Vestibular Rehab Flashcards
Dizziness is a vague term, and can be roughly separated into four
basic categories:
- True Vertigo
- Imbalance
- Lightheadedness, giddiness, queasiness, sea-sickness or nausea (a person’s reaction to vertigo or imbalance)
- Faintness (or weakness)
“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 reactions to vertigo or imbalance. They are sometimes referred to as vegetative symptoms.
4 basic causes of dizzines:
- Otologic (from ear)
- Neurologic (from brain)
- general medical
- psychiatric/undiagnosed (“these dizzi patients are nuts!”
Most common type of otologic dizzines:
Bening Positional Vertigo (49%)
(“the most common is the easiest to treat)
Most common type of neurological dizzines:
Stroke and TIA (35%)
followed by vertebrobasilar migraine (woman who had migraine on the red carpet)
most common type of medical dizziness:
Orthostatic Hypotension (23-43%)
Orthostatic hypotension test:
- Blood pressure screening
- two different positions
- 20 point drop in systolic agnostic for orthostatic hypotension
- PTs don’t treat this, referral to Dr.
“hyperventilation syndrome”, “post-traumatic vertigo,” and “nonspecific” dizziness. About 25% of dizziness or vertigo falls into this category. There is a high correlation with
____________ and dizziness
anxiety disorders
Pt turning head in bed, get few seconds of acute spinning, then it goes away, (+) nystagmus:
Bening Positional Vertigo
patient with permanent dizzines and Gait ataxia, oscillopsia. (–) nystgamus:
Bilateral Vestibular Disorder
Acute onset, motion sensitivity, vomiting that last 48-72 hours, (+) nystagmus:
Vestibular Neuritis (ear infection)
1-24 hours (acute) Fullness of ear, hearing loss, tinnitus, vomiting. (+) nystagmus. Pt wakes up in the morning, an have to crawl to the bed (can’t go to work)
Ménière’s Disease
What are the key points to examine (to know) in vestibular patients?
Is it coming from the brain or from ear?
Is it one side or both?
Most important questions in subjective examination of the vestibular pt:
- Duration
- Frequency
- Precipitating factors
- Medications (drowsiness…)
Oscillopsia
decreased gaze stability
issues with balance in the dark happens to people who rely on vision for balance
older patients
this is why the majority of balance exercise should be done with eyes closed
as I walk towards a subject, I am not able to stabilize gaze and it becomes blurry (oscillopsia)
Bilateral Vestibular Hypofunction
classic vestibular bilateral symptom?
oscillopsia
classic unilateral vestibular symptom
motion sensitivity
vertigo with strain ex. a pt blow their nose or strain in the toilet, they get vertigo
fistula
problems with coordination (ex ataxia)
central involvement patients
Incontinence / memory loss
normal pressure hydrocephalus
Types of Nystagmus:
- Spontaneous (24 hours after the insult)
- Gaze evoked (“hard to see o left”)
- Direction changing or follows Alexander’s Law
Vertical NYSTAGMUS
CENTRAL Finding until proved otherwise
Direction changing nystagmus; Look to the right, right beating nystagmus – look to the left, left beating:
This is a CENTRAL SIGN
Saccades:
Look from target to target
- Significant Overshooting is a Central Sign
- Multiple movements is a Central Sign
- Undershoot is considered normal
Patient follows your finger as you move it through the pattern:
SMOOTH PURSUITS
Look from target to target (“follow my finger”)
SACCADES
Ask patient to focus on your nose, slowly move head side to side, observing for visual fixation
What is the name of this test? What does it test?
VOR, HEAD THRUST
- Left - Right discrimination test
- Decrease in fixation with forced LEFT ROTATION = LEFT DYSFUNCTION, + L Head Thrust test
Left to Right discrimination tests:
- head thrust
- Singleton’s test
VOR stand for
Vestibuloocular Reflex
VOR cancellation test
sign of cerebellar pathology.
The cerebellum cancels VOR when we walk
DYNAMIC VISUAL ACUITY (DVA) test
Bilateral Vestibular Hypofunction
DYNAMIC VISUAL ACUITY (DVA)
for Bilateral Vestibular Hypofunction
- Patient reads Snellen chart – assess score
- Gently turn patient’s head as they try to read at 1 cycle/sec
- Positive test is 3 or more line difference
VOR head thrust test
Classic symptoms unilateral vestibular hypofunction
L and R discrimination test
What is the key thing to understand when assessing balance on a patient?
what system are they relying on
(vestibular, somatosensory, or visual)
Static Balance test
- Romberg EO/EC/Foam
- Sharpened Romberg EO/EC/Foam
- Single Leg Stance
RESULTS WILL VARY WITH PATIENT’S ABILITY TO VISUALLY FIXATE (Grand Canyon)
Dynamic Balance tests:
- Gait with Head Rotation
- Gait with absent Vision
- Decreased Base of Support
- Singleton’s Test (patient may loose balance when turning to affected side)
- Gait Velocity (normal is approximately 3’ per second)
- Standardized Assessments: Dynamic Gait Index, Berg, Timed Up and Go
SINGLETON’S TEST
- Patient walks to therapist at normal speed
- When “at” therapist, patient turns to one side, and assumes the Romberg position with Eyes
closed - Assess this 2x, 1x turning to right , 1x turning to left
- If patient looses balance when turning to right , but not to left, is suggestive of right vestibular
hypofunction
• ROM • Strength • Sensation • Reflex • Spasticity • Coordination • Positionals
Which one of these are central findings?
Spasticity and coordination
Which finding suggest a Central Lesion?
- Vertical gaze nystagmus
- Saccades
- VOR Cancellation
- Coordination deficits
- Spasticity
all
- Initial episode can be with rolling for the snooze alarm or retrieving object from shelf.
- complaints of vertigo (room spinning) with static positioning
- Pt usually knows which positions are involved and avoids them!
- Symptoms usually abate quickly with movement out of provoking positions.
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)
Test for BPPV
- HALLPIKE TEST
- Patient starts in long sit, with head rotated 30 degrees towards the side to test. Ask the patient to keep their eyes open as you quickly bring them into a supine position with their head extended 10 degrees.
- Classically pt will experience vertigo when placed in the hallpike position (affected ear 30 degrees below horizontal) and should demonstrate a torsional nystagmus. Vertigo is caused by excitation of the posterior semi-circular canal (which has now become gravity sensitive.) BPPV of anterior or horizontal SSC is rare. Patient may report episodes of vertigo over past months or years.
after the hallpike test fro BPPV, complaints upon return to sitting are also common. Make sure the therapist is supporting the patient from BEHIND for 60 seconds after a positive hallpike.
Rebound Phenomenom
Otoconia dislodge into the semicircular canals (usually posterior) and become free floating in the endolymph of the canal. When the head is moved into provoking positions endolymph is moved by debris which pulls cupula out of position. In the hallpike expect latency and fatigue nystagmus. Almost all cases of BPPV:
CANALITHIASIS
free floating = latency nystagmus
Otoconia become adhered to the cupula (end organ in the ampulla) making it gravity sensitive. Expect immediate nystagmus which may not fatigue.
CUPULOLITHIASIS
(could be a stroke)
which canal is affected in upgoing, rotary nystagmus to the affected ear
Posterior Canal
which canal is affected in horizontal nystagmus?
horizontal canal
which canal is affected in downgoing, rotary nystagmus to the affected ear
Anterior Canal
As most lesions, ____________ are paretic, this means that most __________beats AWAY from the lesion
Nystagmus
- Rhythmic Oscillation of the eye
- Defined by the FAST phase
- Beats to side of HIGHER activity
NYSTAGMUS
which maneuver would work best for immediate horizontal nystagmus (Cupulolithiasis)?
Liberatory maneuver
which maneuver would work best for latency horizontal nystagmus (Canalithiasis)?
BARBEQUE ROLL
After performing a maneuver on a patient many facilities have their patients abide by the following precautions:
a) patient must sit up for 48 hours including sleeping
b) should issue soft cervical collar in office for use over coming week
c) patient must not bring on symptoms for 1 week
d) patient must not lie on affected side for 1 week (most important, not hard to do)
e) no up or down movement of the head for 1 week
Most facilities are NOT using precautions as the need for them has been called into question
BRANDT’S EXERCISES
- This is habituation for the vertigo (dizziness), needs to be performed 3x per day x 5 cycles
Prognosis
excellent, 80% elimination of dizziness each successive maneuver
What test would be positive with a patient with UNILATERAL VESTIBULAR HYPOFUNCTION
- Head thrust
- Singlestons
- Dizziness (motion sensitivity)
- Possitive Fakuda (stepping on place)
