vestibular rehab foundational knowledge Flashcards
what are the 2 systems that the vestibular system is broken down to
peripheral and central
the inner ear and 8th cranial nerve is apart of which vestibular system?
peripheral
the vestibular nuclei , cerebellum and higher cortical connections is apart of what vestibular system
central
what 2 things give us spatial awareness
vision and somatosensation
spatial awareness gives us what 2 things
balance and gaze stability
what is the most common complaint with people with vestibular problems
dizziness
what is a a strong predictor of falls in the elderly people
presence of dizziness
____ 2nd only to LBP in occurrence in adults
dizziness
Vestibular therapists use ____ to re-train the brain to interpret and utilize vestibular inputs more accurately.
neuroplasticity
Vestibular system functions to sense _____… resulting symptoms of ____
movement
malfunction
what is it called when someone experiences false sense of movement i.e spinning , r4ocking , swaying
vertigo
what kind of movement does the semicircular canals detect
angular and rotational
what part of the ear detects linear movement
saccule and utricle
what is included in the inner ear
semi circular canals
cupola
cochlea
endolymoh
what is important in terms of converting mechanical energy from the nervous system and it is a fluid that fulls the inner ear
endolymph
what has hair receptors cells that get stimulated by the sound vibration ?
cochlea
what is the hair cells within the ampula
cupula
how do the semi circular canals line up with each other
the L post canal is lines up with the R anterior canal
the R anterior canal is lined up with the L postioer canal
and both horizontals line up together
what happens with the endolymph when the head turns to the L
endolymph moves thru the horizontal canal and thru the cupula and bends the hair cells , inhibiting the R ear adn then exciting the L ear
when you turn ur head to the R the endolymph move to the __
left
what sits on top of the hair cells in the utricle and saccule
odoconia
what are microscopic calcium carbonate crystals , that respond to gravity or movement
otoconia , located in the uticle and saccule
what part of the ear detects when u move ur head up , down , left , right and forward and backwards
utricle and saccule
linear movement
what nerve of the vestibuylochoclear nerve is responsible for sound info and which one is responsible for movement info
cochlear and vestibular
where does the vestibulocochlear n travel to
the BS
what part of the brain gets a lot of the sound signals bc it control movement coordination and balance
cerebellum
what tract is activated by reflex when we move our head and it sends a signal straight from BS down to SC to our spinal mm to balance us
vestibulospinal tract
what Cranial nerves are invovled in the vestibulo- ocular reflex
oculomotor nerve (3)
trochlear n (4)
abducens nerve (6)
what is the vestibular ocular reflex
maintains gaze stability during head motion ; controlling eye head coordination
what is the vestibulo spinal reflex
maintains head and body equilibrium by facilitation or inhibiting skeletal mm activity thus controlling coordination for balance
what is the cervical ocular reflex
reflex output to motor cells , signals head position on body
,maintains gaze stability secondary to VOR
where does the otolith ocular reflex receive input from and what does it control
utrucle and saccule ; output to eye mm
controls horizontal and vertical eye movement via linear VOR
what reflex Maintains gaze stability during head motion thus controlling eye-head coordination
vestibular ocular reflex
what higher cortical places in the brain have connections with the vestibular systems
thalamus, visual cortex , hippocampus
the ____ vestibular system affects the motion system
peripheral
• BPPV
• Neuritis
• Labyrinthitis
• Acoustic neuroma
• Hypofunction
• Unilateral
• Bilateral
• Endolymphatic Hydrops/Meniere’s
• Fistula/Dehiscence
these are all pathophysiology of what part of the vestibular system
peripheral
problems with the peripheral vestibular system affects ___ and ____ of movement information
sensation and perception
what problem is it when the otoconia become dislodged from the utricle or saccule and displaced into a semi circular canal and affects endolymph flow thru the canal and cupula deflection
benign paroxysmal positional vertigo (BPPV)
what causes BPPV
idiopathic
head trauma
inflammation
ischemia
pressure fluctuations
what are risk factors for BPPV (6)
age
female
vitamin D deficiency
hypertension
migraine
hyperliipemia
what are the symptoms of BPPV
10-60 sec spell of vertigo with changes in head position against gravity
what is BPPV
when otoconia come out from the utricle or saccule and displace into the semi circular canal
T/F: BPPV is positional and changes with head position
T
what are the two different types of BPPV
canalithiasis and cupuloithiasis
what is BPPV Canalithiasis
when otoconia are free floating in the semicircular canal , causing abnormal flow of endolymph with changes in head position against gravity
How is the onset , symptoms and how long does canalithiasis BPPV last
latent onset of vertigo and nystagmus (seconds)
symptoms gradually intensity then subside (episodic)
last less than 1 min
pertaining to cupuloithiasis BPPV what is the onset , how are the symptoms , and how long does it last
more immediate onset of vertigo and nystagmus
symptoms intensity remains the same
lasts as long as the head is held in the provoking position
what is BPPV; cupuloithiasis
otoconia are stuck to the cupula , causing deflection of the cupula with change in head position against gravity
what part of the ear is common for ear infection
middle ear
what part of the ear is more common for virtual infection
inner ear
what is the pathophysiology of neuritis/ labyrinthitis
inflammation of the inner ear ( labyrinthitis) or vestibular n (neuritis), causing vestibular hypesitmulation and may result in damage leading to hypofunction
what is the main difference between neuritis and labyrinthitis
neuritis has no hearing loss invovled and it affects the nerve
labyrinthitis includes hearing loss and affects the actual strucutre of the inner ear
what are causes of neuritis/ labyrinthitis
viral infection 98% and head injury
is it common for neuritis to reoccur
no viral infections are very unlikely to ever reoccur bc of the body immune system
what are the symptoms of neuritis/ labyrinthitis
sudden onset of vertigo, nausea , lasting 3-7 days with residual balance and dizziness lasting 1-2 weeks
often follows other illness (respiratory infection)
what is hypofunction
damage to the inner ear or vestibular n that results in a diminished or weaker neurological signal
can be unilateral or bilateral
what is the hallmark for bilateral hypofunction
when the patient sees things jumping/bouncing (called oscillopsia)
what are causes of hypofunction
neuritis
labrinthitis
ménière’s disease
acoustic neuroma
ototixic medication
gentamicin
meningitis
ear sx
symptoms of hypofunction
affects VOR and VSR
postural instability
gaze instability
movement related to dizziness
motion sensitivity
foggy headedness
kinesiphobia - fear to exercise
oscillopsia- boucing world
in Hypofunction ____ allows for CNS compensation
neuroplasticity
what is the pathophysiology of acoustic neuroma
benign , slow growing tumor of the myelin sheath (schwann cells) covering the acoustic/ cochlear or vestibular n causing compression of CN 8
what are the casues of acoustic neuroma
idiopathic or genetic
what is acoustic neuroma also called
cerebellopontine angle tumor, vestibular or acoustic schwannoma
what are the symptoms of acoustic neuroma
gradual onset of unilateral hearing loss
tinnitus
imbalance
motion sensitivity
facial numbness/weakness
T/F: acoustic neuroma lacked TRUE vertigo symptoms
T
what is the pathophysiology of endolymphastioc hydrops/ Meniere’s
Build-up of endolymphatic fluid within the inner ear,
causing pressure on the inner ear membranes and hair cells. Can cause inflammation and damage over time.
can be unilateral or bilateral
is Endolymphatic Hydrops/Meniere’s a one time thing or can it be reoccurring
reoccurring
what are causes of Endolymphatic Hydrops/Meniere’s
idiopathic (meniere’s)
sodium/potassium imbalance (systemic)
middle ear congestion
symptoms of Endolymphatic Hydrops/Meniere’s
REOCCURING episodes of vertigo lasting 1-3 days with gradual improvement over 1-2 weeks
low frequency hearing loss
what is the pathophysiology of Fistula/Dehiscence
Structural “hole” in the inner
ear, then unable to regulate endolymph fluid
pressure and flow.
is Fistula/Dehiscence reoccurring or one time
reoccuring
is Fistula or Dehiscence the structural hole in the inner ear
dehiscence
what are the causes of Fistula/Dehiscence
trauma , head injury , or valsalva (rare)
what are the symptoms of Fistula/Dehiscence
reoccuring spells of vertigo , possible associated with loud sounds and barometric pressure changes , hearing hypersentivitiy, imbalance and motion sensitivity
• Stroke
• Brain tumor
• Multiple Sclerosis lesions
• Degenerative neurological conditions
• Vestibular Migraine
• PPPD
• MDDS
• Anything affecting the central vestibular connections in the brain and brainstem
these are all pathophysiology of what part of the vestibular system
central
pathophysiology in the central vestibular system affects ____ and ____ of movement information
perception and integration
what kind of disorder is a vestibular migraine
sensory perception disorder
issue with how the brain receives and interprets sensory information
since the causes of a vestibular migraine is UNKNOWN what are the risk factors (3) and common triggers (6) for it
Risk factors: female, Magnesium deficiency, migraine history
- Common triggers: Stress, hormone fluctuations, weather changes, poor sleep,
caffeine, alcohol,
what are the symptoms of a vestibular migraine
recurring r episodes of vertigo
lasts 1-5 days
often associated with headache , photophobia , phonophobia , brain fog , anxiety , dissociative symptoms and visual issues
what is the pathophysiology of persistent postural positional dizziness (PPPD) (aka chronic functional dizziness)
central issue
autonomic and emotional hyper responsiveness to vestibular stimulus
what are the causes of PPPD
abnormal adapatation following a vestibular trauma ( BPPV , vestibular migraine , unilateral vestibular pathology)
what are the symptoms of PPPD
constant visual motion sensitivity and imbalance coupled with anxiety , kinesiophobia , “visual vertigo” , “space motion discomfort” ,
last over > 3 months
what is the pathophysiology of Mal de Debarquement (MDDS)
mal adaptation following disembarking a moving vehicle (continue sensation of movement after getting off of something that has been moving) `
what are the casues of Mal de Debarquement (MDDS)
unknown but associated with anxiety and emotional responses to dizziness
what are the symptoms of Mal de Debarquement (MDDS)
central issue
persistent sensation of rocking or swaying that lasts beyond the expected period of adaptation
what are the non vestibular pathology associated with cardiovascular
- Orthostatic hypotension
- Low/high blood pressure
- Vertebral basilar artery insufficiency
what are the non vestibular pathology associated with metabolic
- Low/high blood sugar
- Dehydration
- Infection (UTI, URI)
- Medications
what is the most common self report outcome measure for dizziness/vertigo
dizziness handicap inventory (DHI)
what does the dizziness handicap inventory (DHI) ask
25 questions about how dizziness is impacting function
yes, no, sometimes
0: no handicap , 100: complete handicap
what is the most importantly part of the assessment process for a vestibular patient
the subjective
during the subjective what are u looking for
clues for differential diagnosis and functional impact
what is vertigo
illusion of movement (spinning , rocking ,swaying , falling)
what is disequilibrium
sense of being off balance
what is the symptoms of a cardiovascular problem pertaining to a vestibular patient
light headed , pre syncope , tunnel vision
what is the symptoms of a anxiety problem pertaining to a vestibular patient
floating , swimming ,rocking
what is the symptoms of a visual problem pertaining to a vestibular patient
diplopia (seeing double)
oscillopsia (vision jumping)
what is the tempo (frequency and duration) of vestibular neuritis or labrinthitis
sudden onset/acute
lasting days
single event
what is the tempo (frequency and duration) of BBPV
short spells (seconds)
recurring
what is the tempo (frequency and duration) of bilateral hypofunction
gradual onset over months/years
constant/ chronic
what is the tempo (frequency and duration) of meniere’s or vestibular migraine
sudden/acute
recurring spells (hours-days)
what is the tempo (frequency and duration) of wallenberg infarct
sudden onset/acute
hours-days
single event
what is the tempo (frequency and duration) of orthostatic hypotension
short spells (seconds -mins)
recurring
what is the tempo (frequency and duration) of MDDS or PPPD
constant
fluctuating severity ,
chronic
what is the aggravating and easing factor for BPPV
A: positional like lying down , sitting up or turning over
E: holding still, time
what is the aggravating and easing factor for gaze instability
A: head movement , visual vestibular mismatch
E: holding still, closing eyes
what is the aggravating and easing factor for imbalance
A: walking , darkness , unstable surfaces , standing up
E: sitting , support from UEs
what is the aggravating and easing factor for vestibular neuritis
A: spontaneous, exacerbated by head movements
E: holding still , closing eyes , meds
what is the aggravating and easing factor for vestibular migraine or meniere’s
A: spontaneous , exacerbated by head movements and common triggers
E: holding still, closing eyes, meds
what are the co morbidities for a vestibular issue
diabetes
BP
auto immune conditions
anxiety
depression
peipheral neuropathy
what meds are considered vestibular suppressants
meclizine
dramamine
valium
____ is a common medication side effect
dizziness
what are some diagnostic test done for vestibular tests
audiogram , VNG/ ENG
what is nystagmus
rapid repeating eye movement
how is nystagmus names
by the fast phase from the patients perspective
what is slow phase and fast phase nystagmus caused by in the vesitbular system
slow: VOR
fast: caused by corrective saccades by cerebellum
what nystagmus is casues by the CNS
smooth pursuit and saccades - BS and cerebellum
peripheral vestibular nystagmus ….
slow phase caused by ____
fast phase caused by ___ _____
____ fixed
usually _____
decreased in intensity with _____
gaze towards ___ phase increased intensity (____ law)
VOR
corrective saccade
direction
horizontal
fixation
fast
alexander’s
what is the exceptions for peripheral vesitbular nystagmus
BBPPV
what is alexander’s law for peripheral vestibular nystagmus
gaze towards the fast phase increased intensity
so if a patient comes in with left nystagmus and it is peripheral vestibular what should happen when the patient looks left and looks right and what fixation
pertaining to alexander’s law when the painter looks L the intensity should increased bc the patient is gazing toward the fast phase side and when she looks to the eR it should decreased
and it should decreased with fixation bc it is a peripheral issue
central nervous system nystagmus
___ changing (often follows gaze)
can be ___ or _____
not affected by ____
_____
usually from a ___
direction
vertical or pendular
fixation
congenital
trauma
if you are examining a patient w nystagmus and their nystagmus changes when they look to the L and when they look to the R what system is it
central bc it is direction changing
what are 3 tools used for observing nystagmus
frenzel and infrared goggles
VNG/ENG (nystagmography)
rotary chair
what does the frenzel and infrared goggles take away
fixation
what is the gold standard for identifying unilateral vestibular hypofunction
VNG/ENG (nystagmography)
what is the rotary chair the gold standard for
identifying bilateral hypofunction
what is the purpose of an examination for a vestibular patient
screen for vestibular involvement
DD
identify impairments
