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Vestibular Rehabilitation in Acute Care Date: Friday, September 30, 2016 Time: 3:15 PM - 5:15 PM
Session ID & Location: 4E: MtgRm9 CEU Eligibility: 0.20
Presented by: Britta Smith, PT, MMSc, DPT
Session Description: This class will provide an overview of common vestibular diagnoses seen in
the acute care setting and strategies to perform clinical assessments. Differentiation between
causes of acute dizziness will be reviewed. Techniques to perform treatments appropriate to the
bedside and with tools commonly available to the acute care therapist will be shown. This
interactive session will allow attendees to practice bedside tests of vestibular function and discuss
documentation and billing.
Presenter Bio(s): Britta Smith, PT, MMSc, DPT is the Lead Acute Care Therapist at Wellstar Atlanta
Medical Center in Atlanta, GA. In her role at AMC, she treats patients with vestibular disorders in
both inpatient and outpatient settings. She has her competency in vestibular rehabilitation and
has taught vestibular and balance retraining classes. Ms. Smith is a past chair of the Vestibular
Rehabilitation Special Interest Group and current Academy of Neurology Historian. She has
served as a guest editor of a Neurology Report vestibular rehabilitation special topic issue and is a
reviewer for the Journal of Neurologic Physical Therapy.
Vestibular Therapy in Acute Care Georgia and Tennessee PT Association Meeting 2016
Pre-and Post Test
Britta Smith, PT, MMSc, DPT
1. A patient was seen in the emergency room about 30 minutes after awakening with severe, first-ever acute vertigo, nausea, vomiting, and imbalance. The patient is not able to sit or walk unassisted. The PT sees this patient later that morning and observes sustained horizontal nystagmus. Which of the following tests is most useful in determining if this patient has acute vestibular neuritis versus a central disorder?
a. Cranial nerve testing b. CT scan of head c. Head impulse test d. Dix Hallpike test
2. A patient was admitted to the hospital after being thrown from a horse with resulting leg injuries. During evaluation, the PT notices that the patient complains of dizziness immediately upon sitting. Upon inquiry, the patient reports that the same symptoms occur more strongly upon lying back down and rolling in bed. What should be considered as the next step in this patient's evaluation?
a. Dix Hallpike maneuver b. Vestibular function testing c. Recommending to the physician that meclizine be prescribed d. Blood pressure assessment
3. A patient was admitted through ED with acute vertigo with suspicion of stroke, but the CT scan and MRI were both negative. The physician has diagnosed acute vestibular neuritis and has referred the patient to PT to assure safe discharge home alone. The PT notes nystagmus to the right with right gaze and to the left with left gaze. What action should the therapist take?
a. Reassure the patient that the nystagmus will resolve within 72 hours b. Teach the patient gaze stabilization exercises c. Contact the physician immediately as this person probably has had a stroke d. Assessment balance and gait safety and recommend outpatient therapy
4. An elderly patient reports intermittent dizziness and unsteadiness, but all medical tests are inconclusive and the PT evaluation does not show a vestibular cause for symptoms. Does evidence support adding vestibular exercises such as gaze stabilization to reduce fall risk? ___yes ___no 5. When a patient asks the PT not to put the bed flat to assess bed mobility, what is the most likely vestibular problem the PT should investigate further? a. Cervicogenic vertigo b. Vestibular neuritis c. Conditioned-response dizziness d. Benign Paroxysmal Positional Vertigo 6. What is one of the most common medical causes for intermittent dizziness? a. Cardiac arrhythmia b. Drug intoxication c. Elevated blood pressure d. Increased intracranial pressure
VestibularPhysicalTherapyinAcuteCare
BrittaSmith,PT,MMSc,DPTOctober,2016
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CourseObjectives• Understandtheroleofphysicaltherapyinmanagementofpatientswithvestibulardisordersintheacutecaresetting.
• Differentiatebetweencausesofvertigocommonlyseeninacutecareandidentifythosewhoneedmedicalreferral.
• Understandhowtomodifyandperformabedsideclinicalassessmentforpatientswithsuspectedvestibulardysfunction.
• Identifyappropriatetreatmentoptionsforacutephasesofvestibulardysfunction
• Understandhowtodocumentandchargefortherapyinterventions
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PTforDizzinessinHospital
Patientcomplaintofdizzinessiseither:• Newonset,reasonpatientadmittedtothehospital
• Sideeffectorco-morbidity• Pre-existingandfoundanecdotally
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PhysicalTherapist’sRole
• Evaluateapatientwithaprimaryorsecondarycomplaintofdizziness
• Differentiatebetweenvestibularandnon-vestibulardizziness
• Recommendfurtherinpatientworkuportoanappropriateproviderforfurtherevaluationortreatment
• Provideeffectiveintervention• Facilitatesafetransitionhome
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DizzinessinED• Dizzinessthoughttoaccountforupto4.4%ofEDvisitsinUSA
• Approximately4.3millionEDvisitsperyearfordizziness/vertigoinUSA
• Aboutone-thirdareattributedtootologic/vestibularcauses
• Abouthalfaregivenamedicaldiagnosis• ~15%havesymptomsduetomedicallydangerouscause
Newman-Toker,D.E.,Kerber,K.A.,Meurer,W.J.,Omron,R.,Edlow,J.A.,Bisdorff,A.R.,…Lechner,C.(2015).EmergencyNeuro-Otology:DiagnosisandManagementofAcuteDizzinessandVertigo.NeurologicClinics,33(3),i.doi:10.1016/S0733-8619(15)00040-7
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PeripheralVestibularSystem
www.strabismusworld.com/neurology-physiology-psychology-vision/the-vestibular-system-and-vision/
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SensorsofVestibularSystem
• Bonylabyrinthlieswithinthetemporalbone• Fluid-filledmembranouslabyrinthwithinthebonylabyrinth
• SemicircularCanals– 3canals:anterior,posterior,andhorizontal
• Otoliths– Utricle– Saccule
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http://what-when-how.com/neuroscience/auditory-and-vestibular-systems-sensory-system-part-2/
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NormalVestibularFunction
• Gazestabilizationwithheadmovement• Orientingtovertical• Posturalresponses/controllingcenterofmass
• Stabilizingheadposition• Sensingself-motion
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TonicFiringRateofCanalsandOtoliths
• Hairscellshavearestingfiringrate• Thefiringratechangeswhenhaircellsaredeflected– Canalsviafluiddynamics– Otolithsviaweightedotolithic membrane
• Movementinonedirectionincreasesthefiringrate,movementintheotherdirectiondecreasestherate
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FunctionofSemicircularCanals
• Detectangularacceleration(rotation)inanyplaneofmovement
• Normalheadspeedcanexceed300deg/sec
• MaintaingazestabilityinalldirectionsthroughtheVOR(withutricle)
• Withsustainedmovementatconstantspeed,SCCresponsereturnstobaselinerateinabout7seconds
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Vestibulo-ocularreflex(VOR)
• Functionstostabilizevisionwithheadmovement
• Withoutthisreflex,theeyeswouldmovewiththehead
• Produces(nearly)equalandoppositeeyemovementinresponsetoheadmovement
• Bilateralpathwithbothexcitatoryandinhibitoryinputs
• Designedtoworkathigherheadvelocities
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Trythis• Holdyourhandatarmslengthandfocusonapointwhere2linescrossonyourpalm.Moveyourhandslowlybackandforthincreasingthespeeduntilthelinegoesoutoffocus.
• Nowholdyourhandstill,focusonthesamelineandturnyourheadbackandforthwithincreasingspeeduntilthelinegoesoutoffocus.
• Whichareyouabletodomorequickly?
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Otoliths
• Sensoryhaircellsareembeddedintheotolithic membrane
• Otoconiaaddweighttothemembrane• Deflectionofthehaircellsproducedbypulloftheweightedmembranetoincreaseordecreasefiringrate
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FunctionofOtoliths
• Detectlinearaccelerationandheadposition/tiltrelativetogravity
• Perceptionofmotionoftheheadandbody• Gazestabilization– withtheSCCs• Assistinorientingbodytovertical/togravity• Initiateposturalresponses
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http://www.avmed.in/2011/03/orientation-in-aviation-vestibular-apparatus-2/
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VestibularConnections
• Peripherallabyrinth– Semicircularcanals– Otoliths=utricle+saccule
• Vestibularnerve• Throughinternalauditorycanal(IAC)–Withcochlearn.,facialn.,labyrinthineartery
• Synapseinthevestibularnucleusinpons/medulla
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CentralVestibularAfferents
• Contralateralvestibularnucleus• OcularmotornucleiCN3,4,and6thentoocularmusclesviaVOR
• Thalamus• Cerebellum• Brainstemreticularactivatingsystem• SpinalcordtoskeletalmuscleviaVSR
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http://classconnection.s3.amazonaws.com/704/flashcards/586704/png/equilibrium_pathway1310130521369.png
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PeripheralVascularSupply• BasilarArtery• AnteriorInferiorCerebellarArtery(AICA)• LabyrinthineArterybranchingto– AnteriorVestibularArtery
• Vestibularnerve• Lateralandanteriorsemicircularcanals,mostofutricle
- CommonCochlearArt.Cochlea- PosteriorVestibularArt.
• Posteriorsemicircularcanal• Sacculeandinferiorutricle
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http://clinicalgate.com/the-vestibular-system/
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http://www.vestib.com/arterial-supply.html
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LabyrinthVascularRisk
• Labyrinth(vestibularsystemandcochlea)havenocollateralcirculation
• Labyrinthverysusceptibletoischemia• 15secondsoflossofbloodflowisneededtoeliminateauditorynervefunction
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CentralVascularSupply• Centralvestibularsystemreceivesmostofitsbloodsupplyfromthevertebral-basilararteryviatheanteriorinferiorcerebellarartery(AICA)
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https://en.wikipedia.org/wiki/Lateral_medullary_syndrome
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Nystagmus
• Vestibularsystemkeyinproducingnystagmus– Physiologic– Pathologic
• Involuntaryrapideyemovements• Movementshaveaslowandfastcomponent• Isdescribedbythefastcomponent
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Nystagmus• Physiologicorpathologic
• VORcausestheeyestomoveslowlyoppositetheheadmotion(B)=slowphase
• Eyesreachthelimitsonfartheycangointheorbit(C)
• Theeyesspringbackrapidlytoacentralposition(D)=fastphase
– Namedforthefastphase
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PhysiologicNystagmus
• Producedbybodyrotation• Rotationtotherightexcitesrightvestibularneuronsresultingineyemovementtoleft
• Ifthebodykeepsturning,theeyes“runoutofroom”andquicklyshiftrighttoanewvisualfixationpoint
• Rotationtotherightproducesarightbeatingnystagmus(towardexcitedside)
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OptokineticNystagmus
• Nystagmusproducedbyarepeatedmovingvisualstimulus
• Theeyetracksthestimulusuntilit“runsoutofroom”inthesocket,thenquicklyshiftstowatchanewvisualtarget
• Example:watchingthecarsofatrainpassinfrontofyou
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Trythiswithapartner
1. Turnheadtolookatanobjectdirectlybehindyou,thenturntotheoppositedirection.Canyourpartnerseeyourphysiologicnystagmus?
2. Moveastripedfabric/paperslowlybackandforthinfrontofyou,counteachstripeasitcrossesthemiddle.Canyourpartnerseeyouroptokineticnystagmus?
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PathologicNystagmus
• Injurytothevestibularsystem• Producedbyasymmetryoffiringratefromthevestibularafferents
• Nystagmusfromperipheralinjurycanbesuppressedbyvision
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LeftVestibularInjury
• Example:– Damagetotheleftsidedecreasestheleftvestibulartonicfiringrate
– Braininterpretsthedamageasarelativeexcitationoftheright,asifthebodywererotatingtotheright
– Leftvestibularinjuryproducesaright-beatingnystagmus
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VestibularSystemAnatomySummary
• Interactswithothersystemstocontributetogazestability,balanceandperceptionofstabilityandenvironment
• Usesmultipleandpartiallyredundantsensoryinputsandmotoroutputs
• Canadaptinresponsetoinjury• Needsthecerebellumforadaptation
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DefineDizziness(StandardizationofTerms)
• Dizzinessisthesensationofdisturbedorimpairedspatialorientationwithoutafalseordistortedsenseofmotion
• Vertigoisthesensationofself-motionwhennoself-motionisoccurringorthesensationofdistortedself-motionduringanotherwisenormalheadmovement.
• Positionalvertigoisvertigotriggeredbyandoccurringafterachangeofheadpositioninspacerelativetogravity
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StandardizationofTerms-cont
• Unsteadinessisthefeelingofbeingunstablewhileseated,standing,orwalkingwithoutaparticulardirectionalpreference;ratherthandisequilibriumorimbalance
• Pre-syncope– sensationofimpendinglossofconsciousness
Bisdorff,VonBrevern,Lempert,&Newman-Toker.(2009).Classificationofvestibularsymptoms:Towardsaninternationalclassificationofvestibulardisorders.JournalofVestibularResearch. 19:1–13
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DoSymptomsDiagnose?
• Patientdescriptionofsymptomsarenotoriouslyinaccurateandinconsistent
• Manyhavetroubledifferentiatingbetweendizzinessandunsteadiness,vertigoanddizziness
• Timing,duration,triggers,relieversmoreusefultoguidedecisions
Kerber,K.,&Newman-Toker DE.(2015).MisdiagnosingDizzyPatients:CommonPitfallsinClinicalPractice.- PubMed- NCBI.Neurol Clin,33(3),565–75.
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ClinicalExamination
• Symptoms– atonsetandcurrent• Medicalhistoryreview• Nystagmus• Oculomotorexam• Neuroexam• Balanceandmobility• Gait
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HistoryofDizzySymptoms
• Isdizzinesspersistent/continuoussymptomsordoesitcomeandgo?
• Isonsetspontaneousorcausedbyevent?• Isthisthefirsttimehavingsymptomsorhasthisoccurredinpast?
• Canyoumakethedizzinesshappenorcanyoure-createsymptoms?
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HistoryofSymptoms
• Onset• Characterization– continuousorintermittent• Duration• Intensity• Associatedsymptoms• Provocativefactors• Alleviatingfactors• Tests/Interventionstodate
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MedicalHistory• CurrentMedicalHistory• PastMedicalHistory– Neurotologic History– StrokeorTIA– Hypertension– AtrialFibrillation– DM–Migraine– Recentheadinjuryorothertrauma(evenminor)
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History- cont
• SocialHistory• FamilyHistory–Meniere’s–Migraine– BPPV
• Medications– Vestibularsuppressants– Recentlybegunorstopped
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Examination:OculomotorTests
Vestibular-mediatedFunctions• Nystagmus• Skew(verticalalignment)• VOR• HeadImpulseTest(HIT)
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Examination:OculomotorTests
Non-vestibularmediatedfunctions• Ocularalignmentandmovement(EOMs)• Visualacuity• Diplopia• Pursuit• Saccades• Convergence
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PracticalOrderofExam
• Nystagmus• EOMs– range,nystagmus,conjugatemvmt• Pursuit• Saccades• Convergence• Skew• VOR/Visualacuitystaticanddynamic• HeadImpulseTest
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NystagmusExam
• Nystagmusinroomlight– Spontaneousnystagmus– incentralgaze– Gazeevokednystagmus- nystagmuswitheyesindifferentpositions
• Suppressionofnystagmuswithvisualfixation• Increaseorappearanceofnystagmuswithremovalofvisualfixation– Gogglesorpenlightinoneeyetoreducefixation
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ExtraocularMovements(EOMs)
• Eyesinpositions15-20degreesfromcenter• Toofarmayproduceend-pointnystagmus– NormalnystagmusatendofeyeROM
• Conjugatemovementandgazeholding– eyesmovetogetherandalignsymmetrically– Askabout“lazyeye”
• Lookfornystagmusineachposition
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Left-beatingNystagmus
LeftRight
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PursuitandSaccades
• Pursuittestedbyfollowingaslowlymovingtarget– TestsCN3,4,and6– Lookforsmoothvsjerky(saccadic)movement
• Saccadicmovementlookingbetweentwotargets~12inchesapart–Watchfor“overshoot”oracorrectivesaccade
• Abnormalitiesdonotindicatevestibularlesion
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Convergence
• Visualtarget– Xontonguedepressor– letteronpocketeyechart
• Slowlymovetowardpatient’snose• Notedistancefromnosethatpatientreportsdiplopia
• Normalis4inchesorless• Notvestibularfunction– testincentrald/o
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ExamTips
• Gogglesifavailabletoreducevisualfixation– Penlightinoneeyereducesfixation
• Visualtargetatleastarmslengthaway– Especiallyover40yearsofage–Mayneedpt’s glasseson
• Discretevisualtarget• SlowmovementofvisualtargetforEOMsandpursuit
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Skew
• ComponentofOcularTiltReaction(OTR)– Lateralheadtilt– Verticalskew– Torsionofeyes
• Maybepresentinbothperipheralandcentrallesions
• Patientmayreportverticaldiplopia• Alterssubjectivevisualvertical(SVV)
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PhysiologicOTR
• Allowsvisiontoremainstablewithhead/bodytilt• Partofposturalrighting• Leftbodytiltresultsinrightoculartiltreactiontocompensate– Tiltheadtoright– Rotatedeyestoright– Upwardrotationofthelowerlefteye,upwardrotationtoupwardrighteye(toelimate torsionoftheeyesrelativetogravity)
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OcularTiltReaction
http://www.eyerounds.org/cases/200-OTR.htm
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PathologicOTR• PresenceofOTRindicatesvestibularpathology– centralorperipheral
• Skewdeviationismostimportanttotest• Tiltsofsubjectivevisualvertical(SVV)aresensitivesignsofvestibularpathology
• Patientperceivesdiplopia• Directionoftiltdoesnotdiagnosesideoflesion
Herdman &Clendaniel (2014)VestibularRehabilitation4th Edition
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OTRPathology
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PathologicOTR
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OTRs/pAcousticNeuromaResection
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Buckettest
• Objectivemeasureofperceptionofvertical(subjectivevisualvertical)
• Forcentralorperipheraldisorders• Reliabletestcomparedtodometest• >2degreesconsideredabnormal• 8.9deg + 5.4deg afterunilateralbraininfarctsorvestibularneuronitis
Zwergal,A.,Rettinger,N.,Frenzel,C.,Dieterich,M.,Brandt,T.,&Strupp,M.(2009).Abucketofstaticvestibularfunction.Neurology,72(19),1689–92.
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Cross- CoverTestCover– UncoverTest
• Havepatientfixateonyournose• Coveroneeyeandobservethemovementoftheoppositeeyetofixate– Coverfor3seconds
• Alternatecoveringeacheye,observingthemovementoftheeyebeinguncovered
• Verticalskewisabnormal(vestibularpathology)• Horizontaleyemovementisnotvestibular• Documentsideofhigheye(sideofhypertropia)
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Trythiswithapartner
• Pursuit• Saccades• Convergence• Testofskew
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VOR
• Gazefixationonatarget– yournose• Slowlyprogressspeed– Slowspeed=pursuit– Fastspeed=VOR
• Lookforlossoffixation• Notewhichsideheadismovingtowardwithlossoffixation
• Symptomincrease=headmovementintolerance
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VORExam
• Examinermoveshead• Smallheadmovement– Nottocornersofeyes
• Startslowly,progressspeed• Looksforvisualfixationmaintained• Monitorfortolerance
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DynamicVisualAcuity(DVA)
• ObjectivetestofVOR• Performwithwallmountedchart– ETDRS– Equaldifferenceofsizebetweenlines
• Assessstaticvisualacuityfirst– Staticacuitylessthan20/50impactsbalance
• Headmovementspeed2cyclespersec(2Hz)• Metronomeforstandardization• Normaldifferencestatic/dynamicis2lines
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ETDRSEyeChart
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HeadImpulseTest(HIT)
• AssessmentoftheVORforeachside• Tiltheadforward30 deg – planeofhoriz.canal• Startwithheadrotated20deg tooneside• Patientfocusesonexaminer’snose• Performbrisk,unpredictableheadturntoneutral• Watchforlossoffixationandcorrectivesaccade• Recorddirectionofheadmovementinwhichlossoffixationoccurs.
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Daniel R. Gold, and Stephen G. Reich Neurology 2012;79:e146-e152Copyright © 2012 by AAN Enterprises, Inc.
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Trythiswithapartner
• VORslow• Progressspeed• HeadImpulseTest
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NeuroExam• Cranialnerves- selected– CN1– smell(injuredinheadtrauma/falls)– CN5– facialsensation– CN7– facialmuscles– CN8– hearing– CN9– swallow
• CN3,4,and6coveredbyEOMs• Strength• Sensation– lighttouchandproprioception• Ataxia,especiallylimbataxia
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Mobility
• BecauseweareacutecarePTs…• Bedmobility,transfers,etc.• Noteifsymptomsappearorchangewithpositionchanges– EspeciallyforpossibleBPPVororthostasis
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Balance
• Sittingandstanding• Noteposturalalignment,includinghead• Canprogresstotestsofsensoryintegrationifpatientabletotolerate– Romberg– eyesopenandclosed(EOandEC)– OnfoamformodifiedCTSIB– EOandEC– Tandemstance – EOandEC– Unilateralstance– EOandEC
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StanceandGait
• Standing– Posture,weaknessorparesis– Changeinsymptoms
• Gait– Ataxia–Weaknessorparesis– Assistivedevice– Changeinsymptoms
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RecommendedOutcomeMeasures
BodyStructure/Function• DynamicVisualAcuity
• ClinicalTestofSensoryInteractiononBalance(modified)
• VisualAnalogueScale(symptomratings)
Activity/Participation• 5timesSittoStand
• 10meterWalkTest
• MiniBalanceEvaluationSystemsTest
• DynamicGaitIndex
• FunctionalGaitAssessment
• Four-SquareStepTest
• TimedUpandGo
HallCD,Herdman SJ,WhitneySL,etal.(2016).VestibularRehabilitationforPeripheralVestibularHypofunction:AnEvidence-BasedClinicalPracticeGuideline:FromtheAPTANeurologySection.JNeurol PhysTherapy40(2):124-155.
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FunctionalTestResources
• RehabilitationMeasuresDatabase• www.rehabmeasures.org• Includes:– Linktoinstrument/pdfoftestifavailable– Lengthoftestandcost,ifapplicable– Description,purpose,andpopulationstested–Metrics,suchasnormativedata,minimaldetectablechange,clinicallyimportantdifference
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SymptomPresentation
ContinuousSymptoms–AcuteVestibularSyndrome
• Spontaneousonset– Noapparentreasonforonset
ofcontinuousdizziness– Symptomspersistatrest
• Traumaticonset
EpisodicSymptoms–EpisodicVestibularSyndrome
• Spontaneous– Comesandgoeswithoutany
apparenttrigger
• Provokedbypositionchanges– Nosymptomsatrest
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AVSSpontaneousOnsetContinuousSymptoms
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AcuteVestibularSyndrome(AVS)SpontaneousOnset
• AcutefirstonsetofCONTINUOUSvertigo/dizziness• +/- Precipitatingevent• Spontaneousorgazeevokednystagmus• Sitting/standing/gaitimbalance• Nauseaand/orvomiting• Headmotionintolerance• Symptomspersistfor24hoursormore(probablydeterminedretroactively)
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SpontaneousOnset- History
• Nopriorexperienceofthesesymptoms• Historyoftrauma/fall– evenminor• Precedingviralinfectionwithin2weeks• Exposuretotoxins
– Medicationtoxicity,esp.anti-convulsants orillicits
• Acuteonsetofhearinglossorearsymptoms• Alteredmentalstatusorlossofconsciousness• CardiovascularRiskFactors– Age,gender,hx stroke/TIA,HTN,A-fib,DM,+tobacco
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AVS- ContinuousSymptoms
SpontaneousOnset-
ContinuousSymptoms
ProbablestrokeorTIA
Peripheralvestibulopathy
ProbableMedicalCause
AdaptedfromNewman-Toker &Edlow,2015
ColorKeyinDecisionTrees- Red=medicalurgency- Yellow=discusswithMD- Green=proceedcPT
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ProbablestrokeorTIA
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EvolutionofDizzyDiagnoses
2008:
• otologic/vestibular(32.9%)
• cardiovascular(21.1%)
• respiratory(11.5%)
• neurologic(11.2%,including4%cerebrovascular)
Newman-Toker,D.,Hsieh,Y.-H.,Camargo,CarlosA.Pelletier,A.,Butchy,G.T.,&Edlow,J.A.(2008).SpectrumofDizzinessVisitstoUSEmergencyDepartments:Cross-SectionalAnalysisFromaNationallyRepresentativeSample.MayoClinicProceedings,83(7),765–775.
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DizzinessEDDiagnoses- 2011
• Benignparoxysmalpositional vertigo (22%)
• Stroke(20%)
• Increaseinstrokediagnosesduetoincreased
researchidentifyingbedside,rapiddiagnosis
ofstrokeproducingdizzinessand
standardizationofscreeningteststorule-in
stroke
Royl,G.,Ploner,C.J.,&Leithner,C.(2011).Dizzinessintheemergency
room:diagnosesandmisdiagnoses.EuropeanNeurology,66(5),256–63.doi:10.1159/000331046
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Dizziness=stroke?• Oftheroughly1.5millionEDpatientsgivenbenignvestibulardiagnosesanddischarged,0.18%to0.70% arehospitalizedforstrokeinthenext30days.
• Thistranslatestoroughly2,600to10,500patientseachyearintheUnitedStateswhoaretoldtheyhaveabenigncauseandthensufferseriousharm(e.g.,majorstrokewithdisability)within1month.
Newman-Toker,D.E.(2016).Missedstrokeinacutevertigoanddizziness:itistimeforaction,notdebate.AnnalsofNeurology,79,27–31.doi:10.1002/ana.24532
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SymptomsofCentralVestibularDysfunction
• Nystagmus– Direction-changing– Up-beatingorDown-beating– Torsional–Maymimicperipheralnystagmus
• Vertigo• Nausea/Vomiting• 80%ofposteriorcirculationstrokesdonothaveadditionalneurosignsatonset
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CentralVestibularNeuroSigns• Hearingloss• Dysphagia• Sensorychanges• Weaknessorparesis• Slurredspeech• Eyemovementabnormalities
• Limbataxia
• Severeimbalanceorlateropulsion
• UMNsignsandsymptoms(spasticity,clonus,+Babinski)
• Lossofconsciousnessoralteredmentalstatus
• Memoryloss
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WhyExamineWhenThere’sMRI?
• Imagingisnot100%accurate• Imagingmaynotbeperformedonyoungerpatientsorthosewithcontraindications
• CTmisses~60%ofacutestroke• MRImissesposteriorcirculationstroke– 10-20%infirst24-48hours– Upto50%forsmall(<1cmdiameter)infarcts– RepeatMRIafter3-7daysmayshowinfarct
Saber– Tehrani,ASetal.(2014).Smallstrokescausingserververtigo:Frequencyoffalse-negativeMRIsandnonlacunar mechanisms.Neurology;83(2):169-173.
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HINTSforStroke
• Combinationof3testsinoculomotorexam
• Quick“downanddirty”exam
• Mustuseallthreeteststogether
• Identifiesstrokewith100%specificityand96%specificity
• ShowntodetectstrokeevenwithnegativeMRI
Newman-Toker,D.E.,Kattah,J.C.,Talkad,A.V.,Wang,D.Z.,Hsieh,Y.-H.,&Newman-Toker,D.E.(2009).H.I.N.T.S.toDiagnoseStrokeintheAcuteVestibularSyndrome—Three-StepBedsideOculomotorExamMoreSensitivethanEarlyMRIDWI. Stroke;aJournalofCerebralCirculation, 40(11),3504–3510.
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OculomotorExam
• Nystagmus• EOMs– range,nystagmus,conjugatemvmt• Pursuit• Saccades• Convergence• Skew• VOR/Visualacuitystaticanddynamic• HeadImpulseTest
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BedsideOculomotorExam–HINTS
1. HeadImpulsetest2. Nystagmusexamination3. TestofSkew
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NystagmusExamination
• Peripheralnystagmusisusuallyhorizontalandmaintainsthesamedirection,increasesingazetowardfastphase
• Centralnystagmusmay– Changedirectionduringeccentricgazetest(EOMtesting
– Purevertical(up-beatingordown-beating)orrotationalnystagmus
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HeadImpulseTest(HIT)
• NormalHeadImpulseTest(nocorrective
saccade)inpatientwithAVSisstrongpredictorofcentraldisorder
• AbnormalHeadImpulseTest(witha
correctivesaccade)usually indicatesperipheraldisorder
– Lateralpontinestrokesmayhaveanabnormaltest
result
Kattah,J.C.,Talkad,A.,Wang,D.,Hsieh,Y.-H.,&Newman-Toker,D.(2009).H.I.N.T.S.
toDiagnoseStrokeintheAcuteVestibularSyndrome—Three-StepBedside
OculomotorExamMoreSensitivethanEarlyMRIDWI.Stroke,40(11),3504–3510.
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LateralMedullarySyndrome• InfarctofPICAorVertebralArterydisease• Keyclinicalsigns:– Ataxiaofgaitand/orlimbs– Facialorbodynumbness– Horner’ssyndrome(constrictedpupil,ptosis)– Oculartiltreactiontowardsideoflesionwithverticalskew/diplopia
• Subjectivevisualverticalmostsensitivesign–presentin94%to100%ofpatientscLMS
http://www.neuroophthalmology.ca/textbook/disorders-of-eye-movements/v-prenuclear-disorders-brainstem/i-wallenbergs-lateral-medullary-syndrome
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HINTS–+forStroke
1. HeadImpulsetest- Nocorrectivesaccade
2. Nystagmusexamination- Directionchanging,up/downbeat,ortorsional
3. TestofSkew- VerticalSkew
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ContinuewithPTExam
• Neuroexam• Balance• Mobility• StanceandGait• Functionaltestsasappropriate:– e.g.CTSIB,TUG,Berg,DGI
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OtherStrokeSigns• Suspiciousofacutelossofhearingoneear– Maybeviralorbacteriallabyrinthitis– Under-diagnosedinstroke
• Positivefindingsonneuroexam– RedFlags– Dysphagia– Diplopia– Limbataxia– Severeimbalance/lateropulsion– Hemiparesisofface/limbs– Alteredmentalstatus
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• ~20%ofallischemicstrokesoccurinthevertebrobasilarcirculation
• Abouthalfofpatientswithvertebrobasilarstrokespresentwithvertigoandnootherfocalneurologicsigns
• Estimated1/6to1/3ofpatientswithposteriorcirculationstrokesaremisdiagnosedashavingperipheralvestibulardisorders
Newman-Toker,D.E.(2016).Missedstrokeinacutevertigoanddizziness:itistimeforaction,notdebate.AnnalsofNeurology,79,27–31.doi:10.1002/ana.24532
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TreatmentforCentralAVS
• Initiationofmedicaltreatmenttopreventworseningofsymptoms
• Dependingonpresenceandseverityofotherstrokesymptoms- typicalstroketherapies
• Attentiontoverticalorientation/visualvertical• Shortterm,symptomatictreatmentofN/V• Vestibularexercisesastolerated• Praycerebellumintactforcompensation!
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Outcomes
• Mayhavepersistentnystagmusinroomlightafterweeks
• OTRmaytakemonthstoresolve• Oculartorsion• Caloricresponsesnormalizein1yearin67%ofpatientsLee,S.-H.,&Kim,J.-S.(2015).AcuteDiagnosisandManagementofStrokePresentingDizzinessorVertigo.NeurologicClinics,33(3),687–98,xi.
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PeripheralVestibulopathy
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HINTSforPeripheralVestibulopathy
• HeadImpulseTest– Positiveforcorrectivesaccadewhenheadmovedrapidlytowardinvolvedside
• Nystagmus– Directionconstant,horizontal– Increasedintensityeyestowardfastphase– Fastphaseawayfrominvolvedside
• TestofSkew– Skew+/-
• Nolossofhearing
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PeripheralVestibulopathyDiagnoses
• Mostcommondiagnosis– VestibularNeuritis–MaybefollowingupperrespiratoryorGIillness
• Lesscommondiagnoses– Followingacousticneuromasurgery– Afterablationoflabyrinth– Acutelabyrinthitis– FirstattackofMeniere’sdisease– Firstattackofvestibularmigraine
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Ifhearinglossispresent
• Otherdiagnosesshouldbeconsidered:• Meniere’s• Labyrinthinearteryischemia• Infectiousdisease:Measles,mumps,infectiousmononucleosis
• HerpesZosterOticus• Lymedisease• Neurosyphillis
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NystagmusAfteraPeripheralVestibularInjury
• Canbeseeninroomlightupto72hoursafteranacuteonset
• Canbeseeninthedarkuporwithvisualsuppression/Frenzel lensesupto1weekafteracuteonset
• Thedirectionofthenystagmusdoesnotchangewitheyeorheadposition
• Nystagmusbecomesgreaterlookingtowardthefastphase
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OtherClinicalFindings
• Reductionindynamicvisualacuity• OTR– towardsideoflesion• Posturalimbalance• Gaitimbalance• Movementintolerance/avoidance• Nausea/vomiting• Anxiety/fearoffalling
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WithintheFirst72Hours
• Spontaneousnystagmusresolvesinroomlight(withvisualsuppression)
• ThisphaseofrecoveryisNOTdependentonbodymovementorvision
• Skewdeviationresolves• Imbalanceandgazeinstabilitypersist
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WithintheFirstWeek
• Spontaneousnystagmusresolvesindark(withoutvisualsuppression)
• AdaptationoftheVORandVSRbeginsinresponsetoerrorsignals
• Recoveryofoculartiltreaction/skew• Adaptationrequiresvisionandmovement• Recoveryrequiresanintactcerebellum
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OngoingRecovery
• Recoveryiscontextdependent• AdaptationcontinuesoftheVOR,VSRwithchangesinthegains– Improvesoverweeks/months
• Substitutionofotherstrategiesmayoccur– preferenceforvisualandsomatosensorycues– potentiationofotherreflexes(e.g.COR)
• Patientmayavoidprovokingactivities
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Long-termDeficitsofUnilateralVestibularDysfunction
• Headimpulsetestpositivetoaffectedside• Oculartorsiontowardaffectedside• Difficultywithdynamicchallengesofbalance• Riskofdecompensationwithillness/stress• Gaitandposturalinstabilitywithalteredvisualandsomatosensoryinfo– Ladders,unevensurfacesatnight
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AcuteMedicalTreatment• Vestibularsuppressants– 24-72hours– Dimenhydrinate – Dramamine–Meclizine– lesssedating– Anti-emeticactionalso
• Corticosteroids–Methylprednisolone– Significantlyimprovedrecoveryofvestibularfunctionifgivenwithin3daysofonset
Strupp et.al.2004.Methylprednisolone,valacyclovir,orthecombinationofboth.NEJM351-354.
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CorticosteroidsvsVestibularTherapy
• Treatmentwithcorticosteroidsforacute
vestibularneuritisvsvestibularexercises
• At6months,completediseaseresolution
corticosteroids groupwassignificantlyhigher
• Nostatisticallysignificantdifferenceswere
foundin clinical,canal,orotolithrecovery at
12months
Goudakos JK, Markou KD, Psillas G, VitalV, Tsaligopoulos M.(2014)
Corticosteroids and vestibular exercises in vestibular neuritis. Single-
blind randomized clinical trial. JAMAOtolaryngol HeadNeckSurg. 140(5):434-40.
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PT:VestibularRehabilitation
• Currentvestibularrehabilitationisanexercise-basedapproachthattypicallyincludesacombinationof4exercisecomponents– gazestabilityexercises– exercisestohabituatesymptomsincludingoptokineticexercises
– balanceandgaittraining– walkingforendurance.
HallCD,Herdman SJ,WhitneySL,etal.(2016).VestibularRehabilitationforPeripheralVestibularHypofunction:AnEvidence-BasedClinicalPracticeGuideline:FromtheAPTANeurologySection.JNeurol PhysTherapy40(2):124-155.
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EarlyIntervention• Earlyanimalstudiesshowedearlymobilityandvisualinteractionimprovedoutcomes
• VORexercisesshowntobeeffectiveinitiatedwithin5daysofsymptomonsetandreduceneedformedicationVenosa AR&Bittar RS.(2007).Vestibularrehabitation exercisesinacutevertigo.Laryngoscope117(8):1482-7
• Afteracousticneuromaresection,vestibularexercisesimproveposturalstabilityandperceptionofequilibriumHerdman,S.J.,Clendaniel,R.A.,Mattox,D.E.,Holliday,M.J.,&Niparko,J.K.(1995).Vestibularadaptationexercisesandrecovery:acutestageafteracousticneuromaresection.Otolaryngology--HeadandNeckSurgery 113(1),77–87.
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GazeStabilityExercises
• VORexercises– visualfixationonastationarytarget,addmovementofthehead– horizontalandverticalmovements
• Lookingbetween2targets– Progresswithincreasedspeed
• VORwitheyesclosed(imaginarytargets)– visuallyfocusontarget,closeeyes,turnhead~20degreesinonedirectionkeepingeyes“focused”througheyelids,openeyes
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Habituation
• Notusuallyinitiatedinacutedisorders• Examplesinclude:– Repetitionsofprovokingmovements– Optokineticstimulation– Performingexerciseswithbusybackgrounds– Computersimulationsofmovingvisualenvironments
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BalanceandWalking
• SittingBalance–Midlineofheadandtrunk– Progresstodynamic
• StandingBalance– Starteyesopen,normalizebaseofstance–Weightshifts,stepping– Headmovements– Ifable,eyesclosed– startintermittently
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NextPhaseBalance
• StandingBalance– Starteyesopen,progresstoeyesclosed– Startonfirmsurface,progresstofoam– Startslowmovement,progresstomoredynamic– Startwithwiderbaseofsupport,progresstoRomberg>tandemRomberg>unilateralstance
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NextPhaseWalking
• Increaseambulationdistance• Progressdifficulty– Headmovements– Dualtasking,especiallywithcognitivetasksorthosewithvisualization(e.g.namestates,tellmewhatyouseewalkingthroughgrocery/hardwarestore)
– Turns– Obstacles
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PTinAcuteCare
• Encouragemovementanduprightpositions• VORexercise– slowly• Encouragevisualfixation• Sittingandstandingbalanceactivities• Gaittraining– assistivedeviceifneeded• Educationonsafety• Educationonprogressionofrecovery• Arrangeoutpatienttherapy
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AquaticExercise
• Familiesaskre:walkinginpool• Aquatictherapyhasbeenshowntobeeffectiveinasmallstudyofchronicvestibulardisorders
• Improvedsway,perceptionofdizzinessandDHIscores
Gabilan YP,Perracini MR,Munhoz MS,Gananc FF.(2008).Aquaticphysiotherapyforvestibularrehabilitationinpatientswithunilateralvestibularhypofunction:exploratoryprospectivestudy.JVestib Res;18(2-3):139-46
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MedicalCausesAcuteContinuousDizziness
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Medication-InducedDizziness
• Medicationtoxicityismostcommonmedicalcauseofcontinuousdizziness
• AMSisusuallypresent• CNS-actingagents– Anti-epileptics andlithiummorecommon– sedatives,tricyclicantidepressants,analgesics,musclerelaxants,anti-parkinsonianagents,barbiturates,hypnotics,anti-psychotics,tranquilizers
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AVSMedicalDiagnoses
• ToxicDisorders–Medicationtoxicity- anti-seizure,lithium– Ototoxicmedication- gentamicin– Drugintoxication– ETOH/illicit– Carbonmonoxidepoisoning
• Cardiovascularmedications– diuretics,Betablockers,anti-arrhythmia,vasodilators
Edlow &Newman-Toker (2104).MedicalandNonstroke NeurologicCausesofAcute,ContinuousVestibularSymptoms.Neurol Clin 33:699-716.
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OtherMedicalCauses
• MultipleSclerosis• MetabolicDisorders– Hyponatremia– Thiamine(B1)deficiency(malnutritionorpostbariatricsurgery)
– Electrolyteimbalance• InfectiousorInflammatoryDisease– Herpeszoster– BacterialMastoiditis– BrainstemorCerebellarEncephalitis
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HINTSforMedicalCauses
• HeadImpulseTest– Nocorrectivesaccade
• Nystagmus– Usuallynospontaneousorgazeevokednystagmus–Mayhavedirection–changingnystagmuswithmedicationoralcoholtoxicity
• TestofSkew– Noskewpresent
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RoleforAcutePT
• Theseshouldalreadybeidentifiedthroughmedicalwork-up
• Medicalcausesforacutevestibularsyndromearerelativelyrare
• Managementislargelymedical• “Typical”PTtreatmentanddischargeplanning
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AVSSummary-HINTstoDifferentiateSymptoms
Spontaneousonset
HINTSwithcentralsigns
HINTS=peripheral
HINTS=notvestibular
HI=nosaccadeN=directionchangingTS=+vertical/horiz(cautionhearingloss)
Treatwithvestex
Medicalworkup
AdaptedfromNewman-Toker &Edlow,2015
HI=+onesideN=directionsameTS=+/- vertical
HI=nosaccadeN=noneTS=none
Neuroworkup
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AVSwithContinuousSymptomsandTraumaticOnset
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Trauma
Symptomsmaybearesultof:• Headtrauma/Braininjury– Blunttrauma– Acceleration/decelerationforce– Falls– Projectile/penetration– Blastwaves
• Barotrauma– Changeinaltitudeordepth
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AVSwithContinuousSymptoms:TraumaticOnset
Traumaticonset
Falls,Whiplash,BluntorOpen
Trauma,BlastTraumawithTBI
Barotrauma
InitiatePTbasedonproblems
andtolerance
Fistula
AdaptedfromNewman-Toker &Edlow,2015
MonitorforBPPV
Neuro-otologyconsult
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TraumaPathology
• Diffusecentralinjury• Temporalbonefracture• Labyrinthineconcussion• Vascularinjuries(SAH,SDH,vasculardissections)
• BPPV• Cervicalinjury/cervicogenicsymptoms• Perilymphatic fistula
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Presentation
• Post-traumaticheadache• Dizzinessandposturalimbalance• Nausea,vomiting,sensitivitytolightandsound• Cognitiveslowing• Emotionalchanges(anxiety,irritability,lability)• Alterationinsleep• Cervicalpain• Autonomicdysregulation
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ClinicalPresentation- AcuteTBI
• PresentationvariablebasedondegreeofTBI• Morelikelytohavemixedsignsofvestibulardysfunctionandcentraloculomotorinjury
• Headacheaslimitingfactor• Mayhaveconcomitantorthopedicinjuries• CTandMRImaynotbesensitiveenoughtodiagnosemildTBI
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Presentation– cont.• Mayhavebothstaticanddynamicvisualacuitydeficits
• Morelikelytohaveimpairmentofpursuitandsaccades– Difficultyscanning,reading
• Mayhaveconvergencedeficit• Mayhavevisualmotionintolerance• Maynotbeabletotolerateinterventions– duetofatigue,headache,cognitiveattentiondeficits
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TemporalBoneFractures
• Nystagmus/vertigoimmediatelyoruptohours• Diagnosedwithimaging,butpresumptivewithbloodbehindeardrum
• 40%withhearingloss• Manyhaveunilateralfacialweakness• WatchforCSFleakfromear• Mayhavemixedperipheralandcentralinjury(TBI)• Consultaudiologist
Patel,A.,&Groppo,E.(2010).ManagementofTemporalBoneTrauma.Craniomaxillofacial Trauma&Reconstruction,3(2),105–113.
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BlastTrauma
• Industrialormilitaryexplosions• Pressurewaveiscausativemechanism– TBI–Middleearinjury– e.g.tympanicperforation– Hearingloss,tinnitus– Veryhighoccurrenceofdizziness
• Almostalwayshavecomplexinjuries
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PerilymphFistula
• Possiblecausesincludebarotrauma,TBI,earsurgery,heavylifting
• Usuallyacuteonsetofcontinuoussymptoms• Hearinglossand/ordizziness• Mosthavetinnitusandfullness• SymptomsincreasewithValsalva,cough/sneeze
• Mayhavepositionalsymptoms
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Sports-RelatedConcussion
• Sport-relatedconcussiongenerallynotadmittedtoacutecare
• Resources:– SCAT3(SportsConcussionAssessmentTool)–ModifiedBESS(BalanceErrorScoringSystem)– SAC(SidelineAssessmentofConcussion)
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TBIExam
• Allcomponentsofnystagmusandoculomotorexaminations
• Intestofskew,lookforhorizontaldeficits• Addconvergencetest– Xontonguedepressor(orletteronpocketeyechart)
– Slowlymoveclosertopt’s nose– Notedistancefromnosethatpt reportsdiplopia– Normalislessthan4inches
Scheiman M,Gallaway M,FrantzKA,etal.Nearpointofconvergence:testprocedure,targetselection,normativedata.OptometryandVisionScience2003;80(3):214-225.
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Exam- continued• Cranialnerveexam• Hearingscreen/Referraltoaudiology• BedsideDynamicVisualAcuity• Bedmobility(andresponsetopositionchanges)– TBImaycauseautonomicdysfunction
• Posturalstability• Neurotests• SensoryOrganization,e.g.CTSIB• Gait• Positionaltesting
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Higher-levelTests
• DynamicGaitIndex(DGI)• FunctionalGaitAssessment(FGA)• High–levelMobilityAssessmentTool(HiMAT)
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DynamicGaitIndex(DGI)
• Validatedforvestibulardisorders,stroke,TBI,fallers
• 8itemtest,score<19fallrisk• http://geriatrictoolkit.missouri.edu/dgi/ShumwayCook-m.DGI-2013-APPENDIX.pdf
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FunctionalGaitAssessment(FGA)
• Validatedinvestibulardisorders,fallers,andstroke
• Individualsscoring≤22onFGAare6timesmorelikelyclassifiedasafallrisk
• SimilartoDGI– addswalkingbackward,witheyesclosed,tandemwalk
• Testavailablethroughlink/pdfofappendix• http://ptjournal.apta.org/content/84/10/906.long
Wrisley,D.M.,Marchetti,G.F.,etal.(2004)."Reliability, internalconsistency,andvalidityofdataobtainedwiththefunctionalgaitassessment."PhysicalTherapy84(10):906-918.
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HiMat
• ValidatedforTBI• Appropriateoncepatientcanwalkindependently
• Highlevelactivities,includingrunning,jumping,hopping,stairs
• http://www.tbims.org/combi/himat/HiMAT.pdf
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TreatmentofTBI• Conservativetreatmentinacutephase• Restifsymptomsincreasewithactivities• Manageenvironmentforstimuli• MonitorforBPPV• Focusonidentifyingproblems,appropriateinterventions,andprogressingonlyastolerated
• Teamapproachisessential• ReferraltooutpatientvestibularPTafterd/c
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AVSContinuousSymptoms:Summary
Spontaneousonset
TraumaticOnset
HINTSwithcentralsigns
HINTS=peripheral
Nonyst &normalEOM
Headtrauma
Barotraumatrauma
Neuroworkup
Treatwithvestex
Medicalworkup
Neurof/uandPT
Neuro-otolconsult
AdaptedfromNewman-Toker &Edlow,2015
MonitorforBPPV
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EpisodicSymptoms-OnsetwithPositionChanges
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BPPV
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BenignParoxysmalPositionalVertigo(BPPV)
• Episodic,briefboutsofvertigo• Provokedbymovingheadintocertainpositions– usuallylyingdown,rolling,lookingup,orbendingover
• Mostoccurspontaneously(+50%)Mayoccurafterheadtraumaorwhiplash,vestibular
neuritis,orvestibularischemia
• Greaterincidencewithincreasedage
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Symptoms
Inadditionaltopositionalvertigotypicallylastinglessthan1minute:• Imbalance• Difficultywalking• Light-headed,ordizziness“insidehead”• Senseoftilt• Nausea• +/- Headimpulsetesttowardaffectedside
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TheoreticalMechanism–Canalithiasis
• Fragmentsofotoconiafromutriclefloatsintothesemicircularcanals,makingthemgravitysensitive
• Movementoftheotoconiastimulatethatcanalandextendtheperceptionofheadmovement
• Thismovementcausesnystagmus/vertigowithdelayedonsetandduration<1minute
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TheoreticalMechanismCupulolithiasis
• Otoconiadebrisadherestocupulaofsemicircularcanal
• Symptomsareimmediateandpersistaslongasheadheldinprovokingposition
• Relativelyuncommonpresentation• Examinehistorytoassurenoneurologicormedicalcauseofnystagmuswithpositionchanges
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Dix-Hallpike Test
• Testforposteriorandanteriorcanals• Assurespineclearedpriortotesting• Turnhead45deg towardsidebeingtested• Liepatientsupinewithheadextendedoveredgeoftableorbed20to30deg
• Observefornystagmusandvertigo,record– Latency– Directionofnystagmus– Durationofnystagmus
• Onreturntosit,patientmayhaveareversalofnystagmus
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http://www.newhealthadvisor.com/Dix-Hallpike-Maneuver.html
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BehaviorofNystagmusAssociatedwithtoBenignParoxysmalPositionalVertigo
https://www.mja.com.au/journal/2011/195/9/practical-neurology-part-4-dizziness-head-movement
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TestInterpretation
RightDix-HallpikeorSidelying Test
Torsionalup-beatingnystagmustowardright ear=lessthan60seconds
RightPosterior canalcanalithiasis
Torsionalup-beatingnystagmustowardright ear=morethan60seconds
RightPosteriorcanalCupulolithiasis,caution forcentralinjury
Torsionaldown-beatingnystagmustowardright ear=lessthan60seconds
RightAnterior canalcanalithiasis
Torsionaldown-beatingnystagmustowardright ear=morethan60seconds
RightAnteriorcanalCupulolithiasis,caution forcentralinjury
LeftDix-HallpikeorSidelying Test
As above,butnystagmustowardleftear
Herdman,S.J.,&Clendaniel,R.A.(2014).VestibularRehabilitation (4thEd).Philadelphia,PA:F.A.Davis.
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Side-lyingTestforBPPV
• Alternativetestforpatients• AboutsamevaliditytoidentifyBPPV• Turnhead45degreestooppositesideoftestandliequicklydownontestingside– nosetowardceiling
• SecondpersonmaybeneededtomanageLEs• RecordtestresultsasforDix-Hallpike
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Side-lyingTesttoRight
http://www.ejo.eg.net/article.asp?issn=1012-5574%3Byear=2013%3Bvolume=29%3Bissue=1%3Bspage=49%3Bepage=55%3Baulast=Mansour
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TestGuidelines
• Fasterpositionchangeswillresultingreatersymptomsandnystagmus,but…
• Nauseacanbesignificantlyreducedbeingslow
• Mosttimescanobservenystagmusinroomlight
• Repeatedtestingshouldresultinfatigueofnystagmus(decreasedamplitude/duration)
• Canmovedirectlyfromtesttotreatment
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Whatif?• Thenystagmusistorsionaltootherear?– Probablyotherear– testthatside– Ifnotoppositeside,centralfinding,discusswithMD
• Bothsidesarepositive?– Onlytreatonesideatatime
• Youseehorizontalnystagmus?– TestforhorizontalcanalBPPV
• Youhavenoresponse?– Retest,butifstillnegative,pt doesnothaveBPPV
• Thereisnystagmus,butthepatientisnotdizzy?– Centralnystagmus– discusswithMD
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CanalithRepositioningTreatment• ObtainDix-Hallpike foraffectedsidewith45degreesheadrotation– holduntilnystagmusresolvesplustimeittooknystagmustoresolve
• Rollheadtooppositesideslowly,allowingnystagmustoresolveplustime
• Rollpatientontosidewithheadrotated45degreestofloor,allownystagmustoresolveplustime
• Directionofnystagmusremainsthesame• Keepingheadrotated45degrees,cometosit
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CanalithRepositioningTreatment
Parnes LS,AgrawalSK,AtlasJ.(2003.BenignParoxysmalVertigo.CMAJ.169:681-693.
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RightCanalithRepositioningTreatmentforbothrightanteriorandposteriorcanals
https://health-conditions.knoji.com/vertigo-the-illusion-of-movement/
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Liberatory Maneuver• Sitedgeoftable,headturned45degreestowardunaffectedside
• Movequicklytosidelying positiononaffectedsidewithangleofheadrotationmaintained–holduntilsymptomsresolve/60seconds
• Moverapidlythroughsittingtooppositesidewithheadrotationmaintained/60seconds–directionofnystagmusshouldremainthesame
• Cometosittingslowly,headrotationmaintained• Sitedgeofbedwithheadslightlyflexed
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RightLiberatory Maneuver(Semont Maneuver)
http://www.nigeriamedj.com/article.asp?issn=0300-1652;year=2012;volume=53;issue=2;spage=94;epage=101;aulast=Ibekwe
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Dix-Hallpike inTrendelenburg
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• Abletoperformtestinpatientswithspineprecautions
• SameinstructionsasCRT,except:–UseTrendelenburgfeatureofhospitalbedtoprovidecervicalextension–Obtainrotationofheadbyrollofbody–Multiplehandstoassistsafely!
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FollowingRepositioning
• Ifdirectionofnystagmuschangedduringrepositioning,treatmentnotsuccessful
• Mayrepeatmaneuvermultipletimesinsession
• Instructpatienttoremainuprightatleastanhouraftertreatment
• Post-treatmentcervicalcollarorsleepinguprightnotneeded
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HorizontalCanalBPPVRollTest
• SupinetestwithheadFLEXED30degreestoplaneofhorizontalcanal
• Rapidlyrotateheadtooneside
• Observefornystagmusandvertigo,record– Latency– Directionofnystagmus
– Durationofnystagmus
• Repeatonoppositeside
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RollTestInterpretation
Geotropic(fastphasetowardground
LastLESSthan60seconds
Horizontal CanalCanalithiasis
Nystagmus/symptomsintensitystrongertowardaffected side
LastMOREthan60seconds
NOTBPPV
Apogeotropic(Ageotropic)(fast phasetowardceiling)
LastLESSthan60seconds
NOTBPPV
LastMOREthan60seconds
Horizontal CanalCupulolithiasis
Nystagmus/symptomsintensitystrongertowardunaffected side
Herdman,S.J.,&Clendaniel,R.A.(2014).VestibularRehabilitation (4thEd).Philadelphia,PA:F.A.Davis.
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BowandLeanTest
• UsedtodeterminewhichisaffectedsideinHorizontalCanalBPPV,especiallyifhardtodeterminewhichispositiveside
• Performedafterpositiverolltest
Choung,Y.-H.,Shin,Y.R.,Kahng,H.,Park,K.,&Choi,S.(2006).BowandLeanTesttodeterminetheaffectedearofhorizontalcanalBPPV.Laryngoscope,16,1776-81.
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HorizontalCanalBPPVTreatment
• Canalithiasis– repositioningmaneuvers– Bar-B-QueRoll– Lempert ManeuvervAppiani ManeuvervForcedProlongedPositioning
• Cupulolithiasis– Casini (akaGufoni)toconvertcupulolithiasistocanalithiasis
– Followwithcanalithiasistreatment
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Appiani Maneuver
• Sitsuprightwithheadstraightonbedside
• Quicklyliesdownonunaffectedsidefordurationofnystagmusplus60seconds
• Rapidlyrotateshead45degreesdowntowardfloor
• Holdsposition2minutes,thenslowlysitsup
• 78%effectiveafter1maneuver,100%after2maneuvers
Appiani,G.,Catania,G.,&Gagliardi,M.(2001).Aliberatory maneuverforthetreatmentofhorizontalcanalparoxysmalpositionalvertigo.Otology&Neurotology :22(1),66-69.
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Appiani Maneuver
http://www.dizziness-and-balance.com/disorders/bppv/lcanalbppv.htm
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ForcedProlongedPositioning
• Patientliesonaffectedsidefor20seconds–headneutral
• Slowlyrollstounaffectedside
• Remainsinsidelying onthatsideallnight,mayusepillow
• Ifpatientgetsupduringnight,repeatspositioning
• 90%remissionafter3nightsoftreatmentVannuchi,P.,Giannoni,B.,&Paganini,M.(1997).Treatmentofhorizontalsemicircularcanalbenignparoxysmalpositionalvertigo.JournalofVestibularResearch,7(1),1–6.
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BPPVResources
• Herdman,S.J.,&Clendaniel,R.A.(2014).VestibularRehabilitation (4thEd.).Philadelphia,PA:F.A.Davis.
• Welgampola,M.S.,Bradshaw,A.,&Halmagyi,G.M.(2011).PracticalNeurologyPart4:Dizzinessonheadmovement.MedJAust.195(9):518-522.
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WhenNottoTest• Cervicalspineinstability• Acuteheadache• Intracranialbleeds/Subarachnoidhemorrhage• PresenceofHorner’ssyndrome– Ptosisofoneeyewithconstrictedpupil
• Syncopalorpre-syncompal episode• ArnoldChiarimalformation• Alteredmentalstatus• Presenceofneurologicsigns
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BPPVConsiderations
• Notanemergency– letcommonsenseprevailwhendecidingtotestinpresenceofothersymptoms
• About60%ofBPPVcasesresolvespontaneouslywithin4weeksZucca Getal.(1988).Whydobenignparoxysmalpositionalvertigoepisodesrecoverspontaneously?JVestib Res.8(4):325
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AtypicalNystagmusDuringBPPVTests
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AtypicalNystagmuswithTesting
• Persistentnystagmus,oftenmorethan60seconds
• DownbeatorhorizontalnystagmusinDix-Hallpike (notorsion)
• Directionofnystagmusmayremainunchangedwithtestingofoppositesideorhorizontalcanals
• Signofcentralparoxysmalvertigoorposteriorfossamasslesions
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OrthostaticDizziness
• Dizzinessuponarisingwithoutnystagmus–Maybelightheaded,sycopal orpre-syncopal,orevenvertigosymptoms
• Shouldnotbesymptomaticuponlyingdown• Diagnoses:– Volumedepletionormedications- common– Sepsis– CardiacdysfunctionorMI– Internalbleeding
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TestingforOrthostasis
• Patientliessupine/flat5minutes• Cometostance,measurebloodpressureat1minutepost-standingand3minutespost-standing
• Orthostatichypotensionif:– SystolicBPdrops20mmHg– DiastolicBPdrops10mmHg– AccordingtoCDC,positiveifpt experiencesorthostaticsymptomsuponstanding
Consensusstatementonthedefinitionoforthostatichypotension,pureautonomicfailure,andmultiplesystematrophy.ConsensusCommitteeoftheAmericanAutonomicSocietyandtheAmericanAcademyofNeurology.Neurology1996;46:1470.
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NoNystagmusinBPPVtests,+Symptoms
Twooptions1. It’sBPPV,butyoucan’tseenystagmus
- Needtoretest,tryanothertestingposition,orhavepatientshowyouprovokingposition- Trytreatment,butconsultMDsymptomsdon’tdiminish
2. It’snotBPPV- Anxiety- Learnedresponse- Tryprogressivehabituationactivities
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D-H&HCneg,+orthostasis
+DixHallpike orHCAtypicalnystagmus
+DixHallpike or+Horiz Canal
OnsetwithPositionChanges
OrthostaticMedicalw/u
Neuroconsult/MRI
TreatforBPPV
AVSwithEpisodicSymptomswithPositionChanges
AdaptedfromNewman-Toker &Edlow,2015
D-H&HCnonystagmus+symptoms- orthostasis
Possibleanxietyorconditionedresponse
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SpontaneousEpisodicDizziness
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Migraine
Incidenceofmigraineinpopulation• Oneormoremigraines/year– 17.6%offemalesage12-80– 5.7%ofmalesage12-80– 4%ofchildren
• Ofthese,about30%experiencevertigowithmigraine
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Migraine
• Vertigois2-3timesmorecommoninpatientswithmigrainethaninheadache-freecontrols
• Patientswithvertigohavehigherprevalenceofmigrainethanthosewithoutvertigo
Vukovic,V.,Plavec,D.,Galinovic,I.,Lovrencic-Huzjan,A.,Budisic,M.,&Demarin,V.(2007).Prevalenceofvertigo,dizziness,andmigrainous vertigoinpatientswithmigraine.Headache,47,1427–1435.
Lempert,T.,&Neuhauser,H.(2009).Epidemiologyofvertigo,migraineandvestibularmigraine.JournalofNeurology,256(3),333–8.doi:10.1007/s00415-009-0149-2
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• BPPVismostcommonvestibulardiagnosisinpatientswithmigraine
• Migraineis2-3timesmorecommoninpatientswithideopathic BPPV
• Alsorelationshipsbetweenmigraineandmotionsensitivity
Lempert,T.,&Neuhauser,H.(2009).Epidemiologyofvertigo,migraineandvestibularmigraine.JournalofNeurology,256(3),333–8.doi:10.1007/s00415-009-0149-2
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ClinicalFeaturesofVestibularMigraine
• Spontaneousvertigoorpositionalvertigo• Spontaneousvertigomaytransitiontopositionalvertigo(40-70%ofpatients)
• Motionintolerance• Imbalance• Nausea• Symptomspersistminutes(30%)tohours(30%)todays(30%)
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• Vertigocanbe“aura”– precedetheheadache• Insome,headacheandvertigoneveroccurconcurrently
• Othercommonsymptoms– Photophobia– Phonophobia– Osmophobia (osmophobia)– Othervisualsymptoms
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• Centralvestibularfindings• Morecommoniscentralvestibularabnormalities(upordownbeatnystagmus)
• Somepatientshavetransientunilateralperipheralhypofunction(horizontalspontaneousnystagmuswithabnormalheadthrust)
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VestibularMigraineDiagnosis
NewcriteriafromInternationalHeadacheSociety(2013)
http://www.ihs-headache.org/ichd-guidelines
• 5+episodesof:– spontaneousorpositionalvertigoorvisuallyinducedvertigo
–Moderatetosevereintensitylasting5minto72hours
• Currentorpriorhistoryofmigraine
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• 50%ormoreofvertiginousepisodeshaveeither:a.Headachewith2ormoreof:– Unilateral– Pulsatilequality–Moderatetoseverepainintensity– Aggravatedbyroutineactivityb. Photophobiaorphonophobiac. Visualaura
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AcuteCareofVestibularMigraine
• Medicationtypicallyusedformigraineprophyaxis– Propranolol– tricyclicantidepressants(amitriptyline)
• Vestibularsuppressants– Promethazine,Dimenhydrinate,Meclizine
• Antiemetics• Educationontriggers,introduceresources
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Meniere’sDisease
• Fluxuating vestibularfunction• Fullnessinear,decreasedhearing,tinnitus• Vertigo,nystagmus• Nausea,vomiting• Severedysequilibrium• Lasts30minutesto72hours• Onsetusually40-60yearolds
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• Typicallypatientreportsmultipleepisodes• Hearinglossistransient,mild,withnoresidualloss
• EtiologyisthoughttobeEndolymphaticHydrops– malabsorptionofendolymph
• Medication– diuretics• Lowsodiumdiet
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AtypicalEpisodicDizzinessMedicalCauses
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Dizziness
• Canbeproducedbyimpairmentin:– cardiopulmonarysystem– metabolicregulation– neurologicsystem– musculoskeletal– psychological– medicationuse– sensorysystemdisorders
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CommonMedicalCausesForIntermittentDizziness
• CardiacArrhythmia• OrthostaticHypotension• Hypoglycemicepisode• Anemia• Dehydration
Edlow,JA&Newman-Toker,DE.(2015).MedicalandNonstroke NeurologicCausesofAcute,ContinuousVestibularSymptoms.Neurol Clin 33:669-716.
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CardiopulmonaryDizziness
• Orthostasis/Posturalhypotension– 20mmHgsystolicor10mmHgdiastolicdropinBPfromsupinetosittingafter2minutes
• Vasovagalsyncope• Cardiacarrythmia• Valsalvainduced• Hypoxiaandanemia• Volumedepletion
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ElectrolyteorEndocrineAssociatedDizziness
• Hyponatremia• Hypoglycemia• Hypoalbuminemia• Adrenalinsufficiency• B12deficiency• Thyroiddisorder
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Diabetes
• 54%ofdiabeticshavevestibulardysfunctionasdefinedasinabilitytomaintainbalanceonfoameyesclosed
2001-2004NationalHealthandNutritionExaminationSurvey(NHANES)
• 70%ofsubjectswithDMdemonstratingimpaired dynamicvisualacuityWard,BKetal.(2015)CharacterizationofVestibulopathyinIndividualswithType2DiabetesMellitus.Otolaryngol HeadNeckSurg.Jul;153(1):112-8.
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NeurologicDizziness
• Demyelinatingdisorders• VertebrobasilarTIA• Post- concussivedizzinessorTBI
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MusculoskeletalDizziness
• CervicalDizziness– vertebralarterycompromise– Cervicaldegeneration– cervicalfacetjointpathology
• TemporalMandibularJointdysfunction
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PsychologicallyInducedDizziness
• Primarypsychologicaldisorders• Panicdisorder• Anxietydisorder
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DizzinessfromMedicationToxicity
• Antibiotics– aminogycosides
• Anti-inflammatoryagents– aspirin
• Alcohol• Solvents,Mercury,LeadExposure• Pharmacologyinteractionsoradversedrugreactions
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DizzinessfromSensorySystemDisorders
• Visual,Somatosensory,Vestibular• Fallers• Dizzinesscanresultfrom– pathologyofoneormoresensorysystems– changeinperceptionofenvironmentorstimulus– alteredweightingandintegrationofsysteminformation
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Treatment
• Medicalinterventionforunderlyingcause
• Considervestibularexercisesforpatients
withoutvestibularpathology
• Fallriskisincreasedinpatientswhocomplain
ofdizziness
• Addinggazestabilityexercisescanreducefall
riskHallCD, Heusel-Gillig L, Tusa RJ, Herdman SJ.(2010).Efficacyofgazestabilityexercisesin
olderadultswithdizziness.JNeurol PhysTher;34(2):64-9
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• ~85%ofpeopleaged80yearsandmorehavevestibulardysfunction
AgrawalY,CareyJ,DellaSantina C,SchubertM,MinorL.(2009).DisordersofbalanceandvestibularfunctioninUSadults:datafromtheNationalHealthandNutritionExaminationSurvey,2001-2004. ArchInternMed.;169(10):938–944.
• Generalvestibularexercisesreducesdizzinessinelderly
JungJYetal.(2009).Effectofvestibularrehabilitationondizzinessinelderly.AmJOto30(5):295-9.
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EarfullnessHearingchange
TinnitusMeniere’sHx
AnxietyorpanicConversiond/oMalingering
Atypicalsymptoms
Neurotology orNeurof/u
ConsultwithMD
TIA,MI,PE,hypoglycemia
SpontaneousOnset-
Occursatrestorwithout
headmovement
AVSwithEpisodicSymptoms-WithoutProvokingMovement
AdaptedfromNewman-Toker &Edlow,2015
MigraineHx,H/AcMigraine
features
SOB orsmotheringTrembling
BilateralnumbnessFear/anxiety
Aphysiologic gait
ConsultwithMD
ProbableMigraine
ProbableMeniere’s
Neurotology orNeurof/u
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Documentation
• DocumentationsystemsatmyfacilityareCernerandMedilinks – neitherhasorganizedvestibularevaluation.
• Findcomponents– e.g.EOMsormodifiedCTSIBmaybeunderVisionorBalancesections
• Nystagmusandotherspecificvestibulartestsusuallydescribed
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GCodes
• Inacutecare,Iselectthefunctionaltaskthatneedstobeaccomplishedfordischarge
• Oftenthisisambulation,butmaypick:– Timedupandgoifolderadultwithfallrisk– Stairsifneededforhomeentry– FunctionalGaitAssessmentifhigh-levelheadinjurywith+walkingability
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Charging
• Evaluationforinitialevaluation
• Treatmentchargesifassessingonceplan
established
– Neuromuscularre-ed andTherapeuticActivity
– Therex forHEP• MustchargeCanalithRepositioningTreatment
(CPT95992)forBPPVtreatment– flatrate
charge
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Resources
• Recommendedoutcomemeasuresforpatientswithvestibulardisordershttp://www.neuropt.org/professional-resources/neurology-section-outcome-measures-recommendations/vestibular-disorders.
• NeuroPTpodcastondizzinessintheEDhttp://neuropt.org/podcasts/vertigo-in-the-er.mp3
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PatientandProviderEducation• PublicationsfreetoprovidersandpatientsfromtheVestibular
DisordersAssociation– http://vestibular.org/publications-membership/pubs.-amp-dvd/free-
publications.php
• PatientEducationFactSheetsfreetopatientsfromtheAPTANeurologySectionVestibularSpecialInterestGroup– http://neuropt.org/go/special-interest-groups/vestibular-
rehabilitation/patient-education-fact-sheets
• PhysicianEducationFactSheetsfreetoprovidersfromtheAPTANeurologySectionVestibularSpecialInterestGroup– http://neuropt.org/go/special-interest-groups/vestibular-
rehabilitation/physician-education-fact-sheets
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Conclusion
• AcutePTroleistodifferentiatebetweenwhensymptomsareorarenotvestibularinnature
• Vestibularexerciseshavebeenshowntobeeffectiveinpatientswithvestibulardisorders
• Vestibularexercisesaregoodadjuncttotreatmentofpatientswithdizzinessand/orbalanceissuesevenwhennotfromvestibulardeficit
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Vestibular Therapy in Acute Care Georgia and Tennessee PT Association Meeting 2016
Pre-and Post Test
Britta Smith, PT, MMSc, DPT
1. A patient was seen in the emergency room about 30 minutes after awakening with severe, first-ever acute vertigo, nausea, vomiting, and imbalance. The patient is not able to sit or walk unassisted. The PT sees this patient later that morning and observes sustained horizontal nystagmus. Which of the following tests is most useful in determining if this patient has acute vestibular neuritis versus a central disorder?
a. Cranial nerve testing b. CT scan of head c. Head impulse test d. Dix Hallpike test
2. A patient was admitted to the hospital after being thrown from a horse with resulting leg injuries. During evaluation, the PT notices that the patient complains of dizziness immediately upon sitting. Upon inquiry, the patient reports that the same symptoms occur more strongly upon lying back down and rolling in bed. What should be considered as the next step in this patient's evaluation?
a. Dix Hallpike maneuver b. Vestibular function testing c. Recommending to the physician that meclizine be prescribed d. Blood pressure assessment
3. A patient was admitted through ED with acute vertigo with suspicion of stroke, but the CT scan and MRI were both negative. The physician has diagnosed acute vestibular neuritis and has referred the patient to PT to assure safe discharge home alone. The PT notes nystagmus to the right with right gaze and to the left with left gaze. What action should the therapist take?
a. Reassure the patient that the nystagmus will resolve within 72 hours b. Teach the patient gaze stabilization exercises c. Contact the physician immediately as this person probably has had a stroke d. Assessment balance and gait safety and recommend outpatient therapy
4. An elderly patient reports intermittent dizziness and unsteadiness, but all medical tests are inconclusive and the PT evaluation does not show a vestibular cause for symptoms. Does evidence support adding vestibular exercises such as gaze stabilization to reduce fall risk? ___yes ___no 5. When a patient asks the PT not to put the bed flat to assess bed mobility, what is the most likely vestibular problem the PT should investigate further? a. Cervicogenic vertigo b. Vestibular neuritis c. Conditioned-response dizziness d. Benign Paroxysmal Positional Vertigo 6. What is one of the most common medical causes for intermittent dizziness? a. Cardiac arrhythmia b. Drug intoxication c. Elevated blood pressure d. Increased intracranial pressure