vestibular rehabilitation Flashcards
assessment of dizzy patient
questionaires (dizziness handicap inventory, activities of balance confidence scale) onset symptoms how often and when circumstances functional limitations PMH
symptoms
imbalance lightheadedness rocking or swaying motion sickness nausea and vomiting Oscillopsia Floating, spinning inside of hear Vertical diplopia vertigo
dizziness
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
circumstances
movement of the body
vertical or oblique head movements
eye movements with head still
without provocation
how long and how many times
acute attack (3 days or less)
chronic dizziness (>3days) continuous ?
spells of dizziness: episodic (minutes, hours, days)
when and what caused it
spontaneous induced by movement induced by position worse with fatigue worse inside vs outside worse in the dark on flat or uneven floor
fall history
where, when lighting, and what were they doing.
frequency and last occurrence
Occupational performance interference
ADLs, Driving, Working, Exercise, Social
objective tests/ measures
Cervical ROM/cervical instability (PT) Gross strength and mobility History of previous injuries ocular motor system special tests balance assessment (berg balance)
Cranial Nerve
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)
testing for peripheral vestibular
Only if BPPV is suspected
Dix Hallpike maneuver to diagnose
Epleys maneuver if anterior or posterior canal suspected
saccadic
rapid eye movements to bring new objects being viewed on to the fovea
Smooth pursuit
eye movements to keep a moving image centered on fovea
Vestibulo-ocular
Keeps image steady on fovea during head movements
Vergence
keep image on fovea predominately when the viewed object is moved near.
assess for spontaneous nystagmus
hold patients head still while they look straight ahead and observe for nystagmus
if present it is indicative for central vestibular processing problem
fixed gaze nystagmus
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
oculomotor ROM
looking to see if the eyes move together smoothly
18-24 inches from patient
smooth pursuits
holds images of a moving target on the retina
60 degree total arch
don’t move too fast (may spark saccadic motion)
Cover tests
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
VOR
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
visual acuity
acuteness or clearness of vision, letter chart
vestibular program objectives
Diminish dizziness and vertigo
Enhance gaze stabilization
Enhance postural stability in static and dynamic situations
-enhance overall functional activities and occupational performance
- Patient education
vestibular program goals
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)
therapeutic management
decrease impairments effect on occupational performance
- improve functional performance and postural control
- train the brain
treatment strategies to improve compensation
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.
adaptation exercises
progression:
- duration
- velocity
- patterned/busy backgrounds
- position
- target distance
X2 viewing
progress from static to dynamic.
substitution exercises
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
gaze stability exercises
VOR-head movements
Eye movements- side to side eyes on stationary target (X1), moving target (X2)
Habituation
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.
cervical proprioceptive exercises
head laser with targets
combine with saccades
Eyes open then eyes closed
vestibular recovery rates
UVL- 6-8 weeks
BPPV- remission in 1/few treatments
BVL- 6 months- 2years
CNS- 6 months - 2 years
