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211 exam 1

Vestibular Rehabilitation

3 components of balance Somatosensory Vision Vestibular
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
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
what is nystagmus abnormal eye movements due to interruption in the VOR
how is nystagmus named? by the direction the quick beat
can nystagmus change direction? yes based on the position
what type of nystagmus is seen with BPPV? torsional nystagmus, eyes twist
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
when can CNS dampen nystagmus? when the eyes can fixate why blackout or blurry googles are used for detecting nystagmus in TBI
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
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
most vestibular issues are ____ episodic, they come and go, spinning not present all the time
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?
vestibular neuritis vestibular system can become inflamed after a viral infection
with vestibular pts we need a way to determine if patient has ____ symptoms or ____ symptoms peripheral, central
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
What things might we see if patient has central signs? Vertical nystagmus
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
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
why is vertebral artery testing important? we can make the occlusion worse during BPPV testing, can result in stroke
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
what does HINTS stand for? Head Impulse Nystagmus Test of Skew
head impulse test test for VOR- peripheral reflex, oculomotor, vestibular cranial nerves
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
direction changing nystagmus is usually a ____ sign central
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
onset of BPPV mid 50's
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
two main types of BPPV Canalithiasis- free floating otoconia Cupulolithasis- otoconia adhered to cupula
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
cupulolithiasis BPPV symptoms onset of vertigo immediate, presence of nystagmus immediate, intensity persistent, length of symptoms greater than 60 seconds, otoconia adhered to cupula
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
what should you monitor in dix hallpike position? length of symptoms and nystagmus if visible for further diagnosis
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.
why would you use modified dix hallpike? Best for patients who have limited neck extension ROM
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.
gold standard for posterior canal canalithaiasis Epley maneuver
steps for epley for PSCC BPPV steps on slide 20
remission rate for posterior canal canalithiasis using epley 85-95%
foster half summersault is for what type of BPPV? PSCC BPPV steps on slide 22
tests for horizontal canal involvement roll test (slide 23, steps on slide 24,26)
what is bow and lean test used for? to determine the affected slide in horizontal SCC BPPV (steps slide 27)
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
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
what is damaged in vestibular neuritis/labyrinthitis? the nerve
causes of unilateral vestibular hypofunction Labyrinthitis, neuritis, tumors/neuroma resections
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
prognosis for unilateral vestibular hypofunction Generally good Only about 10-30% of subjects with UVH do not experience improvement
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
what can cause ototoxicity Gentamycin and other aminoglycosides Chemo meds Also caused by Meningitis, neurodegenerative disorders
what type of nystagmus will be seen with posterior semicircular canal BPPV up beating torsional toward to affected ear
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
what type of nystagmus will be seen with anterior semicircular canal BPPV down beating and torsional nystagmus that goes toward the affected ear
Created by: bdavis53102
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