Podcast
Questions and Answers
Which of the following is the MOST accurate description of 'true vertigo'?
Which of the following is the MOST accurate description of 'true vertigo'?
- A tendency to fall, particularly in dark environments.
- A feeling of imbalance when walking on uneven surfaces.
- Loss of consciousness accompanied by feeling faint.
- The sensation that you are moving when you are not. (correct)
A patient reports feeling faint but denies any true spinning sensations. This is MOST consistent with which type of dizziness?
A patient reports feeling faint but denies any true spinning sensations. This is MOST consistent with which type of dizziness?
- Lightheadedness (correct)
- True Vertigo
- Unsteadiness
- Oscillopsia
Which of the following is the MOST common cause of otologic dizziness?
Which of the following is the MOST common cause of otologic dizziness?
- BPPV (correct)
- Unilateral Vestibular Paresis
- Fistula
- Meniere's Disease
Stroke and TIA are the MOST common causes of neurological dizziness, what percentage of cases do they account for?
Stroke and TIA are the MOST common causes of neurological dizziness, what percentage of cases do they account for?
Which of the following is characteristic of Persistent Postural-Perceptual Dizziness (PPPD)?
Which of the following is characteristic of Persistent Postural-Perceptual Dizziness (PPPD)?
A patient reports episodes of vertigo lasting 1-24 hours, coupled with hearing loss and aural fullness. This symptomology is MOST indicative of:
A patient reports episodes of vertigo lasting 1-24 hours, coupled with hearing loss and aural fullness. This symptomology is MOST indicative of:
Individuals with vestibular disorders often limit their activities. What is a common adaptation they might make to minimize movement-related symptoms?
Individuals with vestibular disorders often limit their activities. What is a common adaptation they might make to minimize movement-related symptoms?
A patient presents with gaze-evoked nystagmus and reports difficulties with coordination. These findings are suggestive of:
A patient presents with gaze-evoked nystagmus and reports difficulties with coordination. These findings are suggestive of:
What is the MOST important characteristic to observe when assessing nystagmus to differentiate between peripheral and central vestibular disorders?
What is the MOST important characteristic to observe when assessing nystagmus to differentiate between peripheral and central vestibular disorders?
What condition is suggested by a nystagmus that changes direction with gaze?
What condition is suggested by a nystagmus that changes direction with gaze?
During a smooth pursuit test, the patient is unable to smoothly follow the target, exhibiting 'catch-up' saccades. This finding could indicate:
During a smooth pursuit test, the patient is unable to smoothly follow the target, exhibiting 'catch-up' saccades. This finding could indicate:
During a saccades test, a physical therapist observes significant overshooting and multiple movements as the patient looks from target to target. These findings may indicate:
During a saccades test, a physical therapist observes significant overshooting and multiple movements as the patient looks from target to target. These findings may indicate:
A physical therapist performs the head thrust test on a patient and observes a decrease in visual fixation when the head is rotated to the left with a corrective saccade. What does this finding indicate?
A physical therapist performs the head thrust test on a patient and observes a decrease in visual fixation when the head is rotated to the left with a corrective saccade. What does this finding indicate?
Impaired VOR cancellation points to potential pathology in which area of the brain?
Impaired VOR cancellation points to potential pathology in which area of the brain?
A physical therapist performs a Dynamic Visual Acuity test and finds a difference of '3 or more' lines on the Snellen chart. What does this result indicate?
A physical therapist performs a Dynamic Visual Acuity test and finds a difference of '3 or more' lines on the Snellen chart. What does this result indicate?
When performing the Head Shaking Test, nystagmus beats towards the intact ear, this is indicative of:
When performing the Head Shaking Test, nystagmus beats towards the intact ear, this is indicative of:
Which of the following BEST describes Singleton's Test?
Which of the following BEST describes Singleton's Test?
What is the interpretation of the Activities-Specific Balance Confidence (ABC) scale?
What is the interpretation of the Activities-Specific Balance Confidence (ABC) scale?
Which of the following findings suggests a central lesion rather than a peripheral one?
Which of the following findings suggests a central lesion rather than a peripheral one?
A patient is suspected of having BPPV. During the Dix-Hallpike test, the patient reports vertigo and exhibits nystagmus when the head is turned to the right. The vertigo subsides with subsequent retesting. This clinical presentation is MOST consistent with:
A patient is suspected of having BPPV. During the Dix-Hallpike test, the patient reports vertigo and exhibits nystagmus when the head is turned to the right. The vertigo subsides with subsequent retesting. This clinical presentation is MOST consistent with:
"5 Ds and 3 Ns" apply to:
"5 Ds and 3 Ns" apply to:
If a patient reports vertigo upon returning to sitting after the Dix-Hallpike test, this is best described as:
If a patient reports vertigo upon returning to sitting after the Dix-Hallpike test, this is best described as:
In cases of canalithiasis, you expect which of the following:
In cases of canalithiasis, you expect which of the following:
Horizontal canal BPPV is being assessed with the roll test, and the patient is in the supine position. The nystagmus beats toward the undermost ear and also shows intense symptoms. This presentation Indicates:
Horizontal canal BPPV is being assessed with the roll test, and the patient is in the supine position. The nystagmus beats toward the undermost ear and also shows intense symptoms. This presentation Indicates:
Following the Epley maneuver and Semont maneuver, what specific advice would you give to a patient?
Following the Epley maneuver and Semont maneuver, what specific advice would you give to a patient?
Brandt's Exercises are MOST appropriate for patients who exhibit:
Brandt's Exercises are MOST appropriate for patients who exhibit:
What type of exercises should Vestibular Rehabilitation therapists apply to stimulate the Vestibular system without exacerbating a patient?
What type of exercises should Vestibular Rehabilitation therapists apply to stimulate the Vestibular system without exacerbating a patient?
If a patient has minimal to no remaining vestibular function. What is the MOST appropriate compensation to be prescribed?
If a patient has minimal to no remaining vestibular function. What is the MOST appropriate compensation to be prescribed?
Which of the following BEST describes the concept of compensation in vestibular rehabilitation?
Which of the following BEST describes the concept of compensation in vestibular rehabilitation?
A patient presents with episodic vertigo, reduction in hearing and aural fullness. Which of the following intervention would be LEAST appropriate in the pre-op phase?
A patient presents with episodic vertigo, reduction in hearing and aural fullness. Which of the following intervention would be LEAST appropriate in the pre-op phase?
Which of the following statements BEST describes the primary difference between Meniere's disease and Migraine with Aura w/ vertigo?
Which of the following statements BEST describes the primary difference between Meniere's disease and Migraine with Aura w/ vertigo?
Management of Perilymphatic Fistula includes all of the following EXCEPT:
Management of Perilymphatic Fistula includes all of the following EXCEPT:
Cervicogenic dizziness is:
Cervicogenic dizziness is:
What is the initial focus of treatment for cervical pathologies of Cervicogenic Vertigo?
What is the initial focus of treatment for cervical pathologies of Cervicogenic Vertigo?
What is the BEST course of treatment for cervicogenic vertigo once the client presents with concussion related dizziness?
What is the BEST course of treatment for cervicogenic vertigo once the client presents with concussion related dizziness?
Which parameter should the physical therapist monitor to measure the intensity of the vestibular exercises?
Which parameter should the physical therapist monitor to measure the intensity of the vestibular exercises?
What is the MOST important concept to acknowledge with VOR adaptation?
What is the MOST important concept to acknowledge with VOR adaptation?
For both saccade and smooth pursuit exercises, how long should these interventions be performed?
For both saccade and smooth pursuit exercises, how long should these interventions be performed?
Which of the following statements BEST describes the purpose of the saccade exercises?
Which of the following statements BEST describes the purpose of the saccade exercises?
Which of the following subjective complaints is MOST indicative of a vestibular-related issue rather than a cardiac issue?
Which of the following subjective complaints is MOST indicative of a vestibular-related issue rather than a cardiac issue?
According to the data presented, which of the following is the LEAST likely cause of dizziness?
According to the data presented, which of the following is the LEAST likely cause of dizziness?
A patient describes their dizziness as a tendency to fall, especially in the dark. Which of the following BEST describes this type of dizziness?
A patient describes their dizziness as a tendency to fall, especially in the dark. Which of the following BEST describes this type of dizziness?
Which of the following is the MOST common cause of otologic dizziness as per the information provided?
Which of the following is the MOST common cause of otologic dizziness as per the information provided?
Which of the following is the LEAST common cause of neurological dizziness?
Which of the following is the LEAST common cause of neurological dizziness?
A patient reports persistent dizziness that is worse when upright and in busy environments, but doesn't experience rotational vertigo. This presentation is MOST consistent with:
A patient reports persistent dizziness that is worse when upright and in busy environments, but doesn't experience rotational vertigo. This presentation is MOST consistent with:
A physical therapist observes direction-changing nystagmus during an oculomotor examination. This finding is MOST indicative of:
A physical therapist observes direction-changing nystagmus during an oculomotor examination. This finding is MOST indicative of:
During a smooth pursuit test the physical therapist notes that the patient is unable to smoothly follow a moving target, with frequent 'catch-up' saccades. This finding indicates:
During a smooth pursuit test the physical therapist notes that the patient is unable to smoothly follow a moving target, with frequent 'catch-up' saccades. This finding indicates:
During the head thrust test, the patient exhibits a corrective saccade when the head is rapidly rotated to the right. This finding suggests:
During the head thrust test, the patient exhibits a corrective saccade when the head is rapidly rotated to the right. This finding suggests:
A physical therapist is performing VOR cancellation testing. Which of the following results would MOST suggest cerebellar pathology?
A physical therapist is performing VOR cancellation testing. Which of the following results would MOST suggest cerebellar pathology?
During a Dynamic Visual Acuity (DVA) test, a patient's vision decreases by three or more lines on a Snellen chart with head movement compared to static conditions. This finding is MOST indicative of:
During a Dynamic Visual Acuity (DVA) test, a patient's vision decreases by three or more lines on a Snellen chart with head movement compared to static conditions. This finding is MOST indicative of:
During the Head Shaking Test, the therapist observes nystagmus with the fast component beating toward the left ear. This typically indicates:
During the Head Shaking Test, the therapist observes nystagmus with the fast component beating toward the left ear. This typically indicates:
In Singleton's Test, a patient walks toward the therapist and turns to assume the Romberg position with eyes closed. The patient loses balance when turning to the right, but not to the left. This suggests:
In Singleton's Test, a patient walks toward the therapist and turns to assume the Romberg position with eyes closed. The patient loses balance when turning to the right, but not to the left. This suggests:
According to the classification of the Motion Sensitivity Quotient (MSQ), an individual scoring 15% would be classified as having:
According to the classification of the Motion Sensitivity Quotient (MSQ), an individual scoring 15% would be classified as having:
A physical therapist uses the Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) to assess a patient with balance issues. A patient demonstrates the MOST difficulty in maintaining balance with which of the following conditions?
A physical therapist uses the Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) to assess a patient with balance issues. A patient demonstrates the MOST difficulty in maintaining balance with which of the following conditions?
A patient’s Dizziness Handicap Inventory (DHI) score improved from 40 to 25 following vestibular rehabilitation. Based on total score >18 has 94% specificity for BPPV, what can you infer from this result?
A patient’s Dizziness Handicap Inventory (DHI) score improved from 40 to 25 following vestibular rehabilitation. Based on total score >18 has 94% specificity for BPPV, what can you infer from this result?
Regarding the Activities-specific Balance Confidence (ABC) scale, what level of self-rated percentage would be MOST indicative of a risk of falling?
Regarding the Activities-specific Balance Confidence (ABC) scale, what level of self-rated percentage would be MOST indicative of a risk of falling?
Which of the following is the BEST initial step when assessing a patient for possible BPPV?
Which of the following is the BEST initial step when assessing a patient for possible BPPV?
During the Dix-Hallpike test the patient's affected ear should be in what position to optimally detect BPPV?
During the Dix-Hallpike test the patient's affected ear should be in what position to optimally detect BPPV?
A patient with suspected vertebral basilar insufficiency (VBI) should be monitored carefully during the Dix-Hallpike test for:
A patient with suspected vertebral basilar insufficiency (VBI) should be monitored carefully during the Dix-Hallpike test for:
After performing the Dix-Hallpike test, a patient reports continued symptoms including vertigo, nausea and lightheadedness. What is the MOST appropriate next step?
After performing the Dix-Hallpike test, a patient reports continued symptoms including vertigo, nausea and lightheadedness. What is the MOST appropriate next step?
According to the information presented, which of the following is MOST commonly associated with BPPV?
According to the information presented, which of the following is MOST commonly associated with BPPV?
What finding is MOST indicative of cupulolithiasis?
What finding is MOST indicative of cupulolithiasis?
The BBQ Roll (log roll) maneuver is performed on which canal?
The BBQ Roll (log roll) maneuver is performed on which canal?
After performing canalith repositioning maneuvers, it has been previously recommended to follow these precautions EXCEPT:
After performing canalith repositioning maneuvers, it has been previously recommended to follow these precautions EXCEPT:
Which of the following would be the MOST appropriate time at which to introduce Brandt's exercises in a client?
Which of the following would be the MOST appropriate time at which to introduce Brandt's exercises in a client?
What is the MOST important concept to AVOID when applying vestibular rehabilitation?
What is the MOST important concept to AVOID when applying vestibular rehabilitation?
Which of the following interventions are MOST appropriate for a patient with minimal to no remaining vestibular function?
Which of the following interventions are MOST appropriate for a patient with minimal to no remaining vestibular function?
A physical therapist is treating a patient with vestibular neuritis. What is the expected prognosis for this patient?
A physical therapist is treating a patient with vestibular neuritis. What is the expected prognosis for this patient?
A patient presents with unsteadiness, wide-based gait and gaze instability when moving. Which of the following conditions is MOST likely?
A patient presents with unsteadiness, wide-based gait and gaze instability when moving. Which of the following conditions is MOST likely?
Which of the following should be determined from a VNG/Rotary Chair test?
Which of the following should be determined from a VNG/Rotary Chair test?
Which of the following are components of what makes up the VESTIBULAR SYSTEM?
Which of the following are components of what makes up the VESTIBULAR SYSTEM?
A patient is diagnosed with Ménière's Disease. Which of the following statements is MOST accurate concerning vestibular rehabilitation?
A patient is diagnosed with Ménière's Disease. Which of the following statements is MOST accurate concerning vestibular rehabilitation?
Which of the following is the LEAST effective strategy for managing Migraine with Aura?
Which of the following is the LEAST effective strategy for managing Migraine with Aura?
Upon examination of a patient, they make the following complaints: episodic vertigo; sensorineural hearing loss; and report hearing a "pop" preceding the onset of vertigo. Based on these complaints, which of the following is your PRIMARY concern?
Upon examination of a patient, they make the following complaints: episodic vertigo; sensorineural hearing loss; and report hearing a "pop" preceding the onset of vertigo. Based on these complaints, which of the following is your PRIMARY concern?
What is the recommended treatment for Perilymphatic Fistulas?
What is the recommended treatment for Perilymphatic Fistulas?
A patient presents to your clinic with neck pain and dizziness that appears to be related to their cervical spine. What is the MOST appropriate course of action?
A patient presents to your clinic with neck pain and dizziness that appears to be related to their cervical spine. What is the MOST appropriate course of action?
What does the research BEST suggest for what will improve Cervicogenic Dizziness?
What does the research BEST suggest for what will improve Cervicogenic Dizziness?
During Visual Oculomotor Retraining for Vestibular patients, it is recommended to do VORx1 before
During Visual Oculomotor Retraining for Vestibular patients, it is recommended to do VORx1 before
If a patient is showing multiple saccades, what should you do?
If a patient is showing multiple saccades, what should you do?
Which of the following is the MOST likely subjective complaint for a patient with a Perilymphatic Fistula?
Which of the following is the MOST likely subjective complaint for a patient with a Perilymphatic Fistula?
To effectively assess Cervicogenic Dizziness, which of the following tests BEST isolates cervical involvement from vestibular dysfunction?
To effectively assess Cervicogenic Dizziness, which of the following tests BEST isolates cervical involvement from vestibular dysfunction?
What intervention should be prioritized when addressing visual and vestibular dysfunction concurrently?
What intervention should be prioritized when addressing visual and vestibular dysfunction concurrently?
A therapist is observing a patient perform VOR x1 exercises, and notes that the patient is constantly losing focus of the central object. What parameter should be adjusted FIRST?
A therapist is observing a patient perform VOR x1 exercises, and notes that the patient is constantly losing focus of the central object. What parameter should be adjusted FIRST?
When using a 'Number Board' for a patient, which issue are you likely treating?
When using a 'Number Board' for a patient, which issue are you likely treating?
When prescribing balance exercises, which variable is MOST important to modify to promote central compensation?
When prescribing balance exercises, which variable is MOST important to modify to promote central compensation?
What is the PRIMARY reason that habituation exercises are recommended towards the end of treatment?
What is the PRIMARY reason that habituation exercises are recommended towards the end of treatment?
What BEST describes the parameters for habituation exercises?
What BEST describes the parameters for habituation exercises?
Regarding medical management of vestibular pathologies, which of the following types of medications should be carefully considered by the therapist, due to their potential hindrance of central compensation?
Regarding medical management of vestibular pathologies, which of the following types of medications should be carefully considered by the therapist, due to their potential hindrance of central compensation?
When prescribing aerobic activity for a patient with vestibular dysfunction, what intensity is recommended with a Borg scale?
When prescribing aerobic activity for a patient with vestibular dysfunction, what intensity is recommended with a Borg scale?
A patient with incomplete Bilateral Vestibular Hypofunction (BVH), can sometimes return to function, EXCEPT:
A patient with incomplete Bilateral Vestibular Hypofunction (BVH), can sometimes return to function, EXCEPT:
Which action is MOST appropriate when treating a patient with near complete Vestibular loss?
Which action is MOST appropriate when treating a patient with near complete Vestibular loss?
A patient is receiving vestibular rehabilitation, and you notice improvement to the point where they are discharged. All of the following indicate treatment EXCEPT for:
A patient is receiving vestibular rehabilitation, and you notice improvement to the point where they are discharged. All of the following indicate treatment EXCEPT for:
All of the following are included with components that help to identify Peripheral Dysfunction EXCEPT:
All of the following are included with components that help to identify Peripheral Dysfunction EXCEPT:
When testing a patient for Cervicogenic Dizziness, and performing Cervical kinesthesia exercises, all are are recommended EXCEPT:
When testing a patient for Cervicogenic Dizziness, and performing Cervical kinesthesia exercises, all are are recommended EXCEPT:
Which of the following statements BEST describes the process of saccadic training?
Which of the following statements BEST describes the process of saccadic training?
According to the parameters with patients with head trauma, what distance should be measured from the bridge of the nose?
According to the parameters with patients with head trauma, what distance should be measured from the bridge of the nose?
All of the following are true regarding Vertigo and BPPV EXCEPT:
All of the following are true regarding Vertigo and BPPV EXCEPT:
If a patient is suffering from dizziness and other issues from vestibular issues, all are likely symptoms presented during an assessment EXCEPT:
If a patient is suffering from dizziness and other issues from vestibular issues, all are likely symptoms presented during an assessment EXCEPT:
When discussing static activities while unstable surfaces, which is LEAST appropriate according to the parameters?
When discussing static activities while unstable surfaces, which is LEAST appropriate according to the parameters?
Flashcards
Vestibular Rehabilitation Goals
Vestibular Rehabilitation Goals
Differentiate dizziness subjective complaints, (vestibular vs. cardiac). Understand vestibular dizziness types presentation, like treatment plans.
Dizziness
Dizziness
A vague term, separated into three categories: 'true vertigo'(illusion of movement), 'unsteadiness' (tendency to fall), and 'lightheadedness'(feeling faint, loss of consciousness).
Nystagmus
Nystagmus
An involuntary, rhythmic, rapid eye movement considered a cardinal sign of vestibular dysfunction that differentiates peripheral versus central disorders.
How common is Dizziness?
How common is Dizziness?
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Causes of Otologic Dizziness %?
Causes of Otologic Dizziness %?
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Causes of Neurological Dizziness %?
Causes of Neurological Dizziness %?
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Causes of Medical Dizziness %?
Causes of Medical Dizziness %?
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Functional Implications of Vestibular Disorder
Functional Implications of Vestibular Disorder
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Examination for Vestibular Disorders
Examination for Vestibular Disorders
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Oculomotor Examination
Oculomotor Examination
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Types of Nystagmus
Types of Nystagmus
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Saccades examination
Saccades examination
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Head Thrust Test
Head Thrust Test
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VOR Cancellation
VOR Cancellation
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Dynamic Visual Acuity (DVA)
Dynamic Visual Acuity (DVA)
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Head Shaking Test
Head Shaking Test
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Static Balance
Static Balance
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Dynamic Balance
Dynamic Balance
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What is the Singleton Test?
What is the Singleton Test?
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Motion Sensitivity testing
Motion Sensitivity testing
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CTSIB test
CTSIB test
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Activities-Specific Balance Scale (ABC)
Activities-Specific Balance Scale (ABC)
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Complete Examination
Complete Examination
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Central Lesion Symptoms
Central Lesion Symptoms
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Onset peripheral vs central?
Onset peripheral vs central?
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Components of the Vestibular System.
Components of the Vestibular System.
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Vestibulo-ocular reflex (VOR)
Vestibulo-ocular reflex (VOR)
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Vestibulospinal reflex (VSR)
Vestibulospinal reflex (VSR)
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Cervico-ocular reflex (COR)
Cervico-ocular reflex (COR)
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Semicircular canals
Semicircular canals
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Function of Otolith
Function of Otolith
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What is VideoNystagmography (VNG)
What is VideoNystagmography (VNG)
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Rotational Chair testing
Rotational Chair testing
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Modified Clinical Test mCTSIB.
Modified Clinical Test mCTSIB.
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BPPV the patients experiences?
BPPV the patients experiences?
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What to do with alternative testing position hallpike?
What to do with alternative testing position hallpike?
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Dix Hallpike test
Dix Hallpike test
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Rebound Phenomenon
Rebound Phenomenon
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Epley maneuver is what and why?
Epley maneuver is what and why?
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Semont maneuver is used what and why?
Semont maneuver is used what and why?
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BBQ Roll for?
BBQ Roll for?
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The roll Test?
The roll Test?
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Pathogenesis of BPPV.
Pathogenesis of BPPV.
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central lesions
central lesions
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Hair cells
Hair cells
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Bilateral Vestibular Hypofunction is used this what?
Bilateral Vestibular Hypofunction is used this what?
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It should be ascertained (from VNG/Rotary Chair tests
It should be ascertained (from VNG/Rotary Chair tests
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DÉBARQUEMENT SYNDROME (MDDS)
DÉBARQUEMENT SYNDROME (MDDS)
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Term for Cervical Vertigo
Term for Cervical Vertigo
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Cervical Vert
Cervical Vert
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Treatment for Cervicogenic Dizziness
Treatment for Cervicogenic Dizziness
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Various Habituation
Various Habituation
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Study Notes
Vestibular Rehabilitation Goals
- Differentiate subjective complaints of dizziness (vestibular vs cardiac)
- Understand common vestibular causes of dizziness and their presentation
- Develop a treatment plan for each diagnosis based on presented case studies
What is Dizziness?
- Dizziness is a vague term separable into three basic categories
- True Vertigo: An illusion of movement that makes you feel you're moving or that the room is moving
- Unsteadiness: A tendency to fall, especially in darkness
- Lightheadedness: Feeling faint, loss of consciousness, commonly associated with nonvestibular disorders such as hypoglycemia, orthostatic hypotension, and/or anxiety.
Importance of Dizziness
- Dizziness leads to 2.6 million ED visits per year (3.3%)
- Dizziness leads to 2.5% of all primary care visits (8 million/year)
- Categories of dizziness causes:
- Otologic
- Neurologic
- General Medical
- Psychiatric/Undiagnosed
Causes of Otologic Dizziness
- BPPV: 49%
- Meniere's Disease: 18.5%
- Unilateral Vestibular Paresis: 13.5%
- Bilateral Vestibular Paresis: 8%
- Middle Ear Dysfunction: 6%
- Fistula: 5%
- n=119
Causes of Neurological Dizziness
- Stroke and TIA: 35%
- Vertebrobasilar Migraine: 16%
- Nystagmus: 8%
- Sensory Ataxia: 7%
- Basal Ganglia Dysfunction: 4%
- Cerebellar Ataxia: 5%
- Seizure: 3%
- Miscellaneous Disorders: 22%
- n=74
Causes of "Medical" Dizziness
- Cardiovascular 23-43%
- Hypotension
- Cardiac Arrhythmia
- Coronary Artery Disease
- Infection 4-40%
- Medication 7-12%
- Hypoglycemia 4-5%
- n=40
Persistent Postural-Perceptual Dizziness (PPPD)
- The primary symptoms include persistent postural dizziness without rotational vertigo
- Worse when upright or in busy environments, illness or stressed events, and no identifiable cause
- Renamed Chronic Subjective Dizziness (CSD) by Staab in 2012
- Exacerbated by movement, no identifiable vestibular or visual impairment to explain the dizziness
Summary of Vestibular System Disorders
- A chart was included summarizing the different vestibular system disorders
- BPPV
- Nystagmus: + present
- Duration: seconds
- Specific Symptoms: Acute spinning
- Precipitating Action: turning in bed
- Vestibular Neuritis
- Nystagmus: Not present
- Duration: 48-72 hours
- Specific Symptoms: Acute onset, motion sensitivity and vomiting
- Precipitating Action: not applicable
- Meniere's Disease
- Nystagmus: + present
- Duration: 1-24 hours
- Specific Symptoms: Fullness of the ear ,hearing loss tinnitus and vomiting
- Precipitating Action: Not applicable
- Bilateral Vestibular Disorder
- Nystagmus: +/- present
- Duration: permanent
- Specific Symptoms: Gait ataxia, oscillopsia
- Precipitating Action: not applicable
- Fistula
- Nystagmus: - present
- Duration: Seconds
- Specific Symptoms: Loud Tinnitus
- Precipitating Action: Head trauma, sneezing or nose blowing
Functional Implications
- Individuals suffering from a vestibular disorder limit their activities
- Adopt a rigid head position to minimize movement-related systems
- May develop fear of falling, anxiety and even depression
- Have difficulty walking on uneven surfaces
- Tend to limit head movements and avoid busy visual environments
- Adopt a wide base of support and frequently hold on to walls or nearby objects
Examination
- Subjective
- Oculomotor
- Balance (Static and Dynamic)
- Function
- Motion Sensitivity
- Posture
- ROM
- Strength
- Coordination
Subjective Examination
- Chief Complaint
- Onset
- Duration
- Frequency
- Provocative positions / situations
- Remitting positions / situations
- PMHx, FamHx, SocHx
- Medications
- Diagnostic Test Results
Specific Questions
- Oscillopsia
- Headaches
- Positioning Symptoms
- Motions Sensitivity
- Issues in dark, busy environments
- Exertion Induced (vertigo with strain may suggest a fistula)
- Coordination Issues
- Incontinence/Memory Loss (normal pressure hydrocephalus)
Oculomotor Examination
- Ocular Motility (simple ROM of eyes)
- Nystagmus
- Spontaneous
- Gaze evoked
- Direction changing or follows Alexander’s Law
- Saccades
- Smooth Pursuit
- Head Thrust
- VOR Cancellation
- Dynamic Visual Acuity (DVA) Head Shaking Nystagmus
Nystagmus
- Nystagmus involves involuntary, rhythmic and rapid eye movement as a cardinal sign of vestibular dysfunction
- Critical factors to observe with Nystagmus includes latency, plane, direction and duration for peripheral vs central disorders
- Includes a fast phase movement in one direction and a slow phase in the opposite direction
- Nystagmus is named based on the direction of the fast phase
- A patient with acute unilateral vestibular lesion (UVL) might present with a right beating nystagmus
- Indicates the eyes are moving quickly to the right in the horizontal plane, then slowly to the left with each cycle
- View eyes looking left, strait and right and observe of Nystagmus
- Vertical Nystagmus, it is a central finding
Direction Changing Nystagmus
- If it switches directions in gaze right vs gaze left, it is suggestive of central pathology
Smooth Pursuits Examination
- Patient follows your finger as you move it through a pattern
- Assess the quality of movement for any “catch up” saccades
Saccades Examination
- Observe as a patient looks from target to target
- Significant overshooting and multiple movements is a Central Sign
- One undershoot is considered normal
Head Thrust Test (Head Impulse Test)
- Tilt head forward 30 degrees, ask patient to focus on your nose, slowly move head side to side while observing for visual fixation
- Randomly turn there head quickly and ask the patent to remain focused towards the nose (20 degrees)
- Positive head thrust can increase sensitivity by randomizing the direction of movement, be careful not to force ROM
- Highly Specific 95%, not highly sensitive (38%)
- HEAD MOVEMENT = DIRECTION of Dysfunction
- a decrease in fixation with forced LEFT ROTATION means LEFT DYSFUNCTION
VOR Cancellation
- VOR is suppressed during head movement in order to keep focused on the target
- Unilateral Vestibular lesions do not impair VOR Cancellation unless the spontaneous nystagmus prevents eye tracking systems
- Impaired VOR cancellation is an indication of Cerebellar Pathology
- Tested by titling patient head forward 30 deg, then keeps patient's head facing while stepping side to side
- Tested when subject clasps hand together and points their thumbs upwards, then rotates head and body 30 degrees right
Dynamic Visual Acuity Test
- Patient reads Snellen Chart and score
- Check if it there is a "3 or more" line different
Head Shaking Test
- VOR performed using Frenzel of infrared goggles as fixation must be eliminated for accuracy
- Eye movements observes in complete darkness for 10s, and neck placed in 30 degrees of flexion
- Head vigorously shakes in rotation at 2 Hz, and neck moves from 30-45 degrees for 20-30 cycles. Document nystagmus
- Individuals w/unilateral vestibular hypofunction/loss will exhibit nystagmus that will beat (fast part) towards the intact ear and absent in those with bilateral vestibular loss
Static Balance
- Romberg EO/EC/Foam
- Sharpened Romberg EO/EC/Foam
- Single Leg Stance
- Results will vary with patient's Visual Fixation
Dynamic balance
- Gait with Head Rotation
- Gait with absent vision
- Decreased base of support
- Singleton's Test
- Gait Velocity (normal is approximately 3' per second)
- Standard Assessments DGI, Berg, Timed Up and Go
Singleton’s Test
- Patient walks towards therapist a normal speed and assumes romberg position with eyes closed
- Assessed this 2x, 1x turning to the right, 1x turning to the left
- If patient loses balance when turning to the right, but not to the left is suggestive of right vestibular hypofunction
Function
- Ambulation: indoors, outdoors, uneven surfaces
- Picking up objects off the floor
- Stepping over objects
- Carrying objects (laundry)
- Cooking, Shopping, Work and Lesiure
Motion Sensitivity
- Positions being tested:
- Sitting to supine
- Supine Left side
- Supine Right Side
- Supine to sitting
- Left Dix Hallpike
- Right Dix Hallpike
- Sitting to nose to left knee
- Sitting erect
- Sitting nose to right knee
- Sitting neck rotation
- Sitting neck flexion and extension
- 180 deg turn to right
- 180 deg turn to left
- Symptom intensity rated on scale from 0-5 ( subjective or patient response)
- Sympton Duration rated on Scale from 0-3
- (5-10 sec = 1, 11-30 sec 2, > 30 sec = 3)
- Total score intensity plus duration for each position change
MSQ ( motion sensitivity quotient) # of Positon x totals score/ 20.48
Abbott rating
- 0-10 mild
- 11-30 moderate
- 31-100 severe
Dizziness Handicap Inventory
Functional: (9questions and max points is 36) Emotional: (9 questions , max points is 36) Balance is common for all Activities Physical:(7 questions and max points is 28) Total Point is 100( a minimum score is 0) Rating for score the higher the score, the greater perceived handicap due to dizziness 0 = is interpreted of nor perceived disability
18 has 94 percent specifically for BPPV Minimum clinically important difference for DHI IS II POINTS
Activities-Specific Balance Confidence Scale (ABC), measured elder patients level of confidence in performing community activities without the loss of balance in falls upon (16 functional activities: an individual self-rates on a continuum scare 1005 confident With a representing no confidence
The ABC score has been show in the elderly:
- decreases their mobility and is highly correlated with the DH1
- For the patients over 65 years of age (Durachingsky. Zoof)
- scores less than 671 Indicates a risk of falling and can occurutely classify by People, WHO, fall 841 of the time minimal climically importand difference has to been obtained
- for patients with vestibular dysfunction
Complete examination
- Strength, Sensation and Reflex
- Spasticity. Coordination
- Positionals and function
- ROM
Findings suggest a Central Lesion
- Vertical gaze nystagmus
- Saccades. VOR Cancellation
- Direction Changing Nystagmus
- Coordination deficits
- Spasticity
Characteristics of vertigo - Peripheral Vs Central Pathology
Peripheral onset is sudden (often to follow an illness) VS. Central is slow and gradual ( sometimes without warning) maybe associated with medication
- intensity Severe vs. Poorly defined
- duration is brief, episodic VS. is constant, longer
- Nausea is Frequent S/S Present VS Infrequent S/S
- Tinnitus/Hearing loss can be Present VS Absent
- Central Nystagmus is Vertical versus Torsional/horizontal when Peripheral
Type of Central Lesions
Traumatic Brain Injury
- Epilepsy
- Demyelinating diseases and Tumors
- Vascular (including CVA. VBI)
- Degenerative changes
Findings in the examination may necessitate further diagnostic imaging if cause is not 'known'
Key Components of Vestibular
- Three main components:
- Peripheral sensory apparatus.
- Central processor that include Cerebellum and the vestibular nuclear
- Mechanism for motor output:
- motor neurons and positioning movements
Important Reflexes
- Vestibulo-ocular reflex (VOR): stabilzes gaze during head movement
- Vestibulospinal reflex (VSR): helps maintain head and postural stability
- Cervico-ocular reflex (COR): ocular stabilization reflex that is elicited by rotation of the neck
Semi Circular canals
- (SCCs) Provide sensory input regarding head velocity, which enables the (VOR) in order to generate an eye
- movement that which matches the velocity of the head moment,The designed results that the eye which remains clear in
- space during head motion which includes (Anterior, Lateral and posterior Semilunar canals hair cells is that which helps each, and that there's 2. specialing
Hair Cells
- hair cell, otolith organ:
- that are biological sensors, and that converts dispalcement due to head motion and is
- which the neural system functions
linear
Otolith: Measure Acceleration,Otolithia in otoconia top section part
Saccule measure vertical force Utricle measure horizontal force
Videonystagmography (VNG)
Systems offer more advanced diagnostic info through measuring eye moment under various conditions.
- Infraad a Camera system in which is mounted on a google set, also allows for Review testing and findings
BPPV is dizziness with patients with static head positioning
- The patient knows which position are involved and avoids them, symptoms usually abate quickly with movement out of provoking positions. Patients complain of vertigo (spinning) while head moving in static positions
Patient presentation: dizziness with static head position
- Patient's usually do not know which positions are involved
- Symptoms usually abate quickly with movement out of provoking positions
- The first episode is usually the rolls during the snoozing alarm or retrieving object item/s, can you try to be still
- Patient will decrease balance secondary ( VT /Visual testing for balance)
BPPV Cont.
- If it moves into 30 degrees below horizontal, the client experiences Hallpike symptoms (vertigo)
- Vertigo and torsoinal Nystagmus is caused of posterior rare = is that a lot the episodes are going on and on, for past Patient can reports dizziness
Test for BPPV Dix Hallpike Test
Patients starts in long sit with head rotation towards the side The patient test is kept there eye's open , quick bring In the spine position which a head extension or more
Alternative texting postion for postier canal if clients are on test / testing
Turn patient's head 45 degrees away from the opposite side
- if testing the correct canal is turn head 45 degrees to the ( Left) side
- the the patient should be guided quickly the patient that is on the ( right side canal) observe for the same in directional, the duration and in (Nystagmus.
Hall Pike Cont. vs Vertebal Artery Insuficeincy
Hall pike: extension is only at 10- 20 degrees with rotation is 30 degrees VBI : Extension is 30 degree rotation : Hold for 30 seconds and they count from 10 to 0 backwards ( if client is setting / and or test) is with 5.DS. and 5(N)
Vertiabl basliar Insuffinceiny can be referred for a follow ( Double , Dizzy,Dsyarthria, Drop /Dsyphiga and (N)/ Nystagmus which is the worst and (unilateral numb
Plus VBI which is under 1% of New England medical Center(posterior of Over 400 patients . vertiago
- ** Perform the Dix-Hallpike on the unaffected first for speed
Rebound PHENOMENON: common complaints after test, support behind them for 60 seconds
PATHOGENESIS: is more common in the elderly and is idiopathic
- including : head trauma,viral labyrinthitis, vestibular neurtisis and perlymphfisula
the time
Canlathisis :disalodge is in the semiar canals , ( usually positor) to the will in for pulling cupula out of positoin ( EXPECT LATENCY
CUPULOLITHIASIS
Oithoca is an in end the making expect immenstgmus OR IT IS IS INFRAT
Use the Semont a library
(WHICH CANAL THE TESTS)
IF ITS IS ( RIGHT AND BEST OF SIDE) :upberT AN THE torsion + the direction
- Anterior the( down beat a d torsion and is ( contolateral the worse ( straight on ( (supine
( Roll Test) 1)horizontal C: ageoptiic is Away is one both side/s )
Horizontal the canithiasis Geo trophic's what to is is word one both / side's)
-
- ** FRENSEL lenser this helps make observation, magnifies their eyes and prevents individuals fixation.
ROLL TEST CANAL BPPV
Patient is in supine neck flex at 30 degrees. then returns head to midline, then holds side position 60 seconds.. then repeat other side again Nystagmus is the horizontal canal in geotopic position
- If positive it indicated cupuliolathiasis and its essential to rotate head right or left -If its Geotropic
Anterior Canal for the ( less evidence) - but its. - may - be, 39% but most studies lack of in diagnostics - there more effective at those are also (www.dizesess.com/sess.com/ balance balance -
TREATMENT
Epley Is mostly used/ mostly for (PosterotCanithias for which to has Latins and Fatigue The Semont a library: is used For: Cupullo for which No Latency or The horizontal . Canel BBQ Roll: the log: For . - horizontaliathe . ( Cannithais Brandt Exercies: Is to repeat movements that per day until no systems are, to Consective. to. be . to used. by the are be those effective
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ESTIMED LENGTH OF STAY
Patient with respond. quickly to a few treatments (generally Ix per week) with a decrease in symptoms greater than 75%. 50 % occurs at 5% a years, but it is also common Posterior unstable also ( bpev) ,
Most patients should have full return to activities as they compensate through the intact 1/2 Vestibular & through visual/somatosensory system PT stay is a range of about 1-2 months
Unilateral Hyop function (peripheral)
Which is caused by inside issues, from vestibular or that that's common a a Sudden. one set that is has with , to for that there are the to , to one other the
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