Vestibular Rehab Flashcards
True vertigo
An illusion of movement: either you feel that you’re moving, or that the room is moving
Imbalance
A tendency to fall, especially in darkness
Lightheadedness, Giddiness, Queasiness, Sea-sickness or Nausea
These are a person’s rxns to vertigo or imbalance
Sometimes referred to as vegetative symptoms
Faintness
Weakness
Harder to treat continuum
True vertigo
Imbalance
Lightheadedness, Giddiness, Queasiness, Sea-sickness or Nausea
Faintness
Causes of Dizziness
Otologic
Neurologic
General medical
Psychiatric/undiagnosed
Otologic cause of Dizziness
BPPV
Meneiere’s disease
Unilateral Vestibular paresis
Bilateral Vestibular paresis
Middle Ear Dysfx
Fistula
Causes of Neurological Dizziness
Stroke and TIA
Vertebrobasilar migraine
Nystagmus
Sensory ataxia
Basal ganglia dysfunction
Cerebellar ataxia
Seizure
Miscellaneous disorders
Causes of Medical Dizziness
Cardiovascular - hypotension, cardiac arrhythmia, CAD
Infection
Medication
Hypoglycemia
Correlation btwn anxiety disorders and dizziness
HIGH correlation
BPPV
Nystagmus: +
Duration: Seconds
Specific symptoms: Acute spinning
Precipitating action: Turning in bed
Vestibular Neuritis
Nystagmus: +
Duration: 48-72 hours
Specific symptoms: Acute onset, motion sensitivity, vomiting
Precipitating action: N/A
Meniere’s Disease
Nystagmus: +
Duration: 1-24 hours (Acute)
Specific symptoms: Fullness of ear, hearing loss, tinnitus, vomiting
Precipitating action: N/A
Bilateral Vestibular Disorder
Nystagmus: -
Duration: Permanent
Specific symptoms: Gait ataxia, oscilliopsia
Precipitating action: N/A
Fistula
Nystagmus: +
Duration: Seconds
Specific symptoms: Loud tinnitus
Precipitating action: Head trauma, sneezing, nose blowing
Subjective Exam
Chief complaint Onset Duration Frequency Associated symptoms Provocative positions/situations Remitting positions/situations PMH, FH, SH Medications Diagnostic test results
Oscillopsia
Decreased ability to stabilize gaze
Snellen chart test
Specific Questions
Oscillopsia
Headaches
Positioning symptoms
Motion sensitivity
Issues in dark, busy environments
Exertion induced
Coordination issues
Incontinence/memory loss
Fistula
Hole that can happen from trauma
Peripheral causes of dizziness
Inner ear
Central causes of dizziness
Brain
Tests for coordination
Finger to nose
Toe tapping with noise
Oculomotor Examination
Ocular motility Nystagmus Saccades Smooth pursuit Head thrust VOR Cancellation Dynamic Visual Acuity (DVA) Head Shaking Nystagmus
Vertical Nystagmus
CENTRAL finding until proven otherwise
Direction Changing Nystagmus
CENTRAL sign
Looking left, left beating nystagmus
Looking right, right beating nystagmus
Saccades
Significant overshooting is a central sign
Multiple undershoots is a central sign
***One undershoot is considered normal
Smooth Pursuits
Look for quality of movement
Pt follows your finger as you move it
VOR
Head Thrust
Ask pt to focus on your nose, slowly move head side to side, observing for visual fixation
Discriminates LEFT from RIGHT dysfunction – One of the most effective
Direction of HEAD MOVEMENT = DIRECTION of Dysfunction
Positive sign - If eyes go with head turn then correct back to focus on examiner
VOR Cancellation
Almost always a cerebellar pathology
Signs of Central Involvement
Saccades Coordination deficits Spasticity VOR Cancellation Vertical Gaze Nystagmus
DVA
Suggestive of a bilateral lesion
Reading Snellen chart while head is turning side to side
3 line difference?
Head Shaking Test
Sensitive for concussions
Move head back and forth
Nystagmus often seen in patients with unilateral vestibular lesions
Static Balance
Romberg EO/EC/Foam
Sharpened Romberg EO/EC/Foam
SLS
RESULTS WILL VARY WITH PT’S ABILITY TO VISUALLY FIXATE
Dynamic Balance
Gait with head rotation
Gait with absent vision
Decreased BOS
Singleton’s Test
Gait Velocity
Standardized Assessments
Singleton’s Test
Pt may lose balance when turning to affected side
Pt walks towards examiner, turns around to one side and assumes the Romberg position with eyes closed
Left vs Right
Does NOT distinguish central vs peripheral
Left vs Right
Head thrust
Singleton’s
Motion Sensitivity
16 positions
Crazy long test
Most he’ll do is 4 positions
Just need to answer the question about motion making them dizzy
Types of Central Lesion
Epilepsy
Demyelinating diseases
Tumors
Vascular (including CVA, VBI)
Traumatic
Degenerative changes
Tumor vs Stroke
Onset
All at once - stroke
Insidious onset - tumor
Cerebellum and Inner Ear
Cerebellum throttles input (diminishes input)
Utricle
Bag of rocks
When you tilt your head to the side, it tells your body you’re tilted to the side
Semicircular Canals
Tells brain when we’re moving
Spinning to the R - hair cells will deflect to side sending message to brain that you’re spinning
Utricle and Semicircular Canal
Utricle crystals can get into semicircular canals and send confusing signals to brain
Hallpike test Latency
1 second delay before true vertigo and nystagmus begins
Looking for combination of nystagmus and vertigo
Symptoms DECREASE with repetition of this test
BPPV
Eppley Maneuver
Took crystal that was out of whack and brought it out of the semicircular canal to be reabsorbed into utricle
VBI
Full extension and full rotation
This occludes the Vertebral artery and they can get these symptoms
Hallpike does not engage this amount of extension and full rotation
You can test for VBI in sitting before applying Hallpike maneuver
Rebound Phenomenon
Complaints upon return to sitting are common
Make sure the therapist is supporting the pt from BEHIND for 60 seconds after a positive Hallpike or Eppley maneuver
BPPV Pathogenesis
Posterior semi-circular canal (SSC) becomes gravity sensitive (SSCs normally respond to dynamic changes while otoliths respond to static positioning)
More common in the elderly, and usually idiopathic; with identifiable causes including head trauma, viral labyrinthitis, vestibular neuritis, and perilymph fistula
Canalithiasis
Rocks from utricle are free floating in the inner ear
Cupulolithiasis
Rocks become adhered to the cupula (end organ in the ampulla) making it gravity sensitive
Expect IMMEDIATE nystagmus which may not fatigue
Use the Liberatory maneuver
Treatment of BPPV
Epley - posterior
Liberatory - posterior adherence OR horizontal nystagmus withOUT latency
BBQ Roll - horizontal canal involvement WITH latency
Brandt’s exercises - repeat til symptoms relax
After a maneuver…
Don’t sleep on affected side for 1 week
Estimated tx length
Generally pts respond quickly to a few txs (generally 1x a week) with a decrease in symptoms greater than 75%
Prognosis - excellent, 80% elimination of dizziness each successive maneuver
Spontaneous nystagmus
Nystagmus in all quadrants
Gaze-evoked nystagmus
Nystagmus in specific direction of gaze
Posterior canal
Rotational nystagmus
Anterior canal
Vertical nystagmus
Horizontal canal
Horizontal nystagmus
BPPV what percentage?
50% of otolithic causes of dizziness
Unilateral Vestibular Hypofunction
Mismatch between both ears
So when a pt is spinning, the L is functioning correctly and R is sending poor information
Causes motion sensitivity*** characteristic complaint
Cause - ear infection (development of an UNCOMPENSATED vestibular hypofunction)
Other symptoms - minimally decreased balance (use hard balance tests), slightly ataxic with head rotations during gait
Unilateral Vestibular Hypofunction
Pathogenesis
Neuronitis (no hearing loss)
Labyrinthitis (hearing loss)
Weakness/damage to one vestibular organ
Acoustic neuromas
UVH treatments
VOR exercises
Repeated movements
Balance retraining
UVH Prognosis
Excellent
Pts will get back to all premorbid activities
We can teach them to compensate with full vestibular fx on good side and visual/somatosensory systems
Bilateral Vestibular Hypofunction
Usually happens from ototoxic medications - they damage hair cells of vestibular system (Streptomycin, vancomycin…usually given after open heart surgery)
Pts have problems reading, driving (secondary to Oscillopsia), and difficult with visually stimulating situations
***Oscillopsia primary complaint
PT Eval
BVH
Positive Snellen chart (Oscillopsia test)
Pts with complete or severe vestibular loss may be unable to perform Romberg EC/Foam
LOB with Fukuda’s stepping test
Gait analysis reveals increased BOS (> 2-4 in)
Pathogenesis BVH
Ototoxic drugs
Inner ear autoimmune disease
Paget’s disease
Bilateral tumors
Meningitis
Endolymphatic hydrops
BVH tx
Train other systems
Assistive devices
Strengthening, stretching of LE’s
Use reachers
Gait training to eliminate furniture walking
Modify home to minimize fall risks
Meniere’s disesase
Classic - episodic debilitating vertigo that lasts hours to a day or two, then it’s gone
Days weeks months years normal and then they’ll have another hit
Progressive unilateral hearing loss
Dx test - simple hearing test
Onset btwn 30-50 years
Drop attacks
Tumarkin’s otolithic crisis
Meniere’s disease
Pathogenesis of Meniere’s disease
Malabsorption of fluid
Mechanical problem at the ear
Meniere’s disease tx
During remission, tx aimed at reduction of episodes
Dietetic programs - restricting salt, water, alcohol, and nicotine
Ablation surgery after they have it 3 times a week in frequency
After ablation, considered to have Unilateral Vestibular Hypofunction
Migraine
One of the presentations of dizziness that come back negative
Vestibular migraine aura
Most have dizziness with personal movement, but some had vertigo while still sitting or in supine
Migraine with Aura
Transient neurological symptoms (sensory, motor, or cognitive)
Migraine tx
Reduction of risk factors
Stop smoking
Reduce estrogen supplements
Diet - avoid aged alcohols, red wine, MSG, chocolate, nuts, cheese, Nutrasweet, caffeine
Keep diary to ID causative factors
If several migraines per month, consider prophylactic meds
Meniere’s vs Migraine Aura without headache
Tinnitus in both
Phonophobia and photophobia in migraines
Naps usually help migraines
Motion sickness common in migraines
Perilymphatic fistula
Causation - blowing nose, BM
Report hearing a pop in the past
Symptoms will reside with rest and reoccur with activity
PF tx
Absolute bed rest for 5-10 days with head elevated
Avoidance of straining, sneezing, coughing, or head hanging positions
Use of stool softeners
If symptoms last > 4 weeks or hearing loss worsens consider exploratory tympanotomy with surgical packing of fistula
Cervicogenic dizziness
Altered afferent proprioceptive signals from upper cervical spine
Correlated with whiplash/neck pain
Can see with balance/gait dysfunction
Neck movement usually aggravates symptoms
Cervicogenic dizziness tx
Cervical traction as both diagnostic test and tx
Focus on upper cervical spine
Cervical kinesthesia exercises
VOR x1 Viewing
Finger stationary
Pt moves head and keeps object in focus
10 min rule - no worse for wear 10 min after exercises
VOR x2 Viewing
Moving finger, moving head in opposite directions
Keeping object in focus
10 min rule - no worse for wear 10 min after exercises
Bifocals and VOR
Ask them to do it in ONE area or with glasses off
VOR for visual acuity
If someone wears glasses all the time, they would need to do training with glasses on
Pts that use reading glasses need to train with glasses both on and off
VOR training
Week 1 and 2
Habituation
Choose up to 4 activities that bring on mild to moderate dizziness
Client performs these exercises quickly
As motion sensitivity improves, can substitute more difficult activities
Duration of symptoms more important than intensity of symptoms
Improvement in Habituation indicated by…
Decreased number of provoking positions
Increased number of reps before symptom occurrence
Decreased intensity of symptoms
Shorter duration of symptoms
Cervico-ocular reflex
Parallels VOR, contributes to a slow-component eye rotation in the direction opposite to head movement in place of a deficient vestibular system
Generated by joints in neck
Works at slower speeds than VOR
Imaginary target exercise
Visualize target, turn head, see if you’re still focused on it
Number Board
Tx of gaze evoked nystagmus
Look at different sides of number board
Given during week 3 or 4
Saccades improvement
Central dysfunction
Try to work on decreasing amount of undershoots and avoiding overshoots
Convergence exercises
After stroke
Easier to focus on something distally than closely because of double vision
Antivert
Vestibular inhibitor
Helpful if the system is sending excessive, overwhelming information
ACUTE stage of ear infection, CVA, MS, Meniere’s
Long term use depresses the system we’re trying to retrain in PT
DISCUSS WITH REFERRAL SOURCES
VOR order
Horizontal then Vertical
No vestibular system?
COR exercises
Assistive devices
Compensation
Vestibular Rehab Goals
Differentiate subjective complaints of dizziness
Understand most common types of vestibular causes of dizziness and their presentation
Develop a treatment plan for each dx based on case studies presented
Double vision
Corrects all at once
