Vestibular Rehabilitation Quiz

Questions and Answers

What is vestibular rehabilitation?

Specialised assessment and treatment techniques aimed at addressing vestibular dysfunction.

Which of the following are symptoms of vestibular disorders? (Select all that apply)

Euphoria

Dizziness/light-headedness (correct)

Vertigo (correct)

Hearing loss (correct)

Dizziness is the most common complaint of patients over 75 years presenting to primary care.

True

What role do hair cells in the semicircular canals play?

They respond to angular velocity of head movement. Signup and view all the answers

Which age group experiences the highest prevalence of dizziness?

Older than 65 years Signup and view all the answers

Match the following vestibular terms with their definitions:

Vertigo = The sensation of self-motion when no motion is occurring Dizziness = A disturbed or impaired spatial orientation Nystagmus = Involuntary eye movement Oscillopsia = False sensation of the visual surroundings oscillating Signup and view all the answers

What percentage of patients with dizziness consult their general practitioner?

Approximately 60% Signup and view all the answers

What are the three types of semicircular canals?

Anterior Signup and view all the answers

Which two main areas does the vestibular nerve send fibers to?

Vestibular Nuclei Signup and view all the answers

What does VOR stand for?

Vestibular Ocular Reflex Signup and view all the answers

What is the primary function of the vestibulospinal reflex?

Maintain postural control Signup and view all the answers

Nystagmus is a rhythmical oscillation of the _____

eyes Signup and view all the answers

What does a decrease or absence of firing in the vestibular system indicate?

Loss of vestibular function Signup and view all the answers

Which of the following is a central vestibular disorder?

Ischaemia Signup and view all the answers

The _____ is responsible for integrating information from the vestibular system with other sensory systems.

Cerebellum Signup and view all the answers

What are commonly reported symptoms associated with a diagnosis of vestibular migraine?

Spinning vertigo Signup and view all the answers

What causes nystagmus to be named?

The direction of the fast phase Signup and view all the answers

Vestibular migraine can only occur in conjunction with other neuro-otological events.

False Signup and view all the answers

Vertigo and dizziness are always caused by vestibular system pathology.

False Signup and view all the answers

How long must vestibular symptoms last to meet the diagnostic criteria for vestibular migraine?

5 minutes to 72 hours Signup and view all the answers

Which of the following diagnostic criteria have been established for vestibular migraine?

Episodes of vertigo Signup and view all the answers

What is the commonest cause of vertigo in peripheral vestibular disorders?

Benign Paroxysmal Positional Vertigo (BPPV) Signup and view all the answers

What can trigger symptoms of BPPV?

Certain head movements Signup and view all the answers

What percentage of patients reported difficulty with balance tasks during posturography?

70% Signup and view all the answers

Patients with vestibular migraines often experience increased symptoms with __________ changes.

postural Signup and view all the answers

What percentage of BPPV cases does it affect the posterior semicircular canal?

85%–95% Signup and view all the answers

What type of imaging is recommended for patients with persistent or progressive dizziness?

MRI Signup and view all the answers

BPPV is thought to be caused by detached ______________ entering one of the SCCs.

otoconia Signup and view all the answers

The symptoms of BPPV generally take a long time to resolve.

False Signup and view all the answers

Name one condition that may cause dizziness and hearing loss.

Ménière's disease Signup and view all the answers

Vestibular sedatives are effective for managing acute vertigo.

True Signup and view all the answers

What is the treatment approach for BPPV?

Physical manoeuvres to reposition displaced otoconia Signup and view all the answers

What symptoms characterize an attack of Ménière’s disease?

All of the above Signup and view all the answers

Bilateral vestibular hypofunction usually results in vertigo.

False Signup and view all the answers

What is Persistent Postural Perceptual Dizziness (PPPD) also known as?

Chronic subjective dizziness Signup and view all the answers

What is the ability to move the eyes from one stationary target to another called?

Saccades Signup and view all the answers

What does VOR cancellation allow the patient to do?

Suppress the VOR and move the eyes in phase with the head Signup and view all the answers

The normal VOR allows the eyes to make a compensatory movement to stay on a ______ when the head moves.

stationary target Signup and view all the answers

In abnormal cases, the eyes may over- or under-shoot the target.

True Signup and view all the answers

Match the following tests with their purposes:

Hallpike–Dix test = Diagnostic for BPPV Horizontal roll test = Examine for nystagmus direction and intensity VOR = Compensatory eye movement during head movements Gaze stabilization = Keep eyes steady on a target while head moves Signup and view all the answers

What is the expected nystagmus direction in the left Hallpike Dix position?

Upbeating and torsional towards the affected side Signup and view all the answers

What indicates canalithiasis of the horizontal canal during a horizontal roll test?

Geotropic nystagmus when the head is turned to either side Signup and view all the answers

What is one of the main disadvantages associated with vestibular procedures?

Increased risk of hearing loss Signup and view all the answers

What disease is treated with betahistine and thiazide diuretics?

Ménière’s disease Signup and view all the answers

Betahistine is a vasodilator that works indirectly on the inner ear.

False Signup and view all the answers

What is the preferred surgical option for patients with intractable BPPV?

Occlusion of the PSCC Signup and view all the answers

What is the aim of surgery for patients with unilateral Ménière's disease?

To eliminate all vestibular function Signup and view all the answers

Which management method is reserved for small tumors that are not growing?

Conservative management Signup and view all the answers

What key symptom is assessed in vestibular patients regarding hearing?

Loss of hearing Signup and view all the answers

What condition may indicate a central nervous system lesion based on nystagmus characteristics?

Spontaneous downbeating nystagmus Signup and view all the answers

What does the dynamic visual acuity test measure?

How visual acuity degrades during head movement Signup and view all the answers

Stereotactic radiosurgery accurately applies radiotherapy to the site of the ______ with minimal damage.

acoustic neuroma Signup and view all the answers

What is a primary advantage of the surgery discussed?

Minimal brain retraction Signup and view all the answers

Which technique is specifically mentioned for preserving remaining hearing?

Topical gentamicin ablation therapy Signup and view all the answers

What is a disadvantage of the retrosigmoid approach for tumor removal?

It requires cerebellar retraction Signup and view all the answers

What occurs as a result of topical gentamicin therapy?

It diffuses into the inner ear Signup and view all the answers

What is a characteristic of the middle cranial fossa approach when attempting to preserve hearing?

It is technically demanding Signup and view all the answers

What is the reported treatment success rate of stereotactic radiosurgery for acoustic neuroma?

97.7% Signup and view all the answers

What should be a primary focus during the assessment of a vestibular patient?

Identifying symptoms that can be provoked Signup and view all the answers

Which symptom is specifically assessed to determine a vestibular issue related to hearing?

Ringing in ears Signup and view all the answers

Which neurological symptom might be crucial in the history taking for a vestibular patient?

Numbness or pins and needles Signup and view all the answers

What type of questions are important to address during the history taking of a vestibular patient?

Questions about vision problems during an attack Signup and view all the answers

Study Notes

Introduction to Vestibular Rehabilitation

Vestibular rehabilitation focuses on the assessment and treatment of patients with vestibular dysfunction.
Disorders lead to symptoms such as vertigo, oscillopsia, gait and balance impairment, nausea, and nystagmus.
Recovery after vestibular injury emphasizes the importance of exercise, documented by pioneers Cawthorne and Cooksey in the 1940s.

Epidemiology of Vestibular Disorders

Dizziness affects approximately one in five individuals aged 18 to 64.
Among individuals over 65, prevalence of dizziness rises to one in three, with high rates in those over 75.
Many affected individuals do not seek medical help, indicating underreporting of dizziness issues.

Signs and Symptoms of Vestibular Disorders

Primary symptoms to assess include vertigo, light-headedness, nausea, vomiting, oscillopsia, and nystagmus.
Associated problems may involve neck/back pain, physical deconditioning, agoraphobia, and falls.
Disturbance in balance is often accompanied by fatigue and can lead to secondary issues like hearing loss and anxiety.

Anatomy and Physiology of the Vestibular System

The vestibular system comprises peripheral and central components, located primarily in the temporal bone of the skull.
Peripheral system includes the vestibular end organ (semicircular canals and otolith organs).
Semicircular canals (SCCs) consist of three on each side, functioning to detect angular motion.
Otoliths (utricle and saccule) sense linear acceleration and gravity through specialized hair cells.

Vestibular Reflexes

Vestibular Ocular Reflex (VOR) stabilizes vision during head movements by coordinating eye movement.
Vestibulospinal Reflex assists in maintaining vertical posture and balance.
Disruption in these reflexes leads to significant balance impairment and increased fall risk.

Diagnosis and Assessment

Accurate diagnosis necessitates detailed history taking and assessments of physical impairments and functional ability.
Audiological assessments and imaging may aid in identifying specific vestibular disorders.
Complications from dizziness can lead to severe impacts on quality of life and require targeted management strategies.

Interventions and Management

Management strategies include vestibular rehabilitation exercises designed to improve balance and reduce dizziness.
Treatment for conditions like Ménière’s disease, vestibular migraine, and Benign Paroxysmal Positional Vertigo involves a combination of physiotherapy and medical approaches.
Collaboration with a multidisciplinary team is crucial for effective treatment planning.

Patient-Centered Care and Resources

Support groups and specialist centers provide additional resources for patients experiencing vestibular disorders.
Patient education plays a significant role in managing expectations and understanding rehabilitation processes.

Conclusion

Vestibular rehabilitation remains a vital field in physiotherapy, addressing a wide range of disorders that significantly affect balance and overall quality of life.
Continued research and investment in this specialty can enhance treatment outcomes for those affected by vestibular dysfunction.### Peripheral and Central Vestibular System
The vestibular system comprises semicircular canals (anterior, posterior, horizontal) and otoliths (utricle, saccule).
The vestibular nerve transmits signals from the peripheral apparatus to the central nervous system.
Key areas influenced by the vestibular system include the cerebellum, vestibular nuclei, and oculomotor nuclei (cranial nerves III, IV, VI).

Function of the Vestibular System

The vestibular system is responsible for maintaining balance, spatial orientation, and stabilizing vision through reflexes.
The vestibulo-ocular reflex (VOR) allows the eyes to maintain fixation on an object while the head moves, counteracting movement with equal velocity in the opposite direction.
The vestibulospinal reflex (VSR) plays a vital role in postural control, adjusting body position in response to changes in head position.

Pathophysiology of Vestibular Disorders

Disorders are classified into peripheral (e.g., vestibular neuritis, Ménière’s disease) and central (e.g., ischemia, multiple sclerosis) based on anatomical location.
Symptoms include vertigo, nystagmus (eye oscillations), nausea, and vomiting, often resulting from abnormal autonomic pathway activation.
Vestibular neuritis is characterized by acute vertigo, nausea, and vomiting, often precipitated by a viral infection and leading to unilateral vestibular hypofunction.

Nystagmus Characteristics

Nystagmus is categorized by a slow phase in one direction and a fast corrective phase in the opposite direction, named according to the fast phase.
Common example: left-beating horizontal nystagmus involves slow eye movement towards the right and fast movement towards the left.

Implications of Asymmetry in Vestibular Function

An imbalance in firing rates between the two sides of the vestibular system can lead to dizziness and instability.
Loss of function on one side results in compensatory increased firing on the intact side, contributing to symptoms and reflexive adjustments.

Other Causes of Dizziness

Besides vestibular pathologies, conditions such as orthostatic hypotension, cardiac issues, psychiatric disorders, and hyperventilation may also induce dizziness and should be evaluated before physiotherapy referral.### Vestibular Disorders and Symptoms
Spontaneous nystagmus can appear in acute peripheral vestibular disorders, with the fast phase beating away from the affected side.
Nystagmus may not be visible in room light but can be observed with infrared goggles, which remove visual fixation.
Disorders affecting the central vestibular system include cerebrovascular accidents, traumatic brain injury, and multiple sclerosis.
Symptoms of vestibular disorders typically resolve within 2 to 6 weeks.

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most common cause of vertigo in peripheral vestibular disorders.
Lifetime prevalence of BPPV is 2.4%, with a yearly incidence rate of 0.6%; prevalence increases significantly in individuals over 60 years.
Characterized by short-lived, positional vertigo (usually under 1 minute) triggered by specific head movements, such as rolling over in bed.
Two types of BPPV are recognized: canalithiasis (otoconia floating in the canal) and cupulolithiasis (otoconia adhering to the cupula).

Diagnosis and Treatment of BPPV

The Hallpike–Dix test is used for diagnosing BPPV.
Commonly affects the posterior semicircular canal (85-95% of cases), with occasional involvement of horizontal and rarely anterior canals.
Effective treatment involves physical maneuvers aiming to reposition displaced otoconia, leading to symptom resolution in most cases.
BPPV has a recurrence rate of about 25%.

Ménière’s Disease

Caused by increased volume or absorption issues with endolymph, leading to endolymphatic hydrops.
Symptoms include ear fullness, hearing reduction, tinnitus, and episodes of vertigo lasting 30 minutes to 72 hours, often accompanied by nausea and vomiting.
Management includes medication, dietary changes, rest, and sometimes surgery for severe cases.

Bilateral Vestibular Hypofunction

Causes include infections (meningitis), tumors, Ménière’s disease, autoimmune diseases, and ototoxic drugs.
Patients typically do not report vertigo but experience balance issues, abnormal gaze stability, and oscillopsia, a condition where surroundings seem to bounce.
Vestibular rehabilitation can be used for improvement, though outcomes may vary.

Persistent Postural Perceptual Dizziness (PPPD)

A chronic functional vestibular disorder characterized by non-spinning vertigo and unsteadiness lasting more than three months.
Typically triggered by postural changes or various visual stimuli, with symptoms exacerbated by head movements.
Diagnosis criteria include a history of migraine, occurrence of symptoms on most days, and episodes lasting from 5 minutes to 72 hours.

Vestibular Migraine

Considered a prevalent cause of episodic vertigo, often underdiagnosed.
Diagnosed with criteria from the International Headache Society, focusing on migraine history and vestibular symptoms.
Episodes often coincide with anxiety and may include significant head motion intolerance and unsteadiness.
Vestibular rehabilitation, along with medication and counseling, is suggested for management.

Key Observations and Studies

Vestibular migraines display more anxiety compared to healthy individuals and non-vestibular migraine patients.
Up to 70% of patients may show abnormal oculomotor testing during attacks.
Vestibular rehabilitation may include habituation exercises and balance retraining tailored to patient needs.

Surgical Techniques for Acoustic Neuroma Management

Minimal brain retraction is a significant advantage of certain surgical approaches for acoustic neuroma.
Retrosigmoid and middle cranial fossa approaches aim to preserve remaining hearing; however, they can be technically demanding.
If hearing is not viable, gentamicin ablation therapy may be employed, involving topical gentamicin instillation into the middle ear for diffusion into the inner ear.
Topical gentamicin therapy poses risks including potential cerebellar retraction in other surgical methods.

Stereotactic Radiosurgery

Provides targeted radiotherapy to acoustic neuromas with minimal damage to surrounding tissue.
Reported treatment success rate is 97.7%, along with an acceptable toxicity profile.

Assessment Procedures

A thorough assessment is essential for vestibular patients, integrating standard physiotherapy examinations with specific vestibular tests.
Important symptoms to assess include:
- Hearing loss
- Tinnitus (ringing in ears)
- Episodes of dizziness, falling, or loss of consciousness
- Ocular symptoms such as double vision, trouble swallowing, or speaking difficulties
- Other neurological symptoms (e.g., weakness, numbness)

Test Protocols

Proper history taking includes onset, nature, severity, duration, symptom triggers, and associated symptoms.
Differentiation between true vertigo and other forms of dizziness is crucial.
Special tests may provoke symptoms; having an accompanying person during assessment is advised for safety.
Assessment of oculomotor function includes checking for spontaneous nystagmus and performing gaze-evoked tests.

Key Assessment Findings

Oculomotor Examination Procedures:
- Spontaneous Nystagmus: Observing eye movements under room light for abnormal nystagmus.
- Visual Fixation: Test with Frenzel lenses to magnify the eyes and assess nystagmus suppression.
- Smooth Pursuit: Assessing the ability to track moving objects smoothly.
- Saccades: Evaluating the ability to switch focus between stationary targets.
- VOR Cancellation & Gaze Stabilization: Testing how well patients can keep their eyes on a target when the head moves.

Cervical Spine Assessment

Screening of the cervical spine range of movement is part of the initial examination for vestibular issues.
An assessment of visual acuity is conducted using standardized charts to determine the lowest recognizable visual line.

Nystagmus Evaluation

Direction of nystagmus (e.g., upbeating, downbeating, horizontal) is indicative of the underlying vestibular condition.
Evaluating the relationship of nystagmus to head movements helps identify the type of vestibular disorder and its origin.

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Test your knowledge on Vestibular Rehabilitation concepts outlined by Dara Meldrum and Rory McConn-Walsh. This quiz covers essential elements of vestibular function and rehabilitation techniques. Perfect for students and professionals in physical therapy and rehabilitation.