Vestibular Rehab Skill Check

Question 1

Saccades

Answer 1

Test: Hold your finger tip about 20 degrees to one side of your nose. Ask the pt to look at your nose, then at your finger, repeating several times. Do this from the center to right to center, center left to center, center to up to center, and center to down to center. Should be a single point in line with the nose.

Normal response- the eyes should be conjugate, have normal amplitude and velocity; saccades to eccentric target are no >10% hypometric; saccades back to center no >10% hypometric or hypermetric; the number of eye movements it takes to reach target should be < or = 2

Abnormal response = consistent overshoots (hypermetric saccades) or multiple small saccades (hypometric saccades) to get to the eccentric target; accuracy- hypermetria from center to target is abnormal

Positive test is indicative of a central pathology

Question 2

Smooth Pursuit

Answer 2

Task: Single point target held 18-24” in front of patient’s face. Have patient follow your flowly moving finger (`20 degrees/sec) and at a low frequency (<1Hz), horizontally (from center 30 degrees to right and left) and then come back to center and test for vertical from center 30 degrees up and down.

Normal: eyes track the target smoothly

Abnormal: consistent saccadic intrusion

Positive test is indicative of a central dysfunction

Question 3

VOR cancellation

Answer 3

Task: Grasp pateint’s head firmly with both hands of the side of their head. Instruct the patient to look at your nose. Slowly (1Hz) move the patient’s head from side to side about 30 degrees while you move in the same direction.

Normal: patient can maintain visual fixation

Abnormal: Saccadic eye movements (eyes move off target, eyes jumping back to target)

Postive test is indicative of a central dysfunction (usually in the cerebellum)

Question 4

Dynamic Visual Acuity

Answer 4

Task: Patient positioned 2-4 meters away from the acuity chart. Have the patient read to the lowest line possible until they cannot correctly identify al the letters on a given line. Now, stand behind the patient, grasp their head firmly with both hands on the side of their head. Move head side to side at a frequency of 2Hz (2 complete side to side cycles) per second. Have the patient read to the lowest line they can until they cannot correctly identify all the letters on a given line.

Normal: A 2-line or less difference between static and dynamic visual acuity

Abnormal: 3 lines or greater difference

A positive test is indicative of a vestibular deficit

Question 5

Head Thrust

Answer 5

Task: Grasp the patient’s head firmly with both hands on the side of their head. Instruct the patient to look at your nose, relax and not blink. Move the patients head back and forth slowly just to make sure the patient is relaxed. Then move the patient’s head to one side with a quick velocity yet small amplitude (20 degrees).

Normal: Visual fixation maintained

Abnormal: Corrective saccade after head rotation

Postive test is indicative of a peripheral hypofunction on that side

Question 6

Head Shake

Answer 6

Task: Only performed with fixation blocked (i.e. Frenzel Lenses). Grasp the patient’s head firmly with both hands on side of their head. Tilt head forward 30 degrees. Have the patient close their eyes. Oscillate head side to side for 20 cycles. Quickly cue patient to open eyes and observe for nystagmus. If nystagmus is seen, note the direction of the fast phase and the number of beats.

Normal: no nystagmus or 1-2 beats

Abnormal: > or =3 beats or if an existing nystagmus is accentuated.

Horizontal nystagmus that was not there initially is consistent with a U/L vestibular deficit, with the nystagmus beating to the more active side. Vertical nystagmus is consistent with a central vestibular disorder.

Question 7

Dix-Hallpike