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NMR II > Vestibular Rehab Part 2 > Flashcards

Vestibular Rehab Part 2 Flashcards

1
Q

What does the vestibular ocular reflex do?

A
  • Maintain stability of an image on the fovea of the retina during rapid head movements
  • Eyes move opposite the head
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2
Q

Peripheral Vestibular system connects to Central vestibular system pathways where?

A

Brainstem

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3
Q

What is VOR gain?

A

Relationship of eye velocity to head velocity (head & eyes move in opposite direction at equal speeds)

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4
Q

What is VOR Phase?

A

Relationship of amplitude between eyes & head

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5
Q

What is the definition of Unilateral Vestibular Hypofunction (UVH)?

A

One vestibular apparatus is “hypo functioning” = low tonic firing rate

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6
Q

What are some common diagnoses of UVH?

A
  • Vestibular Neuritis/Labyrinthitis
  • Meniere’s Disease
  • Perilymph Fistula
  • Vestibular Schwannoma/ Acoustic Neuroma
  • Chronic BPPV
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7
Q

What is Vestibular neuritis and what does it result in?

A
  • Inflammation of the vestibular part of the nerve
  • Results in vertigo only
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8
Q

What is Vestibular labyrinthitis and what does it result in?

A
  • Inflammation of both branches of CN VIII
  • Results in vertigo & hearing loss
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9
Q

What should be done during the acute phase of Vestibular labyrinthitis?

A
  • Rest
  • Medication for dizziness
  • Antibiotics if bacterial
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10
Q

What should be done during the chronic phase of Vestibular labyrinthitis?

A

Vestibular rehab may be helpful

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11
Q

What is Ménière’s disease?

A

Abnormal fluctuations in endolymphatic fluid

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12
Q

Should you treat a patient during an episode of Meniere’s disease?

A

No

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13
Q

How long do Meniere’s attack last? And what are some of the symptoms?

A
  • 2-4 hours
  • Low frequency hearing loss
  • Episodic vertigo
  • Sense of fullness in ear
  • Tinnitus
  • Nausea, vomiting
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14
Q

What is the medical treatment of Ménière’s disease?

A
  • Reducing fluid buildup
  • Reduced sodium diet
  • Avoid caffeine
  • Alcohol
  • Smoking
  • Surgery (may be considered)
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15
Q

What is Perilymph Fistula?

A
  • Rupture of the oval or round window (separate middle from inner ear)
  • Perilymph leaks into the middle ear
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16
Q

What is Perilymph Fistula caused by?

A

Excessive pressure changes (diving), blunt head trauma, extremely loud noise

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17
Q

What are the symptoms of Perilymph Fistula?

A
  • Vertigo
  • Hearing loss
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18
Q

Is vestibular rehab supported for Perilymph Fistula?

A

Contraindicated but may be beneficial after surgery

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19
Q

What is the medical treatment for Perilymph Fistula?

A
  • Bed rest
  • Surgical repair
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20
Q

What is Vestibular Schwannoma/ Acoustic Neuroma?

A
  • Benign tumor from the Schwann cells that gradually compress CN VIII
  • CN VII may also be impacted
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21
Q

What are the symptoms of Vestibular Schwannoma/ Acoustic Neuroma?

A
  • Unilateral Healing Loss
  • Tinnitus
  • Vertigo
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22
Q

What is the medical treatment for Vestibular Schwannoma/ Acoustic Neuroma?

A

Surgical excision

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23
Q

When is vestibular rehab recommended to started if someone has a Vestibular Schwannoma/ Acoustic Neuroma?

A

Early after surgery

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24
Q

What are the acute symptoms (first 2 weeks) of Unilateral Vestibular Hypofunction?

A
  • Vertigo
  • Nausea
  • Spontaneous Nystagmus (unidirectional)
  • Oscillopsia
  • Disequilibrium,
  • Gait/Postural instability may be present
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25
Q

What are the subacute (2wk to 3 months) and chronic (>3 months) symptoms?

A
  • Reduction of vertigo, nystagmus & nausea within 14 days (spontaneous rebalancing of the resting tonic firing rate)
  • Gait instability
  • Oscillopsia
  • Head movement induces symptoms
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26
Q

In spontaneous nystagmus during UVH the fast phase does toward the good ear or the bad ear?

A

Good ear
- Slow phase goes to bad ear

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27
Q

Why does the patient with an acute unilateral vestibular lesion experience spontaneous nystagmus?

A
  • Brain stem is receiving greater afferent input from the intact labyrinth, which responds by generating nystagmus
  • Patient interprets this as rotation (vertigo)
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28
Q

What is oscillopsia?

A

Stationary objects in the environment appear to be in motion when the patient is in motion

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29
Q

What is Bilateral Vestibular Hypofunction?

A

Caused by reduced or absent function of both peripheral vestibular sensory organs and/or nerves

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30
Q

What are some common diagnoses of Bilateral Vestibular Hypofunction?

A
  • Idiopathic
  • Ototoxcity
  • Meningitis
  • Autoimmune disorders
  • Bilateral Meniere’s Disease or vestibular neuritis
  • Neurotoxicity from cancer treatment
  • TIA of blood vessels
  • Bilateral Schwannoma
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31
Q

How does BVH: ototoxicity occur?

A

Certain classes of antibiotics are gradually taken by the hair cells & continue to build in the system rendering the cells unable to respond accurately to head movements

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32
Q

How does BVH: Neurotoxicity from chemotherapy occur?

A

Platinum- based chemo (cisplatin) damage sensory hair cells

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33
Q

What are the symptoms of Bilateral Vestibular Hypofunction?

A
  • Imbalance
  • Gait ataxia
  • Oscillopsia causing decreased visual acuity with head movements
  • Difficulty walking in dark and on uneven surfaces
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34
Q

Do patients with Bilateral Vestibular Hypofunction have vertigo or nystagmus?

A

NO

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35
Q

What is the definition of Central Vestibular Dysfunction?

A
  • Pathology of vestibular system proximal to the vestibular nuclei
  • Begin in brainstem, or beyond (connections with reticular formation, thalamus, cerebellum, cortex)
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36
Q

What are common diagnoses of Central Vestibular Dysfunction?

A
  • Stroke
  • TBI or Concussion
  • MS
  • Multiple System Atrophy
  • Cerebellar Pathology
  • Migraine related dizziness
  • Brain Tumor
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37
Q

What are the symptom of Central Vestibular Dysfunction?

A
  • Nystagmus
  • Vertigo (if present very mild. little change in head position)
  • Dysequilibrium & balance deficits
  • May see: Laterpulsion, Head tilt, oculomotor dysfunction, perceptual; deficits
  • Other neuro findings: Dysphagia, dysmetria, dysarthria, diplopia, dysphonia
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38
Q

What does nystagmus look like in Central Vestibular Dysfunction?

A
  • Pendular
  • Oscillate at equal speeds (no slow/fast phase)
  • Bilateral nystagmus on lateral gaze
  • Typically never resolves
  • Unable to stop with visual fixation
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39
Q

What is motion sickness due to and can vestibular rehab help?

A
  • Due to sensory conflicts
  • Vestibular rehab may help
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40
Q

What is Mal de Debarquement? Can PT help?

A
  • Feeling sick upon disembarkment (exciting from water or airborne vessel)
  • Persistent rocking, swaying while at rest that typically resolved during motion
  • Persists >24 hours
  • PT may not offer benefit
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41
Q

What causes cervicogenic dizziness and what is the treatment?

A
  • From cervical spine or soft tissue, affects proprioceptive input & alter afferent inout
  • Cervical spine sends proprioceptive input to contralateral vestibular nucleus
  • Treatment: address musculoskeletal impairments first then do vestibular rehab
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42
Q

What should be ruled out before beginning vestibular rehab?

A
  • Orthostatic hypotension
  • Hypoglycemia
  • LE somatosensory loss
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43
Q

A patient demonstrates a fast beat nystagmus to the left. Where is the pathology?

A

Right vestibular system

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44
Q

What are some Vestibular System red flags?

A
  • Unilateral hearing loss (Not Menieres)
  • Discharge of fluid from the ear
  • Syncope with light headedness
  • Alterations in consciousness
  • Positive VBI
  • If no known central pathology and presenting with new onset central signs
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45
Q

Smooth Pursuits/ Tracking is used to rule out what?

A

Central pathology

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46
Q

What is an abnormal response to Smooth Pursuits/Tracking?

A

If patients is unable to achieve full ROM in any plane or if there is impaired quality of movement

47
Q

What CN does Smooth Pursuits/ Tracking test?

A

CN III, IV, VI

48
Q

How is Smooth Pursuits/ Tracking performed?

A

Move tip of pen up & down, back & forth slowly at 30 degrees from midline while the patient follows with eye movement

49
Q

What is a positive finding of Smooth Pursuits/ Tracking?

A
  • Unable to follow pen
  • Catch up saccades
  • Reports diplopia
50
Q

What pathologies could a patient have if they have a positive finding on Smooth Pursuits/ Tracking?

A
  • Central lesion
  • CN III, IV, VI lesion
  • Acute peripheral nerve impairment
51
Q

What is saccades assessing and what CN are involved?

A
  • Assessing coordination/ Ocular metria
  • CN III, IV, VI
52
Q

How is saccades performed?

A
  • Hold finger out to the side 15 degrees from patient
  • Have patient look from examiners nose to one finger, back to the nose & then to the other finger (horizontal) (or finger to finger)
  • Examine if both eyes move at the same time to each finger
  • Repeat with finger 15 degrees up & down (vertical)
53
Q

What is a positive finding when performing saccades?

A

Dysmetria (hypometria or hypermetria)

54
Q

What pathologies could be present if a patient has a positive finding when performing saccades?

A
  • Central lesion
  • Acute peripheral nerve impairment
55
Q

How is Convergence performed?

A
  • Use pen with 14 font X taped to cap
  • Start around 24” from eyes
  • Move pen in towards the nose slowly while instructing the patient to look at the X
  • Have person stop the pen when they see 2 distinct images
  • Measure the distance from the tip of the nose to pen
56
Q

What is an abnormal finding for convergence test?

A

> or equal to 6cm

57
Q

What is the CNS: Cover/Uncover test also known as?

A

Test of Skew or Ocular Malalignment

58
Q

How is CNS: Cover/Uncover test performed?

A
  • Pt focuses on examiner’s nose while covering 1 eye (keeping it open) (hold approx 3 sec)
  • As patient maintains their gaze, uncover eye
  • Observe for any ocular malalignment or movement
59
Q

If a patient has a vertical skew deviation during the CNS: Cover/Uncover test, what does that indicate?

A

Concern for central lesion (up or down)

60
Q

If a patient has strabismus during the CNS: Cover/Uncover test, what does that indicate?

A
  • May be due to ocular muscle weakness or peripheral nerve pathology
  • Exotropia (eye abducted)
  • Esotropia (eye adducted)
61
Q

If CNS: Cover/Uncover test is negative what might this indicate?

A

Typical for peripheral vestibular pathology

62
Q

How is Gaze Evoked Nystagmus performed?

A
  • Have patient gaze left (observe nystagmus)
  • Have patient gaze right (observe nystagmus)
63
Q

During Gaze Evoked Nystagmus what does the nystagmus look like for a peripheral lesion (UVH)?

A
  • Remains in same direction no matter which direction you look
  • Greater when looking in the direction of the fast phase
64
Q

During Gaze Evoked Nystagmus what does the nystagmus look like for a central lesion?

A
  • Nystagmus is bidirectional
  • Change depending on which direction the patient looks
65
Q

What are positive findings for VOR: Horizontal & Vertical?

A

Complaints of vertigo or corrective saccade

66
Q

If there is a positive finding for VOR: Horizontal & Vertical what pathologies could that indicate?

A
  • CN VIII pathology
  • Central lesion beyond CN VIII nuclei (negative /normal)
  • UVH or BVH
67
Q

How is VOR: Horizontal & Vertical performed?

A
  • Have patient look at tip of pen or X in front
  • Patient moves their head back & forth at 2 cycles/ second
  • Repeat as they move their head up & down
  • Ask & rate any reports of dizziness
68
Q

How is VOR Cancellation performed?

A
  • Patient sitting with their hands clasped in front of them with their thumbs up
  • Patient can also look at index card in their hands with letter on it
  • As patient rotates their arms, body & head back & forth, their eyes stay on the target
69
Q

What are positive finding for VOR Cancellation?

A
  • Corrective saccades
  • Vertigo
70
Q

What are the implications of positive findings on VOR Cancellation?

A
  • Cerebellar pathology (cerebellum is unable to override or inhibit the VOR)
71
Q

How is Head Impulse Test (HIT) performed?

A
  • Patient neck is passively flexed to 30 degrees
  • Patient looks at a close target (examiner’s nose)
  • Examiner turns head slowly back & forth in small amplitude (15 deg) at moderate velocity
  • Examiner rapidly rotates head to one side (towards midline) while the patient tries to maintain their gaze
  • Repeat both sides (also can be performed in vertical semi-circular canals)
72
Q

What is a positive finding of the Head Impulse Test?

A

Corrective saccade (rapid eye movement back towards the target)

73
Q

When performing the Head Impulse Test why might a patient have corrective saccade?

A
  • In a patient with a loss of vestibular function, the VOR will not move they eyes as quickly as the head rotation & the eyes move off the target
  • Can’t maintain gaze when the head is rotated towards the side of the lesion
74
Q

What pathologies might be present if during the Head Impulse Test there is a positive finding to one side, both sides or negative bilaterally?

A
  • Positive to one side: UVH
  • Positive to both sides: BVH
  • Negative bilaterally: Central
75
Q

Why is it important to perform the head impulse test using rapid velocity?

A
  • Contralateral vestibular labyrinth can detect the head rotation signal for lower velocity rotations only (inhibitory cut off)
  • To ensure an accurate exam, ipsilateral labyrinth should be tested with high velocities to ensure the contralateral labyrinth does not contribute to gaze stability
76
Q

How is the Head Shaking Nystagmus Test performed?

A
  • Head flexed to 30 degrees (eyes closed)
  • Examiner shakes the patient’s head from side to side for 20 cycles at a frequency of 2 reps per second
  • Stop shaking the head & have the patient open their eyes
  • Check nystagmus
  • Repeat with vertical head moments
77
Q

What is a positive finding for the head shaking nystagmus test?

A
  • Nystagmus more the 3 beats
  • Fast phase is towards the intact ear
  • Slow phase is towards involved
78
Q

What pathologies may be present if the head shaking nystagmus test is positive, negative or the patient has a vertical nystagmus?

A
  • Positive: Unilateral peripheral lesion
  • Negative: BVH due to no imbalance of tonic firing rate
  • Vertical Nystagmus: Central lesion
79
Q

How is Dynamic Visual Acuity Test performed?

A
  • Pt sits or stands 10 ft away from Snellen Chart
  • Pt read the lowest line that they can see with the head still (static visual acuity)
  • W/ pt neck flexed at 30 degrees the examiner moves the head back & forth at 2 turns/sec
  • Repeat w/ vertical head movement
80
Q

What findings from the Dynamic Visual Acuity Test may indicate a vestibular hypofunction?

A

If patient cannot read 3 lines or more from baseline indicates hypofunction (bilaterally typically more severe)

81
Q

What must a patient have in order to perform HINTS exam?

82
Q

What is performed in the HINTS exam?

A
  • Head Impulse Test
  • Nystagmus during lateral gaze
  • Test of Skew (Cover uncover test)
83
Q

What is found during the Head Impulse Test if there is stroke concern vs peripheral concern?

A
  • Stroke Concern: Negative bilaterally
  • Peripheral Concern: Positive in one or both direction
84
Q

What is found during the Nystagmus during lateral gaze if there is stroke concern vs peripheral concern?

A
  • Stroke Concern: Bi directional
  • Peripheral Concern: Unidirectional
85
Q

What is found during Test of Skew/ Cover Uncover Test if there is stroke concern vs peripheral concern?

A
  • Stroke Concern: Vertical movement to refixate eyes (up or down)
  • Peripheral Concern: Negative
86
Q

How is cervicogenic dizziness tested?

A
  • Pt sits in chair with wheels or on a mat or chair without armrests
  • Pt looks at a point ahead of then
  • They then turn their body to one side while their head & eyes stay straight ahead
87
Q

What is a positive test for cervicogenic dizziness?

A

Vertigo, paresthesia, pain due to tension on posterior columns

88
Q

What is the intervention for cervicogenic dizziness?

A

Musculoskeletal intervention at cervical muscles

89
Q

Will Smooth Pursuits be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Negative
  • Peripheral Bilateral: Negative
  • Central: Positive
90
Q

Will Saccades be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Negative
  • Peripheral Bilateral: Negative
  • Central: Positive
91
Q

Will Convergence be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Negative
  • Peripheral Bilateral: Negative
  • Central: Positive
92
Q

Will Cover/ Uncover Test be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Negative
  • Peripheral Bilateral: Negative
  • Central: Positive
93
Q

Will there be nystagmus during Gaze evoked nystagmus in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Unilateral towards intact side, spontaneous in acute in horizontal plane
  • Peripheral Bilateral: None
  • Central: Bilateral, spontaneous, vertical
94
Q

Will CN VIII (VOR) be intact or not in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Positive
  • Peripheral Bilateral: Intact unless imbalance
  • Central: VOR gain typically normal
95
Q

Will VOR Cancellation be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Negative
  • Peripheral Bilateral: Negative
  • Central: May be positive
96
Q

Will Head Shaking Nystagmus Test be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Positive
  • Peripheral Bilateral: Negative
  • Central: sometimes
97
Q

Will head impulse test be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Positive one direction
  • Peripheral Bilateral: Positive bilateral direction
  • Central: Negative
98
Q

Will Dynamic Visual Acuity be positive or negative in:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: Positive
  • Peripheral Bilateral: Positive
  • Central: Sometimes
99
Q

Describe the findings found in HINTS Exam (3 part) for:
- Peripheral Unilateral
- Peripheral Bilateral
- Central

A
  • Peripheral Unilateral: ( +HIT, - TS, & horizontal and unilateral direction nystagmus)
  • Peripheral Bilateral: (Should not have nystagmus)
  • Central: ( - HIT, + TS, & vertical or bilateral nystagmus)
100
Q

What does Videonystagmography examine?

A

Nystagmus in different head positions

101
Q

What does Vestibular- evoked myogenic potential (VEMP) examine?

A
  • Otolith function
  • Saccule: Cervical Testing
  • Utricle: Ocular mm testing
  • EMG testing of cervical (SCM) & ocular mm (inferior oblique). No contraction occurs on the side of the UVH
102
Q

How is the Caloric Test performed and what does it examine?

A
  • Temperature gradient of either cold or warm in the ear canal
  • Examines horizontal canals & an equal response between ears
  • Nystagmus is normal response
103
Q

Why was the Vestibular Rehabilitation Benefit Questionnaire (VRBQ) developed?

A

Identify the benefits of Vestibular Rehab

104
Q

What topics are within the Vestibular Rehabilitation Benefit Questionnaire (VRBQ)?

A
  • Dizziness
  • Anxiety
  • Motion provoked dizziness
  • Quality of life
105
Q

How is Motion Sensitivity Quotient performed?

A

Patient is placed in different positions & symptoms are rated for intensity & duration

106
Q

What does the Dizziness Handicap Inventory measure?

A

Self-report to measure individuals perception of disequilibrium & impact on activity

107
Q

When using the Clinical Test of Sensory Interaction & Balance which conditions will the patient sway if they have vestibular dysfunction?

108
Q

What are DGI & FGA common gait findings with UVH?

A
  • Acute: Wide based, slow, limited trunk rotation
  • After 2 weeks: normal
109
Q

What are the DGI & FGA common gait findings with BVH?

A
  • Acute: Wide based, slow, limited trunk rotation
  • After 2 weeks: Mild impairment may be present
110
Q

What are the DGI & FGA common gait findings with central?

A

Impaired/ ataxia may be present

111
Q

What are the common findings of DGI & FGA walking with head turns in UVH?

A
  • initially off balance
  • After 2 weeks: normal
112
Q

What are the common findings of DGI & FGA walking with head turns in BVH?

113
Q

What are the common findings of DGI & FGA while walking with head turns in central?

A

Impaired/ ataxia may be present

NMR II (14 decks)

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