vestibular rehabilitation

Question 1

assessment of dizzy patient

Answer 1

questionaires (dizziness handicap inventory, activities of balance confidence scale)
onset
symptoms
how often and when
circumstances
functional limitations
PMH

Question 2

symptoms

Answer 2

imbalance
lightheadedness
rocking or swaying
motion sickness
nausea and vomiting
Oscillopsia
Floating, spinning inside of hear
Vertical diplopia
vertigo

Question 3

dizziness

Answer 3

non specific term, encompasses any and all of the specific symptoms:
vertigo
imbalance
lightheadedness
combinations of the above.

need to obtain detailed characterizations of the patients symptoms

Question 4

circumstances

Answer 4

movement of the body
vertical or oblique head movements
eye movements with head still
without provocation

Question 5

how long and how many times

Answer 5

acute attack (3 days or less)

chronic dizziness (>3days) continuous ?

spells of dizziness: episodic (minutes, hours, days)

Question 6

when and what caused it

Answer 6

spontaneous
induced by movement
induced by position
worse with fatigue
worse inside vs outside
worse in the dark
on flat or uneven floor

Question 7

fall history

Answer 7

where, when lighting, and what were they doing.

frequency and last occurrence

Question 8

Occupational performance interference

Answer 8

ADLs, Driving, Working, Exercise, Social

Question 9

objective tests/ measures

Answer 9

Cervical ROM/cervical instability (PT)
Gross strength and mobility
History of previous injuries
ocular motor system
special tests
balance assessment (berg balance)

Question 10

Cranial Nerve

Answer 10

1) Olfactory: smell (mint, coffee)
2) Optic: vision (eye chart)
3) Oculomotor: eye movement (dilation of pupils, follow target)
4) Trochlear: eye movement (look down)
5) Trigeminal: facial sensation and chewing (test sensation to touch and clench jaw/open jaw against resistance)
6) Abducens: eye movement (look lateral)
7) Facial: muscles of expression, taste (change expression, sweet/sour/salty/bitter)
8) Vestibulocochlear: hearing and balance (tuning fork, balance with eyes closed)
9) Glossopharyngeal: swallowing and speech (swallow or gag reflex, say ah, ka, ga
10) vagus: swallowing and speech (swallow or gag reflex, say ah, ka, ga
11) Accessory: muscle control (shrug shoulders, turn head)
12) Hypoglossal: tongue movement (stick out tongue)

Question 11

testing for peripheral vestibular

Answer 11

Only if BPPV is suspected
Dix Hallpike maneuver to diagnose
Epleys maneuver if anterior or posterior canal suspected

Question 12

saccadic

Answer 12

rapid eye movements to bring new objects being viewed on to the fovea

Question 13

Smooth pursuit

Answer 13

eye movements to keep a moving image centered on fovea

Question 14

Vestibulo-ocular

Answer 14

Keeps image steady on fovea during head movements

Question 15

Vergence

Answer 15

keep image on fovea predominately when the viewed object is moved near.

Question 16

assess for spontaneous nystagmus

Answer 16

hold patients head still while they look straight ahead and observe for nystagmus

if present it is indicative for central vestibular processing problem

Question 17

fixed gaze nystagmus

Answer 17

observe for any nystagmus at 30 degrees of each range

avoid taking to end range because it is not abnormal to experience end range nystagmus

Question 18

oculomotor ROM

Answer 18

looking to see if the eyes move together smoothly

18-24 inches from patient

Question 19

smooth pursuits

Answer 19

holds images of a moving target on the retina
60 degree total arch
don’t move too fast (may spark saccadic motion)

Question 20

Cover tests

Answer 20

cover uncover test (unilateral)- test for tropia. Perform cover test first on each eye; if no movement of uncovered eye tropia is not present

Alternate cover test (cross over test)- test for phoria or measures the magnitude of phoria or tropia (best to pull out phoria)

can assess ocular alignment

Question 21

VOR

Answer 21

tilt patients head down 30 degrees. Start slowly moving head side to side while they focus on your nose, gradually increasing speed . Repeat in vertical plane

Question 22

visual acuity

Answer 22

acuteness or clearness of vision, letter chart

Question 23

vestibular program objectives

Answer 23

Diminish dizziness and vertigo
Enhance gaze stabilization
Enhance postural stability in static and dynamic situations
-enhance overall functional activities and occupational performance
- Patient education

Question 24

vestibular program goals

Answer 24

ensure patient safety and reduce fall risk.

• compensatory strategies (goal is to improve and equalize normal head conditions)
• active exercises to promote vestibular adaption (recalibration of system)

Question 25

therapeutic management

Answer 25

decrease impairments effect on occupational performance

• improve functional performance and postural control
• train the brain

Question 26

treatment strategies to improve compensation

Answer 26

Adaptation- brain will adapt to input received and either tune out information it determines to be an error or activate another system to correct this mismatch. learns to compensate through the visual system

Substitution- strengthen the function of intact systems to improve performance

Habituation- repeatedly expose the individual to a provoking stimuli so they no longer respond as strongly to it.

Question 27

adaptation exercises

Answer 27

progression:

• duration
• velocity
• patterned/busy backgrounds
• position
• target distance

Question 28

X2 viewing

Answer 28

progress from static to dynamic.

Question 29

substitution exercises

Answer 29

substitution of other strategies to replace the lost or impaired function.

• eye tracking
• oculomotor exercises
• saccades

protocols: progress from easy/static to difficult/dynamic
focus on strengthening weakened system to return to function by challenging remaining ones.
-force remaining systems to become trustworthy when the others are lost

Question 30

gaze stability exercises

Answer 30

VOR-head movements

Eye movements- side to side eyes on stationary target (X1), moving target (X2)

Question 31

Habituation

Answer 31

asymmetrical vestibular function leads to sensory mismatch, which leads to symptom provocation.

Method: systematically provoke symptoms to produce reduction in those symptoms

a reduction in symptoms due to repetition or exposure to the stimuli- due to central process of neural plasticity.

Question 32

cervical proprioceptive exercises

Answer 32

head laser with targets
combine with saccades
Eyes open then eyes closed

Question 33

vestibular recovery rates

Answer 33

UVL- 6-8 weeks
BPPV- remission in 1/few treatments
BVL- 6 months- 2years
CNS- 6 months - 2 years