Chapter 2: Vestibular Disorders

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Chapter 2: Vestibular Disorders
2015-03-10 23:39:35
Vestibular Disorders
NPTE: Chapter 2
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  1. Characteristics
    • Dizziness: sensation of lightheadedness, giddiness, increased risk of falls
    • Vertigo: sensation of moving around in space or having objects move around a person; tends to come in attacks (severe = nausea and vomiting)
    • Visual changes: nystagmus and blurred vision
    • Dysequilibrium or postural instability: vestibular spinal reflex (VSR) dysfunction, ataxia, gait disturbances, increased risk of falls
    • Anxiety, fear, depression
    • Indirect impairments: physical reconditioning, decreased cervical ROM
  2. Nystagmus
    • Involuntary, cyclical movement of the eyeball
    • Horizontal, rotary
  3. Blurred Vision
    • Gaize instability
    • Due to VOR dysfunction
  4. Etiology: Unilateral Vestibular Disorders (UVD)
    • Trauma: vestibular symptoms seen in 30-65% of TBI cases
    • Vestibular Neuronitis, Labyrinthitis
    • Meniere's Disease
    • Benign Paroxysmal Positional Vertigo (BPPV)
    • Tumor: acoustic nueroma, gliomas/brainstem or cerebellar meduloblastoma
  5. Vestibular Neuronitis and Labyrinthitis
    • An acute infection with prolonged attack of symptoms
    • Persists for several days --> several weeks
    • Caused by viral or bacterial infection
  6. Meniere's Disease
    • Recurrent and usually progressive vestibular disease
    • Episodic attacks may last from minutes to several hours with severe symptoms
    • Associated with tinnitus, deafness, sensation of pressure/fullness in ear
    • Etiology unkown
    • Edema of membranous labyrinth
  7. Benign Paroxysmal Positional Vertigo (BPPV)
    • Brief attacks of vertigo and nystagmus that occur with certain head positions (lying down, turning over in bed, tilting head back)
    • May be related to degenerative processes
    • Mechanical impairment of peripheral vestibular system
  8. Etiology: Bilateral Vestibular Disorders (BVD)
    • Toxicity: ototoxic drugs
    • Bilateral infection: neuritis, meningitis 
    • Vestibular neuropathy, otosclerosis (Paget's disease) 
  9. Examination
    • History
    • Subjective
    • VOR Function
    • Sensory Function
    • VSR Function
    • Dix Hallpike Test
    • ROM (especially cervical)
    • Vertebral Artery Compression
    • Functional Status
    • Standardized Tests
  10. Exam: History
    • Type of symptoms
    • Nature of symptoms 
    • Duration of symptoms
    • Triggering stimuli/activity
  11. Exam: Subjective Assessment
    Dizziness Handicap Inventory (DHI)
  12. Exam: VOR Function
    • Examine for:
    • Nystagmus
    • Blurred vision with head and total body movements
  13. Exam: Sensory Function
    • Vision and proprioception (especially feet and ankles) -- important for compensatory postural adjustments with vestibular losses
    • Examine for sensory interaction in balance (CTSIB)
  14. Exam: VSR Function
    • Examine posture and balance
    • Examine for instability in sitting, standing, during functional activities and gait
  15. Exam: Dix Hallpike Test
    • Pt sits on table
    • Clinician turns patients head 45 degrees and quickly moves them down to supine position with neck extended 30 degrees beyond horizontal
    • Check for symptoms (vertigo and nystagmus)
    • Return pt to sitting and test on other side
    • (+) = BPPV on side that produces symptoms
  16. Exam: Vertebral Artery Comrpession
    • Can produce vestibular symptoms
    • In supine position = extend, laterally flex, and rotate head --> hold for 30 seconds 
    • Each side tested separately
  17. Exam: Standardized Tests and Measures
    • Balance disorders standardized tests
    • DHI = pt's self-perceived handicap as result of vestibular disorder (25 questions grouped into functional, emotional, and physical components)
  18. Medical Interventions
    • Vestibular suppressant medications
    • Prolonged use may delay recovery
    • Severe cases may require ablative surgery
  19. PT Goals, Outcomes, and Interventions
    • Implement safety measures
    • Active exercises to promote vestibular adaptation (recalibration of system) 
    • BPPV treatment techniques
  20. Active Exercises to Promote Vestibular Adaptation (Recalibration of System)
    • Habituation training
    • Gaze stability exercises
    • Postural stability
    • Functional mobility skills
    • Relaxation training for anxiety

    • Begin conservatively, avoid excessive exacerbation of symptoms
    • Recovery faster in unilateral than bilateral vestibular dysfunction
  21. Habituation Training
    Repetition of movements and positions that provoke dizziness and vertigo
  22. Gaze Stability Exercises
    • Eye movements --> side to side eyes on stationary target (X1 paradigm); side to side eyes on moving target (X2 paradigm)
    • Head movements up and down, side to side while maintaining eyes focused on visual target 
    • Progressing slow to fast movements, standing to walking
  23. BPPV Treatment Techniques
    • Canalith Repositioning Treatment (CRT): for horizontal SCC BPPV, posterior SCC BPPV
    • Liberatory maneuver: for posterior SCC BPPV
    • Brandt-Daroff exercises: for residual or mild vertigo