Vestibular Rehabilitation
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| 3 components of balance | Somatosensory
Vision
Vestibular
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| purpose of lymphatic fluid in the vestibular system | fluid moves as you move your head, cilia detect the movement of the fluid and send signals to the brain about the movement
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| where are otoconia stones located? | utricle and saccule, if they get into SCC they move at a different speed than the lymph fluid and cause BPPV symptoms
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| what is nystagmus | abnormal eye movements due to interruption in the VOR
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| how is nystagmus named? | by the direction the quick beat
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| can nystagmus change direction? | yes based on the position
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| what type of nystagmus is seen with BPPV? | torsional nystagmus, eyes twist
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| when is vertical nystagmus often seen? | brain injury or bleed, more acute injuries will have a faster nystagmus
things may still look normal to the pt because the brain is overriding the response
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| when can CNS dampen nystagmus? | when the eyes can fixate
why blackout or blurry googles are used for detecting nystagmus in TBI
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| what in a pts history might make you think vestibular? | complain of vertigo/ spinning
dizziness/vertigo with position change (not orthostatic)
nystagmus
neuro injury to brainstem, cerebellum, cranial nerves and possibly oculomotor function
blurred vision with mobility
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| vertigo vs dizziness | vertigo is the feeling of spinning and related to vestibular system
dizziness can occur before passing out (orthostatic), can also be a symptom of other pathology (stroke, MI, low blood sugar), can be from meds too
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| most vestibular issues are ____ | episodic, they come and go, spinning not present all the time
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| things to pay attention when getting vestibular pt history | Initial Onset
Duration of symptoms
Position when symptoms occur
Description of symptoms
Circumstances
What provokes symptoms?
Sick prior?
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| vestibular neuritis | vestibular system can become inflamed after a viral infection
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| with vestibular pts we need a way to determine if patient has ____ symptoms or ____ symptoms | peripheral, central
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| oculomotor exam | Includes ocular ROM, smooth pursuit, gaze holding nystagmus, saccades, head thrust/ head impulse test (HIT), Vestibular-Ocular Reflex (VOR) and VOR cancelation, Test of Skew, resting nystagmus, head shake nystagmus and others
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| What things might we see if patient has central signs? | Vertical nystagmus
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| vertebral/ basilar artery testing | Have pt sit forward with head in hands, elbows on knees.
Turn head to one side
Provide cognitive task for pt such as counting backwards from 30 by 3s
Watch for nystagmus, change in concentration/cognition, dizziness or visual changes
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| red flags that warrant more questions | Numb, Tingling, Weak, Slurring, Progressive hearing loss, Tremors, Poor coordination, UMN signs, LOC, Rigid, Visual Field Loss, Cranial Nerve Dysfn, Spontaneous nystagmus after two weeks, Vertical nystagmus w/out torsional component
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| why is vertebral artery testing important? | we can make the occlusion worse during BPPV testing, can result in stroke
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| HINTS exam | exam designed to rule in/out posterior circulation strokes before they would show up on CT (sometimes takes up to 24 hrs to get on imaging) designed for use in ER
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| what does HINTS stand for? | Head Impulse
Nystagmus
Test of Skew
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| head impulse test | test for VOR- peripheral reflex, oculomotor, vestibular cranial nerves
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| if you have an intact VOR, you will probably have ____ signs VOR is a ____ sign, so if it is working then the problem is most likely central | peripheral. central
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| direction changing nystagmus is usually a ____ sign | central
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| Benign Paroxysmal Positional Vertigo (BPPV) | The most common form of vertigo and balance disorders
60% of all peripheral vestibular disorders2
Otoconia get “knocked loose” into semi-circular canals
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| onset of BPPV | mid 50's
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| characteristics of BPPV | episodic, typically short duration, fatigable, and symptoms correlate to head movements.
While the otoconia are loose, the pt experiences vertigo/dizziness/balance deficits
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| two main types of BPPV | Canalithiasis- free floating otoconia
Cupulolithasis- otoconia adhered to cupula
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| canalithiasis BPPV symptoms | onset of vertigo is delayed, presence of nystagmus is delated (1-40 sec), intensity fluctuates, symptoms last less than 60 secs, caused by free floating otoconia
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| cupulolithiasis BPPV symptoms | onset of vertigo immediate, presence of nystagmus immediate, intensity persistent, length of symptoms greater than 60 seconds, otoconia adhered to cupula
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| dix hallpike position | 45 degrees cervical rotation and 30 degrees cervical extension over edge of bed
Testing posterior canal on down side ear
Keep in this position for at least 30 seconds to ensure no 2/2 delay
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| what should you monitor in dix hallpike position? | length of symptoms and nystagmus if visible for further diagnosis
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| modified dix hallpike | Modified Dix-Hallpike
45 degrees cervical rotation, down on opposite side.
Ex: Right cervical rotation, lay down to the L to test the L ear.
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| why would you use modified dix hallpike? | Best for patients who have limited neck extension ROM
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| original canalith repositioning procedure 5 key elements (now the epley) | Premedication (1 hour prior to tx), specific positions used in maneuver, the timing of shifts from one position to the next, use of vibration during the maneuver, and post-procedure instructions.
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| gold standard for posterior canal canalithaiasis | Epley maneuver
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| steps for epley for PSCC BPPV | steps on slide 20
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| remission rate for posterior canal canalithiasis using epley | 85-95%
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| foster half summersault is for what type of BPPV? | PSCC BPPV
steps on slide 22
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| tests for horizontal canal involvement | roll test
(slide 23, steps on slide 24,26)
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| what is bow and lean test used for? | to determine the affected slide in horizontal SCC BPPV
(steps slide 27)
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| vestibular neuritis | Viral attack to the vestibular system characterized by spontaneous horizontal nystagmus acutely
Results in spontaneous vertigo, nausea, emesis, imbalance, oscillopsia
Hearing is spared
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| labyrinthitis | Viral or bacterial infection involving the entire labyrinth
Spontaneous onset of vertigo, nausea, emesis, imbalance etc.
Key difference from Vestibular neuritis: auditory symptoms present
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| what is damaged in vestibular neuritis/labyrinthitis? | the nerve
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| causes of unilateral vestibular hypofunction | Labyrinthitis, neuritis, tumors/neuroma resections
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| treatments for unilateral vestibular hypofunction | specific vestibular exercises over regular exercise
Gaze Stability Exercises
Research also supports task specific exercise
Do the movements that cause dizziness
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| prognosis for unilateral vestibular hypofunction | Generally good
Only about 10-30% of subjects with UVH do not experience improvement
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| how does bilateral vestibular hypofunction present? | much differently than unilateral
Dizziness and vertigo are less common
Pt typically with significant imbalance and oscillopsia
Loss of VOR
Typically a result of ototoxicity
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| what can cause ototoxicity | Gentamycin and other aminoglycosides
Chemo meds
Also caused by Meningitis, neurodegenerative disorders
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| what type of nystagmus will be seen with posterior semicircular canal BPPV | up beating torsional toward to affected ear
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| what type of nystagmus will be seen with horizontal semicircular canal BPPV | geotropic or ageotropic
strongest, most intense, largest velocity nystagmus going toward the most symptomatic side
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| what type of nystagmus will be seen with anterior semicircular canal BPPV | down beating and torsional nystagmus that goes toward the affected ear
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