Vestibular Rehabilitation Quiz
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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?

    <p>They respond to angular velocity of head movement.</p> Signup and view all the answers

    Which age group experiences the highest prevalence of dizziness?

    <p>Older than 65 years</p> Signup and view all the answers

    Match the following vestibular terms with their definitions:

    <p>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</p> Signup and view all the answers

    What percentage of patients with dizziness consult their general practitioner?

    <p>Approximately 60%</p> Signup and view all the answers

    What are the three types of semicircular canals?

    <p>Anterior</p> Signup and view all the answers

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

    <p>Vestibular Nuclei</p> Signup and view all the answers

    What does VOR stand for?

    <p>Vestibular Ocular Reflex</p> Signup and view all the answers

    What is the primary function of the vestibulospinal reflex?

    <p>Maintain postural control</p> Signup and view all the answers

    Nystagmus is a rhythmical oscillation of the _____

    <p>eyes</p> Signup and view all the answers

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

    <p>Loss of vestibular function</p> Signup and view all the answers

    Which of the following is a central vestibular disorder?

    <p>Ischaemia</p> Signup and view all the answers

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

    <p>Cerebellum</p> Signup and view all the answers

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

    <p>Spinning vertigo</p> Signup and view all the answers

    What causes nystagmus to be named?

    <p>The direction of the fast phase</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

    Vertigo and dizziness are always caused by vestibular system pathology.

    <p>False</p> Signup and view all the answers

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

    <p>5 minutes to 72 hours</p> Signup and view all the answers

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

    <p>Episodes of vertigo</p> Signup and view all the answers

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

    <p>Benign Paroxysmal Positional Vertigo (BPPV)</p> Signup and view all the answers

    What can trigger symptoms of BPPV?

    <p>Certain head movements</p> Signup and view all the answers

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

    <p>70%</p> Signup and view all the answers

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

    <p>postural</p> Signup and view all the answers

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

    <p>85%–95%</p> Signup and view all the answers

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

    <p>MRI</p> Signup and view all the answers

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

    <p>otoconia</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

    Name one condition that may cause dizziness and hearing loss.

    <p>Ménière's disease</p> Signup and view all the answers

    Vestibular sedatives are effective for managing acute vertigo.

    <p>True</p> Signup and view all the answers

    What is the treatment approach for BPPV?

    <p>Physical manoeuvres to reposition displaced otoconia</p> Signup and view all the answers

    What symptoms characterize an attack of Ménière’s disease?

    <p>All of the above</p> Signup and view all the answers

    Bilateral vestibular hypofunction usually results in vertigo.

    <p>False</p> Signup and view all the answers

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

    <p>Chronic subjective dizziness</p> Signup and view all the answers

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

    <p>Saccades</p> Signup and view all the answers

    What does VOR cancellation allow the patient to do?

    <p>Suppress the VOR and move the eyes in phase with the head</p> 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.

    <p>stationary target</p> Signup and view all the answers

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

    <p>True</p> Signup and view all the answers

    Match the following tests with their purposes:

    <p>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</p> Signup and view all the answers

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

    <p>Upbeating and torsional towards the affected side</p> Signup and view all the answers

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

    <p>Geotropic nystagmus when the head is turned to either side</p> Signup and view all the answers

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

    <p>Increased risk of hearing loss</p> Signup and view all the answers

    What disease is treated with betahistine and thiazide diuretics?

    <p>Ménière’s disease</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

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

    <p>Occlusion of the PSCC</p> Signup and view all the answers

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

    <p>To eliminate all vestibular function</p> Signup and view all the answers

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

    <p>Conservative management</p> Signup and view all the answers

    What key symptom is assessed in vestibular patients regarding hearing?

    <p>Loss of hearing</p> Signup and view all the answers

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

    <p>Spontaneous downbeating nystagmus</p> Signup and view all the answers

    What does the dynamic visual acuity test measure?

    <p>How visual acuity degrades during head movement</p> Signup and view all the answers

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

    <p>acoustic neuroma</p> Signup and view all the answers

    What is a primary advantage of the surgery discussed?

    <p>Minimal brain retraction</p> Signup and view all the answers

    Which technique is specifically mentioned for preserving remaining hearing?

    <p>Topical gentamicin ablation therapy</p> Signup and view all the answers

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

    <p>It requires cerebellar retraction</p> Signup and view all the answers

    What occurs as a result of topical gentamicin therapy?

    <p>It diffuses into the inner ear</p> Signup and view all the answers

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

    <p>It is technically demanding</p> Signup and view all the answers

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

    <p>97.7%</p> Signup and view all the answers

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

    <p>Identifying symptoms that can be provoked</p> Signup and view all the answers

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

    <p>Ringing in ears</p> Signup and view all the answers

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

    <p>Numbness or pins and needles</p> Signup and view all the answers

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

    <p>Questions about vision problems during an attack</p> 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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    Description

    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.

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