Vestibular PT Exam Flashcards
What are the components of the PT exam for vestibular disorders?
History
Neuro screen vs exam
Oculomotor screen vs eval
Balance assessment
Positional assessment
Risk identification
What is the dizziness handicap inventory?
A 25 item self reported questionnaire of the life impact and perceived handicap from dizziness that includes three domains (functional, emotional, physical)
What does a score of 0-15 on the dizziness handicap inventory indicate?
No perceived handicap
What does a score of 16-34 on the dizziness handicap inventory indicate?
Mild handicap
What does a score of 35-52 on the dizziness handicap inventory indicate?
Moderate handicap
What does a score of 53-100 on the dizziness handicap inventory indicate?
Severe handicap
With a central problem, their HIT is typically ____ and resting nystagmus is usually _____
Negative, present
With a peripheral issue, HIT is typically _____ with ______ ______
Positive, saccadic intrusions
What is involved in the oculomotor exam?
Observation of normal ocular alignment
Testing for normal eye movt fxn
Testing central vision fxns and reflexes
Testing peripheral VOR fxn and dynamic vision
Testing of otolithic fxn
Differentiation of acute vertigo (rule out CVA)
What test can we use to observe for ocular alignment?
The cover/uncover test
What does the cover/uncover test show us?
Skew eye deviation
Phoria/tropia
Ocular tilt reflex (OTR)
What is phoria?
Resting eye position
What are we looking at with the cover uncover test?
We are looking at what happens to the covered eye when it’s uncovered and what the uncovered eye does when the other eye is covered
What skew direction with the cover uncover test indicates a central issue?
Vertical skew deviation
What a a typical sequence for the cover uncover test?
Cover one eye and look at the uncovered eye
Uncovered the eye and look at the uncovered eye
Cover the eye again and look at the covered eye
Uncover the eye again and look at the covered eye
Do on both sides
What are the triad of signs for the OTR (optic tilt reflex)?
Lateral head tilt
Skew deviation of the eyes
Ocular rotation
What is the interpretation of the cover uncover test?
It could be a central lesion affecting the vestibular nuclei
Or it could be an acute peripheral lesion affecting the otoliths
How do we perform the test for spontaneous nystagmus?
Holding the pts head with one hand, have the pt look straight ahead while you observe for nystagmus at rest
What is a normal result for the spontaneous nystagmus test?
No nystagmus
What is an abnormal result for the spontaneous nystagmus test?
Spontaneous nystagmus present
T/f: spontaneous nystagmus is NEVER normal
True
With a _____ vestibular issue, nystagmus may worsen going from fixation present to fixation removed, but with a _____ vestibular issue, nystagmus may not change with spontaneous nystagmus
Peripheral, central
If vertical/direction changing/different nystagmus in each eye is present with the spontaneous nystagmus test, would this indicate a peripheral or central issue?
Central
If there is no fast/slow phase with nystagmus with the spontaneous nystagmus test, would this indicate a peripheral or central issue?
Central
What tests can we use for testing normal eye muscle function and central vision functions and reflexes?
Smooth pursuits and end gaze nystagmus tests
How do we perform the smooth pursuits and end gaze nystagmus tests?
Hold the pts head stationary and ask the pt to follow a slowly moving (20deg/sec) object (your finger) about 18-24 inches from their face as you slowly make an H pattern (with added diagonals for checking all ocular muscles)
Pause at the end of each end gaze point
Note the quality and smoothness of eye movts, presence of nystagmus, symptom reproduction
What is a normal smooth pursuits and end gaze nystagmus test?
Smooth pursuit w/o saccadic intrusions
No nystagmus at end range points
No symptoms or symptom reproduction
Abnormal smooth pursuits are a soft _____ sign, unless it is significant
Central
Do smooth pursuits degrade with age?
Yes
Can smooth pursuits be affected by meds?
Yes
Do we perform spontaneous nystagmus testing in fixation present or removed?
Either
Do we perform smooth pursuits in fixation present or removed?
Fixation present
Do we perform end gaze nystagmus testing in fixation present or removed?
Either
Abnormal findings in the smooth pursuits and end gaze nystagmus testing indicate what structures are involved?
The cerebellum, cerebellar pathways
T/f: with abnormal results from smooth pursuits and end gaze nystagmus testing, we should report or refer to neuro ophthalmology
True
What is a central end gaze nystagmus?
Direction changing or pure vertical nystagmus
What is peripheral end gaze nystagmus?
Nystagmus that follows Alexander’s Law
What is Alexander’s law?
in individuals with nystagmus, the amplitude of the nystagmus increases when the eye moves in the direction of the fast phase or more neurally active side
What is first degree nystagmus? (These may be wrong so double check)
Nystagmus without direction changing with gaze change
What is second degree nystagmus? (These may be wrong so double check)
Nystagmus not present with the hypoactive direction
What is third degree nystagmus? (these may be wrong, so double check)
Nystagmus only present in the neurally active direction
What is peripheral nystagmus?
Nystagmus that can be decreased with gaze fixation
Nystagmus that follows Alexander’s law
What is central nystagmus?
Pure up and down beating
Direction changing nystagmus with changing eye position in the orbit
Different nystagmus in each eye
Changing intensity of nystagmus
How do we test near point convergence (NPC)?
With the target placed at 18in from the pts eyes, slowly move towards the pt (1-2cm/s) and instruct the pt to try to keep the target single
ID the point at which the target image becomes double and measure it
What is normal NPC?
3-4 inches (<10cm)
No diploplia
How do we test for jump convergence?
Place one finger at the near point (3-4in) and one at far point (18in) and observe the eyes as the pt shifts eyes from far to near to far to near target
What is normal jump convergence?
Smooth, accurate, and asymptomatic
Abnormal convergence is documented as _____ ______
Convergence insufficiency
How do we test for saccades?
Hold the pts head stationary and hold one finger about 15deg to one side of your nose
Instruct the pt to look at your nose then your finger and repeat
Do L/R and up/down
What are normal test results for saccades?
No over/undershooting
Smooth and effective eye movt from target to target
Abnormal saccades testing can be indicative of what?
Central BS involvement that requires a referral
Horizontal saccades indicates that structures?
Pons-PPRF
Vertical saccades indicates what structures?
Midbrain-MLF
Do we do convergence-divergence testing in fixation present or removed?
Fixation present
T/f: convergence-divergence is only (+) with central dysfunction
True
Do we perform saccades tests in fixation present or removed?
Fixation present
What is the position for standard VOR testing?
Can tilt head forward about 30deg
Do we test VOR in fixation present or removed?
Either
What tests can we use for VOR testing?
Head thrust, HIT, or Hamalgi head thrust test
How do we prep for HIT?
Clear the cervical spine
Inform the lt that you will be quickly moving their head a small distance
Instruct the to to keep their eyes focused on your nose
If we thrust a pts head to their intact side, with the HIT, will their eyes stay on the target?
Yes
If we thrust a pts head to their involved side, with the HIT, will their eyes stay on the target?
Nope, their eyes will slip and then jump back tot the target
How do we perform the HIT?
Grasp the pts head firmly with both hands on the sides of their head with or without head tilt
Move the pts head slowly back and forth being sure the pt is relaxed then suddenly move the pts head from out to in and stop OR hold their head still in the center and quickly thrust it from in to out then stop
What is a normal HIT or head thrust?
The eyes stay focused on the nose without slipping off
What is an abnormal HIT or head thrust?
The eyes slip off their focus of the nose and you see a catch up saccades as they bring their eyes back to focus on your nose
T/f: the side the head is being thrust towards with the HIT is the side with the weak VOR
True
Do we test HIT with fixation present or removed?
Fixation present
A positive HIT indicates a _____ disorder
Peripheral
A negative HIT indicates a _____ disorder
Central
Do we test VOR cancellation in fixation present or removed?
Fixation present
How do we perform the VOR cancellation test?
Grasp the pts head firmly with both hands on the sides of their head with or without tilt and instruct the pt to keep their eyes on your nose as you slowly move their head from side to side as you move your nose in the same direction and speed
What is a normal VOR cancellation test?
The eyes are able to state on your nose or their thumbs
What is an abnormal VOR cancellation test?
Inability to follow the target
The VOR reflex must be _____ suppressed or canceled normally
Centrally
Is head shake nystagmus done in fixation removed or present?
Either
How do we do the head shake nystagmus test?
Grasp the pts head firmly with both hands on either side of their head and have the pt close their eyes while you quickly move their head side to side 20x then have them quickly open their eyes and observe for nystagmus
What is a normal head shake nystagmus test?
No nystagmus upon stopping
What is an abnormal finding with the head shake nystagmus test?
Presence of nystagmus (more than 3 beats)
What does a positive head shake nystagmus test indicate?
Peripheral unilateral vestibular deficit
Down beating nystagmus with the head shake nystagmus test is highly suggestive of a ____ disorder
Central
What is the HINTS exam?
Differential of acute vertigo (acute vestibular syndrome) vs a stroke (infarct)
Test used to differentiate the cause of continuous vertiginous symptoms (continuous spinning)
Where is the HINTS exam commonly used?
In the ED
What exam can we use that is more accurate than an MRI for dx of a stroke?
HINTS exam
What are the tests in the HINTS exam?
Head impulse
Nystagmus
Test of skew (cover uncover)
What is a positive HINTS exam?
“Infarct”
Impulse Normal
Fast-phase Alternating (direction changing nystagmus)
Refixation of cover test (vertical refixation)
What is the subjective visual vertical test for?
To determine awareness of upright with suspected central involvement
How do we perform the SVV test?
The pt is asked to orient a rod to gravity (to vertical) when in total darkness (without any visual reference to vertical)
What does the degree of off axis in the SVV test tell us?
It represents the torsion of the eye
What is the optokinetic reflex (OPK)?
The reflex that adjusts the eye position during slow head movt or tracking large objects
Fxn of the unconscious, slower visual system that is mediated through the pretectal area—>medial vestibular nuclei—>oculomotor nuclei
How do we test the OPK reflex?
Using light/dark moving stripes, the eye will naturally track a single stripe to the edge of the visual field
Is the OPK reflex tested vertically or horizontally?
Both
What is a normal OPK reflex test?
OPK induced (physiologic) nystagmus
What are abnormal findings in the OPK reflex test?
No nystagmus observed
Asymmetric finding
What does no nystagmus with OPK reflex testing indicate?
A central problem or BS oculomotor issue
What does asymmetric findings in the OPK reflex test indicate?
Vestibular disorder
What is normal OPK?
Eye reaches the edge of the orbit and follows the next object or stripe
How do we test pressure induced nystagmus?
Observe for nystagmus/drift when you occlude the external auditory canal, performing Valsalva, or blowing air out of closed nostrils as they bear down
What does pressure induced nystagmus indicate?
A fistula or superior canal dehiscence (SCD)
How do we test for hyperventilation induced nystagmus?
Observe for nystagmus as the or hyperventilates for 60sec (one breathe per sec)
What does hyperventilation induced nystagmus indicate?
Possible psych overlay
Demyleination problem
What question are we trying to answer with the dynamic visual acuity test (DVA)?
What is the extend of acuity lost during active head movt?
In a normal individual under 65 yo, how many lines should be lost bw static and dynamic visual acuity?
<2
What test can tell us the laterality of nystagmus with the DVA?
HIT
How do we prep the DVA test?
Clear the cervical spine
Position the pt 20 feet from the chart
How do we perform the DVA?
Determine their static visual acuity by asking the pt to read the lowest line that they can until they can’t correctly ID any of the letters given line and record the Snellen ratio or LogMar
Determine their DVA by standing behind the pt and grasping their head firmly with both hands on the side of their head and move their head side to side at a frequency of 2cycles per sec
Have them read the lowest line that they can until they can’t correctly ID all the letters on a given line
Subtract the two scores to get the difference
What is a normal result of the DVA?
A difference of 1-2 lines bw SVA and DVA
What does 3-5 lines lost on the DVA indicative of?
UVH
What does 5+ lines lost on the DVA indicative of?
BVL
How many deg/sec do we need for walking?
60-70 deg/sec
How many deg/sec do we need for all fxning?
120deg/sec
How many deg/sec do we need for sports?
200deg/sec
What are the slow movt tests?
Smooth pursuits
Saccades
OPK
What are the fast movt tests?
Head thrust
Head shake
DVA
Where are the slow movts mediated?
Centrally
Where are the fast movts mediated?
Peripherally
Can the slower visual systems compensate for faster systems lost?
Yes, to some extent
Who is appropriate for oculomotor testing?
When the hypothesis we have is that the vestibular system is involved
What is the basic oculomotor test battery for all patients?
SpN, SP, EgN, Sacc, vergence, HT, VORc, HSN
What oculomotor tests should we use when impairments are identified in the VOR testing and or when the pt complains of visual blurring, slipping, etc?
DVA
What test should we use when otolith involvement is suspected or head tilt/SCM asymmetry is noted?
SVV
What tests should we do when central dysfunction is suspected?
OPK
Cover/uncover
