis
Perform the Reverse Semont (Liberatory) Maneuver.
Pt sits at edge of plinth with head turned 45 degrees toward affected ASC side / pt moved quickly onto affected side while keeping nose down on mat / hold this position for 1 minute / pt then quickly moves in upward arc to opposite SL while maintaining 45 degree rotation so pt is now looking up (“dump” position) - nystagmus and vertigo should appear (if not, shake head 1-2x to free debris) / hold this position for 1 minute / pt slowly moves to sitting position (keeping head turned 45 degrees towards affected side / hold here for 1 minute / return to neutral / wait 1 minute
Repeat 2-5x in one session (2 on practical, symptoms should lessen in intensity with reps)
What HEP should you prescribe for PSC and ASC Cupulolithiasis?
Provide pt with Semont (Liberatory) or Reverse Semont Maneuvers as HEP - perform 3-5 reps daily until they are vertigo free for 3 consecutive days
Have pt record their symptom intensity and duration each day
Symptoms should lessen / resolve as debris continues to dislodge from cupula
Canal conversion to PSC Canalithiasis may occur - if this happens treat with CRM / Self-CRM
What treatment should you utilize if a patient presents with HSC Canalithiasis?
BBQ / Log Roll (Lempert Maneuver)
Pt begins in supine with head flexed 30 degrees and rotated 90 degrees toward affected ear / remain here for 30 seconds or until symptoms cease + 30 seconds / slowly roll pt’s head 90 degrees toward unaffected side (maintaining flexion) / hold here for 30 seconds or until symptoms cease + 30 seconds / slowly roll head AND body towards unaffected side while maintaining 30 degrees of flexion / pt slowly rolls onto stomach until face is down (30 degrees of flexion / “dump” position) / hold here for 30 seconds or until symptoms cease + 30 seconds / slowly roll pt’s head 90 degrees toward affected side (while maintaining 30 degrees neck flexion) / have pt slowly roll head and body in direction of affected side while maintaining 30 degrees of neck flexion (“dump” position) / pt slowly sits up (keeping head flexed to 30 degrees) / hold here for 30 seconds or until symptoms cease + 30 seconds / return slowly to neutral / hold here for 30 seconds or until symptoms cease + 30 seconds
What treatment should you utilize if a patient presents with HSC Cupulolithiasis?
Casani (Gufoni)
Start with pt sitting EOM with head neutral (supported by examiner) / ask pt to quickly lie down on affected side while maintaining neutral head position / hold here for 2 minutes or until nystagmus and vertigo have stopped or decreased / quickly rotate pt’s head 45 degrees away from affected side and hold for 2 minutes / slowly return to sitting with head in 45 degrees of rotation / wait 2 minutes / slowly bring head to neutral
Repeat 2-5 times as needed (2 reps on practical)
What HEP should you prescribe for HSC Canalithiasis?
Forced Prolonged Positioning (FPP)
Lay on affected ear for 1 minute / lay on your back for 1 minute / quickly roll so that you are laying on your unaffected ear and sleep in this position for the night (provide support behind you to maintain this position)
Finish self-BBQ roll in the morning
Perform this HEP once every night until vertigo free for three days in a row
Have pt record symptom intensity / duration
F/U with clinician in 1 week
What HEP should you prescribe for HSC Cupulolithiasis?
Perform Self-Casani (Gufoni to affected side)
Perform 3-5 reps daily until vertigo free 3 days in a row
Symptoms should lessen / resolve as debris continues to dislodge from cupula
Have pt record symptom intensity / duration
F/U with clinician in 1 week
Perform Gaze Evoked Nystagmus (GEN) assessment.
Instruct pt to keep head still / have them follow a target (pen or “X”) held at eye level 12-18” away / move the target to the L, R, then center with fixation first (room light) / then have them follow the object without fixation (FRENZELS)
Observe their nystagmus at each point
(+) Peripheral Vestibular Sign (Non-BPPV): Intensity of nystagmus increases when gazing in direction of fast phase (fatigable)
GEN (Central NS Origin)
Seen with fixation (in room light) due to acute or chronic (> 3 mo) lesion of CNS
Direction changing / bi-directional (R beat with R gaze, L beat with L gaze)
Pure vertical / torsional / rebound
More intense with fixation present and little to no change when fixation removed (Frenzels)
NOT FATIGABLE
GEN (Peripheral NS Origin)
Nystagmus increases in intensity as patient gazes further in the direction of the fast component of the nystagmus (INTACT EAR, lesion is on the opposite side)
Nystagmus increases when fixation is removed (Frenzels)
FATIGABLE
Nystagmus is direction fixed (R beating with R gaze / center gaze / L gaze)
GEN: Degrees of Nystagmus in Peripheral Vestibular Lesions (Non-BPPV)
3rd Degree (Acute): Nystagmus present in all directions / most intense when gaze is directed towards healthy ear - could be seen with room light but would intensify with Frenzels
2nd Degree: Nystagmus present with gaze center and away from side of lesion (towards healthy ear - increases when looking in this direction)
1st Degree (Chronic): Nystagmus ONLY present with gaze away from side of lesion (towards healthy ear)
Perform Vergence Assessment.
Slowly bring target towards patient’s nose / ask pt to keep eyes on the target and inform you at what point they get diplopia
Normal: Target at least 6 cm from nose before patient sees double
Abnormal: Diplopia (central) before target is 6 cm from nose
Aversion reaction (jerking away) is also possible (Sympathetic NS)
Perform the Smooth Pursuit eye movement assessment.
With head still, ask pt to follow a target 12-18” in front of them at eye level / move target slowly 30 degrees in each direction (horizontal - within ears / vertical - top of head, bottom of chin / diagonal) for several reps / ask pt to make you aware if they are experiencing any symptoms
Observe smoothness of movement
Abnormal: Saccadic intrusions (central signs)
Perform the Saccades eye movement assessment.
With head held still, ask pt to quickly look back and forth between your nose (center target) and “X” held to R or L of center - target at eye level 12-18” in front / repeat up, down, diagonally
“Quickly look from my nose to the ‘X’ as I tell you and let me know if this causes any symptoms.”
Observe accuracy and quickness of movement
Abnormal: Overshooting / undershooting / slow scan instead of quick jump (central signs)
Administer the Head Shake Nystagmus Test (HSNT).
Stimulates Horizontal Canal VOR
Place FRENZELS on patient / ask pt to close their eyes / pitch patient’s head down 30 degrees and passively shake their head side to head at 2 Hz for 20 seconds / have pt open their eyes and look straight ahead (center gaze - observe Nystagmus) / if nystagmus is present, have them look to the R and L to determine degree (also inquire about symptoms at each point of gaze)
Abnormal: Peripheral vestibular imbalance with direction-fixed (3+ beat) nystagmus beating towards intact ear
Perform the Head Impulse / Head Thrust Test (HIT or HTT).
Sit in front of patient at eye level (12-18 inches away) / pitch their head down 30 degrees / ask pt to fixate on your nose while you passively and slowly move pt’s head side to side (each direction, several times) / then quickly and unexpectedly thrust pt’s head to one side and stop - observe if eyes remain on your nose or jump to one side and return (abnormal) / repeat 3x to each side in random order
Remind pt to make you aware of any symptoms along the way
Abnormal: Pt’s eyes jumping to side of the thrust before re-fixating on your nose (Corrective or Re-Fixation Saccade) - this indicates vestibular hypofunction to the side of the head thrust
Symptoms evoked when head thrusted to both sides indicator of Bilateral Vestibular Hypofunction
Perform the Dynamic Visual Acuity (DVA) Test.
Ensure pt is in supported sitting / ask patient to flex head 30 degrees / place eye chart appropriate distance from patient at eye level / test static visual acuity first (have them read lowest line possible) / while maintaining flexion passively move pt’s head side to side at 2 Hz velocity - then ask them to read lowest line with head moving
Abnormal: Unilateral Vestibular Hypofunction = > or = 3-line difference or (+) dizziness / Bilateral Vestibular Hypofunction = > or = 3-line difference, (-) dizziness, (+) oscillopsia, (+) postural instability
Administer VOR x1.
Active head movement at 2 Hz with target “X” stable
Ask pt to actively move head side to side at 2 Hz velocity while keeping their eyes on the “X” in the center (12-18 inches away at eye level) / keep going until and when “X” blurs
Abnormal: Target getting blurry or jumping and / or (+) dizziness or unable to move their head at 2 Hz
Document speed at which target becomes blurry (their baseline)
If unable to do at 2 Hz, determine speed they can do this task (baseline)
Administer VOR x2.
Pt keeps their head on “X” at all times / PT moves “X” to the R and patient is asked to move their head to the L while keeping their eyes on the “X” and vice versa
Goal is to do this active movement as fast as they can - if unable to do it quickly, find speed where they are able to do it (baseline)
Remind pt to make you aware if the “X” becomes blurry or if symptoms come on / get worse
Abnormal: Target becomes blurry or is jumping and / or (+) dizziness
Administer the VOR Cancellation (VORc).
Patient seated in rotary chair, stool or standing / have their arms extended in front of them while they focus on their grasped thumbs held at eye level / pitch head down 30 degrees and passively move their head and body side to side at 50 bpm / can also be done actively
10 reps (1 movement side to side = 1 rep_
Abnormal: Saccadic intrusions or (+) dizziness or (+) imbalance
DO NOT DO THIS ON ASSESSMENT PORTION OF PRACTICAL, INTERVENTION ONLY!
How can the VORc be used as an intervention?
Start on mat / stationary chair then progress to rolling, rotary chair or stool
Only do this if appropriate for your practical case / patient is deemed safe
Non-BPPV Testing Sequence
Oculomotor:
Gaze Evoked Nystagmus (GEN)
Vergence
Smooth Pursuit
Saccades
VORc
VOR:
Head-Shaking Nystagmus Test (HSNT)
Head Thrust Test (HTT)
Dynamic Visual Acuity (DVA)
VOR1
VOR2
VORc
Adaptation
Recover mechanism for VOR
Allows for system to make long-term changes in how it responds to input by utilizing remaining capabilities
Can be induced with periods of stimulation as short as 1-2 minutes at a time (pt will experience symptoms but must attempt to continue exercises for 1 full minute w/o stopping as long as target remains in focus)
Decrease velocity if target becomes blurred - progress to full velocity (2 Hz) and then increase duration to 1 minute / 2 minutes
Substitution
Increasing utilization of other strategies to replace lost vestibular function
Useful after Bilateral VOR loss
Adaptation exercises are indicated to treat what type of Non-BPPV diagnosis?
Unilateral Peripheral Vestibular Hypofunction (PVH / L)
Oscillopsia is an indicator of which Non-BPPV Diagnosis?
Bilateral Vestibular Hypofunction
