Vestibular Rehab

Question 1

Dizziness is a vague term, and can be roughly separated into four
basic categories:

Answer 1

1. True Vertigo
2. Imbalance
3. Lightheadedness, giddiness, queasiness, sea-sickness or nausea (a person’s reaction to vertigo or imbalance)
4. Faintness (or weakness)

Question 2

“True vertigo”:

Answer 2

An illusion of movement: either you feel that you’re moving, or that the room is moving.

Question 3

“Imbalance”:

Answer 3

A tendency to fall, especially in darkness.

Question 4

“Lightheadedness, giddiness, queasiness, sea-sickness or nausea”:

Answer 4

These are a person’s reactions to vertigo or imbalance. They are sometimes referred to as vegetative symptoms.

Question 5

4 basic causes of dizzines:

Answer 5

1. Otologic (from ear)
2. Neurologic (from brain)
3. general medical
4. psychiatric/undiagnosed (“these dizzi patients are nuts!”

Question 6

Most common type of otologic dizzines:

Answer 6

Bening Positional Vertigo (49%)

(“the most common is the easiest to treat)

Question 7

Most common type of neurological dizzines:

Answer 7

Stroke and TIA (35%)

followed by vertebrobasilar migraine (woman who had migraine on the red carpet)

Question 8

most common type of medical dizziness:

Answer 8

Orthostatic Hypotension (23-43%)

Question 9

Orthostatic hypotension test:

Answer 9

• Blood pressure screening
• two different positions
• 20 point drop in systolic agnostic for orthostatic hypotension
• PTs don’t treat this, referral to Dr.

Question 10

“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

Answer 10

anxiety disorders

Question 11

Pt turning head in bed, get few seconds of acute spinning, then it goes away, (+) nystagmus:

Answer 11

Bening Positional Vertigo

Question 12

patient with permanent dizzines and Gait ataxia, oscillopsia. (–) nystgamus:

Answer 12

Bilateral Vestibular Disorder

Question 13

Acute onset, motion sensitivity, vomiting that last 48-72 hours, (+) nystagmus:

Answer 13

Vestibular Neuritis (ear infection)

Question 14

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)

Answer 14

Ménière’s Disease

Question 15

What are the key points to examine (to know) in vestibular patients?

Answer 15

Is it coming from the brain or from ear?

Is it one side or both?

Question 16

Most important questions in subjective examination of the vestibular pt:

Answer 16

• Duration
• Frequency
• Precipitating factors
• Medications (drowsiness…)

Question 17

Oscillopsia

Answer 17

decreased gaze stability

Question 18

issues with balance in the dark happens to people who rely on vision for balance

Answer 18

older patients

this is why the majority of balance exercise should be done with eyes closed

Question 19

as I walk towards a subject, I am not able to stabilize gaze and it becomes blurry (oscillopsia)

Answer 19

Bilateral Vestibular Hypofunction

Question 20

classic vestibular bilateral symptom?

Answer 20

oscillopsia

Question 21

classic unilateral vestibular symptom

Answer 21

motion sensitivity

Question 22

vertigo with strain ex. a pt blow their nose or strain in the toilet, they get vertigo

Answer 22

fistula

Question 23

problems with coordination (ex ataxia)

Answer 23

central involvement patients

Question 24

Incontinence / memory loss

Answer 24

normal pressure hydrocephalus

Question 25

Types of Nystagmus:

Answer 25

* **Spontaneous** (24 hours after the insult) * **Gaze evoked** ("hard to see o left") * Direction changing or follows Alexander’s Law

Question 26

Vertical NYSTAGMUS

Answer 26

**CENTRAL** Finding until proved otherwise

Question 27

Direction changing nystagmus; Look to the right, right beating nystagmus – look to the left, left beating:

Answer 27

This is a **CENTRAL SIGN**

Question 28

Saccades:

Answer 28

Look from target to target * Significant Overshooting is a **Central Sign** * Multiple movements is a **Central Sign** * Undershoot is considered **normal**

Question 29

Patient follows your finger as you move it through the pattern:

Answer 29

SMOOTH PURSUITS

Question 30

Look from target to target ("follow my finger")

Answer 30

SACCADES

Question 31

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?

Answer 31

VOR, HEAD THRUST * **Left - Right discrimination test** * Decrease in fixation with forced LEFT ROTATION = LEFT DYSFUNCTION, + L Head Thrust test

Question 32

**Left to Right** discrimination tests:

Answer 32

1. head thrust 2. Singleton’s test

Question 33

VOR stand for

Answer 33

**Vestibuloocular Reflex**

Question 34

VOR cancellation test

Answer 34

sign of cerebellar pathology. The cerebellum cancels VOR when we walk

Question 35

DYNAMIC VISUAL ACUITY (DVA) test

Answer 35

Bilateral Vestibular Hypofunction

Question 36

DYNAMIC VISUAL ACUITY (DVA)

Answer 36

**for _Bilateral_ Vestibular Hypofunction** 1. Patient reads Snellen chart – assess score 2. Gently turn patient’s head as they try to read at 1 cycle/sec 3. Positive test is 3 or more line difference

Question 37

VOR **head thrust test**

Answer 37

Classic symptoms unilateral vestibular hypofunction L and R discrimination test

Question 38

What is the key thing to understand when assessing balance on a patient?

Answer 38

what system are they relying on | (vestibular, somatosensory, or visual)

Question 39

Static Balance test

Answer 39

* Romberg EO/EC/Foam * Sharpened Romberg EO/EC/Foam * Single Leg Stance RESULTS WILL VARY WITH PATIENT’S ABILITY TO VISUALLY FIXATE (Grand Canyon)

Question 40

Dynamic Balance tests:

Answer 40

* 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

Question 41

SINGLETON’S TEST

Answer 41

* 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

Question 42

• ROM • Strength • Sensation • Reflex • Spasticity • Coordination • Positionals Which one of these are central findings?

Answer 42

**Spasticity** and **coordination**

Question 43

Which finding suggest a Central Lesion? * Vertical gaze nystagmus * Saccades * VOR Cancellation * Coordination deficits * Spasticity

Answer 43

all

Question 44

* 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.

Answer 44

BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)

Question 45

Test for BPPV

Answer 45

* **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.

Question 46

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.

Answer 46

Rebound Phenomenom

Question 47

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:

Answer 47

**CANALITHIASIS** free floating = latency nystagmus

Question 48

Otoconia become **adhered** to the cupula (end organ in the ampulla) making it gravity sensitive. Expect **immediate nystagmus** which may not fatigue.

Answer 48

CUPULOLITHIASIS | (could be a stroke)

Question 49

which canal is affected in upgoing, **rotary** nystagmus to the affected ear

Answer 49

Posterior Canal

Question 50

which canal is affected in horizontal nystagmus?

Answer 50

horizontal canal

Question 51

which canal is affected in downgoing, rotary nystagmus to the affected ear

Answer 51

Anterior Canal

Question 52

As most lesions, ____________ are paretic, this means that most \_\_\_\_\_\_\_\_\_\_beats AWAY from the lesion

Answer 52

**Nystagmus**

Question 53

* Rhythmic Oscillation of the eye * Defined by the FAST phase * Beats to side of HIGHER activity

Answer 53

NYSTAGMUS

Question 54

which maneuver would work best for immediate horizontal nystagmus (Cupulolithiasis)?

Answer 54

Liberatory maneuver

Question 55

which maneuver would work best for latency horizontal nystagmus (Canalithiasis)?

Answer 55

BARBEQUE ROLL

Question 56

After performing a maneuver on a patient many facilities have their patients abide by the following precautions:

Answer 56

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

Question 57

BRANDT’S EXERCISES

Answer 57

* **This is habituation for** **the vertigo (dizziness),** needs to be performed 3x per day x 5 cycles

Question 58

Prognosis

Answer 58

excellent, 80% elimination of dizziness each successive maneuver

Question 59

What test would be positive with a patient with UNILATERAL VESTIBULAR HYPOFUNCTION

Answer 59

* Head thrust * Singlestons * Dizziness (motion sensitivity) * Possitive Fakuda (stepping on place)