Lecture 15 - VR and BPPV

If you have a BPPV, what bedside test should you do? What does rehab include? (16)

1. dix hallpike 2. canalith repositioning maneuver (CRM)

diagnosis - based strategies (17) 1. functional symptom: visual and surface dependence (vision and touch substitute for vestibular). what is the treatment protocol

1. substitutions: forces increased vestibular function

What does adaptation do? (10) PROGRESSION*** 1. What does it reset or retune? 2. What do activities include? 3. provide an example

Done to restrengthen the VOR 1. the VOR by repetitive actions 2. movements/situations that provoke the patients symptoms 3. complex activity: have the pt sit on balance ball with slight bounce, while turning the head from side to side and reading two separate word lists

Side-Lying maneuver for ___SCC (go to slide 30 for visual) 1. describe the protocol for right side affects

PSCC 1. head rotated 45 degrees to the left (away from the ear being assessed) 2. Clinician assists patients into right side-lying position with the head turned towards the ceiling (affected ear towards the table) 3. clinician monitors for symptoms and nystagmus 4. after 60 seconds, clinician assists the patient to sitting position with the head still turned 45 degrees, monitors symptoms and nystagmus

diagnosis - based strategies (17) 1. functional symptom: oscillopsia. what is the treatment protocol

adaptation - gaze stabilization. Resets the VOR gain

diagnosis - based strategies (17) 1. functional symptom: vestibular recruitment (exaggerated or hypersensitivity to movement or sense of after motion) what is the treatment protocol

adaptation and habituation: extinguished noxious signal

Semont's liberators maneuver - PSCC BPPV; reserved for those with ______ (34) 1. why is the intensity of head movement important

cupulolithiasis 1. it is helpful for dislodging particles from the cupula

Describe ewald's first law (27)

eye and head movements occur in plane of canal being stimulated or in the same direction as the flow of the endolymph fluid

Roll maneuver to diagnose HSCC BPPV (5%) (37/38 for visual) Considerations: Patients with HSCC BPPV will generate ____ ___ when the head is turned either way (R/L). 1. Geotropic nystagmus (describe) indicates ____ on the side of stronger response 2. Apogeotropic (describe) indicates _____ on the side of the weaker response

horizontal nystagmus 1. (nystagmus beating towards ground, toward affected ear), canalithiasis 2. (nystagmus towards the sky, unaffected ear), cupololithiasis

Describe ewald's third law (27)

-ASCC and PSCC: utriculofugal (away from the utricle) > utriculopetal (toward utricle) excitatory response occurs when the endolymph flows away from the ampullated end causing the kinocilium to shear away from the utricle. VSCC, kinocilium arrangement is away from the utricle EXCITATION > INHIBITION: CAN EXCITE MORE THAN YOU CAN INHIBIT

What assessment can we use for patient with contraindications to dix hall pike when testing for PSCC BPPV?

-side-lying maneuver

Diagnose BPPV TYPE FIRST (25) 1. ____ BPPV is in ~1-2% of patients 2. What assessments can we use to diagnose 3. anterior canal BPPV can be purely ____-beating

1. ASCC 2. deep head hang 3. down

If you have a VSR/VCR postural stability issues with degraded somatosensory input and no visual input, what bedside test should you do? What does rehab include? (16)

1. CTSIB 2. protocols to reduce visual and/or surface dependence forcing vestibular input to be maximized (substitution)

If you have dizziness in general, what bedside test should you do? What does rehab include? (16)

1. DHI 2. provides pre-therapy baseline and validation of outcomes post-therapy

If you have a VOR that has abnormal gain at test frequencies, what bedside test should you do? What does rehab include? (16)

1. DVA 2. adaptation with emphasis on gaze stabilization in the place and frequency of the deficiency

What are the two assessments for PSCC BPPV (28)

1. Dix-Hallpike and Side-Lying

1. The ____ maneuver: treats PSCC BPPV (Canalithiasis) 80% effective 2. The ____ maneuver: treats PSCC BPPV (cupulolithiasis) 3. BBQ/Log _____ : treats ____ BPPV 4. ____ maneuver: treats HSCC BPPV 5. the brandt-daroff maneuver: home method for treating BPPV usually when the side of the BPV is unclear (25% effective) use has declined due to effectiveness of epley

1. Epley 2. Semont 3. Roll 4. Gufoni

What are the two treatments for PSCC BPPV (28)

1. Epley carnality repositioning maneuver (CRM), Semont

If you have a VOR input that is asymmetrical, what bedside test should you do? What does rehab include? (16)

1. Head impulse testing (HIT) 2. adaptation tests including gaze stabilization

Diagnose BPPV TYPE FIRST (25) 1. ____ BPPV is in 93% of patients 2. What assessments can we use to diagnose

1. PSCC 2. Dix-Hallpike and Side-Lying Maneuver

Common vestibular exercise program (19): 1. Describe VOR 2 and how to advance 2. Describe the position

1. Perform VOR x 1, but have head move in opposite directions of the target (held at arms length) 2. all exercises started in sitting position then advanced to standing (further advanced to unstable support surfaces (do not perform if pt falls on mCTSIB)

Vestibular disorders affect three output modalities. What are they? (7)

1. VOR (vestibulocular reflex) 2. VSR (vestibulospinal reflex) 3. vestbiulocolic reflex

Habituation (11) 1. Subset of ____ 2. Describe 3. give an example

1. adaptation 2. exercises to reduce hallucination of motion and extinguish sensation of after-motion feelings 3. ex: sonstrom in car and grading papers

List the three types or rehabilitation

1. adaptation 2. habituation 3. substitution

Gufoni Geotropic maneuver (HSCC) (44) 1. what is it used for 1. patient sits on the exam table with the head centered 2. clinician quickly moves patient on the the ____ side, keeping the patients head and body in the same plane 3. patient remains in this position for about 30 seconds 4. the patients head is then quickly turned 45 degrees (nose to ground), held in this position for 2 minutes 5. finally, the clinician assists the patient into a sitting position, keeping their head turned over the unaffected shoulder; once in a final position, clinician rotates the patients head back to the center

1. canalithiasis 2. unaffected

The vestibular evaluation (6): 1. patient ___ ____ 2. ___ examination (what does it include? what will affect VR outcome?) 3. Oculomotor examination includes 6 things

1. case history 2. a. includes: strength, Range of motion, sensation b. lower extremity weakness and adequate neck and foot range of motion will affect 3. a. CN III, IV, VI b. spontaneous nystagmus and gaze evoked nystagmus c. dix-hallpike/modified version d. head impulse test e. head-shake nystagmus f. DVA

Which ear is affected? (HSCC BPPV) (39) CANALITHIASIS 1. with the head turned towards the affected side, ____ occurs 2. With the head turned away from the affect side, ____ occurs AFFECTED SIDE IS THE SIDE WITH THE GREATEST NYSTAGMUS if you cannot tell, use the BOW and LEAN test

1. excitation 2. inhibition

Which ear is affected? Bow and lean test (HSCC BPPV) (40) CANALITHIASIS 1. BOW: 2. LEAN:

1. excitation when bowing, so nystagmus will beat towards the involved side 2. inhibition hen leaning back, so nystagmus will beat away from the involved side

How is the VOR affected when there is a vestibular disorder? (7)

1. eye movement and gaze stabilization during active head movement

Considerations with vestibular rehabilitation (3): 1. Time to ____ ___ varies from person to person 2. Many ___ affect functional recovery 3. ___ ____ seems the most likely basis of recovery (WHY?) 4. Disorders of the _____ affect recovery (an intact cerebellar ____ is important for vestibular ____ to occur) WHY? 5. VR is context specific, therefore; VR should occur in various positions at different _____ and in different environments 6. ___ stimulation appears to be critical for adapting the ___ ___; it is reported there is no increase in VOR gain if the person is not exposed to light 7. ___, ____, and length of symptoms do ___ ___ vestibular ____ (it might just take a bit longer for compensation) 8. Those with ____ lesions are thought to have better outcomes than those with central vestibular disorders; especially related to ____ ____ (critical for VOR) 9. ____ ___ to reduce symptoms can affect compensation and ___/___ recovery

1. functional recovery 2. factors 3. CNS plasticity (compensation) 4. cerebellum (flocculus, adaptation) COMPENSATION 5. velocities 6. visual, dynamic VOR 7. age, gender, not affect, compensation 8. peripheral; cerebellar dysfunction 9. prescribed medications, slow/inhibit

Which ear is affected? (HSCC BPPV) (39) CUPULOTHIASS 1. with the head turned towards the affected side, ____ occurs 2. With the head turned away from the affect side, ____ occurs AFFECTED SIDE IS THE SIDE WITH THE WEAKER NYSTAGMUS if you cannot tell, use the BOW and LEAN test

1. inhibition 2. excitation

Which ear is affected? Bow and lean test (HSCC BPPV) (40) CUPULOTHIASS 1. BOW: 2. LEAN:

1. inhibition when bowing, so nystagmus will beat away from the involved side 2. excitation when leaning, so nystagmus will beat towards the involved side

Vertical canal diagnosis criteria (25) 1. What canal is being stimulated with down beating nystagmus with left torsion?

1. left anterior canal

Vertical canal diagnosis criteria (25) 1. What canal is being stimulated with up beating nystagmus with left torsion?

1. left posterior canal

Semont's liberators maneuver - PSCC BPPV (KEEP YOUR CHIN ON THIS SHOULDER NO MATTER WHAT - GO to slide 35 for visual) 1. Patient sits on the edge of the exam table with... 2. Turn the head 45 degrees ____ from the ____ ear 3. Maintain the head orientation as you move the patient rapidly toward the ____ ear and place them in the ___-____ position (patient will be ____) 4. wait until nystagmus and symptoms _____ 5. move patient ____ to ___-side lying position with head still turned 45 degrees away from the involved ear 6. Bring the patient back to the sitting position after the responses subside

1. legs hanging over side 2. away, involved 3. involved, side-lying 4. dissipate 5. rapidly, opposite

Considerations for VRT (21): 1. encourage ___ extremity strengthening 2. ask patient to increase their ___ ____, especially via walking 3. avoid ____ ___ if pt falls during mCTSIB 4. To strengthen vision, have the pt stand on ____ surfaces (ex: foam) with eyes ____; vision is important for ____ ____ 5. to strengthen somatosensory, have the pt stand with eyes ___ on a ___ surface 6. To strengthen vestibular, have the patient stand with eyes ____ on an ____ surface (ex: foam) 7. progress exercises in an incremental manner and as quickly as possible to improve the function and patients overall QOL

1. lower 2. activity level 3. uneven terrain 4. uneven, open; postural control 5. closed, flat 6. closed, uneven

How is the vestibulocolic reflex affected when there is a vestibular disorder? (7)

1. otolith gravity sensors (utricle/saccule) and neck proprioceptors cervicogenic screener (body left and body right)

How is the VSR affected when there is a vestibular disorder? (7)

1. postural stability translated via musculoskeletal system

horizontal canal diagnosis criteria (25) 1. What is head left canalathiasis (geotropic or apogeotropic?) 2. What about head left cupulolithiasis (geotropic or apogeotropic?)

1. pure horizontal LB (geotropic) 2. pure horizontal RB (apogeotropic)

horizontal canal diagnosis criteria (25) 1. What is head right canalathiasis (geotropic or apogeotropic?) 2. What about head right cupulolithiasis (geotropic or apogeotropic?) 3. what does geotropic mean? 4. What does apogeotropic mean?

1. pure horizontal RB (geotropic) 2. pure horizontal LB (apogeotropic) 3. towards the ground 4. towards the sky

Vertical canal diagnosis criteria (25) 1. What canal is being stimulated with down beating nystagmus with right torsion?

1. right anterior canal

Vertical canal diagnosis criteria (25) 1. What canal is being stimulated with up beating nystagmus with right torsion?

1. right posterior canal

What teatments can we perform for HSCC BPPV

1. roll maneuver 2. log roll 3. gufani

Vestibular Rehab background (2) 1. Historical programs consisted of eye-head exercises designed to simulate the ____-_____ ___ and ____ organs 2. Exercises gradually became ___ and more ___ as the individual improved 3. The original group exercise program would be considered dangerous today 4. What is it important that we do for our patients for the best care and outcome?

1. semi-circular canals and otolith 2. faster and more difficult 4. find a PT thats certified in vestibular system

Substitution (12): 1. Describe 2. for vestibular loss, reduce the somatosensory input (have the patient on uneven ground such as a trampoline), secondly, reduce visual input by have the patient close their eyes on the uneven ground - such as done in mCTSIB)

1. strengthen the weakened system by reducing the dependence on the remaining ones (use one modality to compensate for one that is lost/lesioned) (ISOLATE THE WEAK SYSTEM AND MAKE IT STRONGER)

Roll maneuver to diagnose HSCC BPPV (5%) (37) 1. Begin with patient lying ____ on exam table 2. while supporting the neck, have the patient move up until the head is over the table edge 3. Tilt the head forward at an angle of ____ degrees with the horizontal plane (caloric position) 4. turn the head rapidly toward the right ear while maintaining the head orientation (patient will be symptomatic) 5. wait until the symptoms ____ 6. Turn the head rapidly to the ___ ear wile maintaining the head orientation (patient will be symptomatic) 7. After response subside, return the head to the ___-___ position

1. supine 3. 30 5. dissipate 6. left 7. nose-up

What assessments can we perform for HSCC BPPV

1. supine roll maneuver 2. bow and lean (Affected side)

Assessment overview - eye movements, lets focus on; 1. Direction of the ____ and the ____ (what do they both indicate?) 2. ____ (type of BPPV) 3. Nystagmus duration for canalathiasis 4. Nystagmus duration for cupulolithiasis

1. torsion (indicates the side involved) and the beat (indicates canal involved) 2. Duration 3. less than 60 seconds (this is the most common) 4. more than 60 seconds

Prior to referral for VR, define and categorize status of the ____ _____ (what is specifically involved?) Who is the ideal patient (7)

1. vestibular invovlement 2. patient with stable, yet uncompensated unilateral vestibular dysfunction (ex: lack of episodes, nausea, emesis)

Common vestibular exercise program (19): 1. Exercises incorporate ____, _____, and/or ____ function 2. Describe VOR 1 and how to advance

1. vestibular, somatosensory, and visual 2. Focus on the target while moving head up-down and back-forth ADVANCED: advanced by changing backgrounds, increasing speed of head movement and position of patient

What are some predictive factors with negative implications for vestibular rehabilitation (4/5) -List 5-7

1. vision issues 2. age 3. comorbidities (MS, ALS, parkinsons) 4. cerebellar implications 5. medications 6. circulation issues / BP 7. motor abilities (physical) prosthesis

Describe ewald's second law (27)

HSCC: utriculopetal (towards utricle) > utriculofugal (away from utricle) Excitatory réponse occurs when the endolymph flows towards the ampullated end, causing the kin cilium to shear toward the utricle (ampullopetal) HSCC, kinocilium arrangement is close to the utricle!! ***

Epley canalith repositioning maneuver (CRM) treatment for __SCC (go to slide and read + 31/32) 1. Patient sits on the table with the head turned ____ side of ____ 45 degrees 2. While maintaining head orientation, move the patient ____ from ___ to ____ position, with head hanging slightly over the edge of the table; support the patients next (Dix-Hallpike; patient is symptomatic) 3. Wait until nsyagmus/symptoms _____ 4. Begin ____ head ____from the involved ear until it is turned 45 degrees toward the intact ear 5. Maintain head orientation with respect to the torso as the patient rolls his body ___ degrees towards ____ ear (head will be 45 degrees downward) Often performed either slowly over minutes for each maneuver or in a steady motion over a few seconds 6. after the patient's symptoms subside, bring them back to the sitting position while keeping the head turned ____ the ___ ear What is the consideration?

PSCC 1. toward, BPPV 2. rapidly, sitting to supine 3. dissipate 4. rotating, away 5. 90, intact 6. toward, intact Consideration: if the nystagmus reverses during CRM, this means the canaliths are moving in the wrong direction; abort the procedure and repeat from the beginning

Gufoni Apogeotropic maneuver (HSCC) (46) 1. what is this used for 1. patient sits on the exam table with the head centered 2. clinician quickly moves patient on the the _____ side, keeping the patients head and body in the same plane 3. patient remains in this position for about 30 seconds 4. the patients head is then quickly turned 45 degrees (nose to ground), held in this position for 2 minutes 5. finally, the clinician assists the patient into a sitting position, keeping their head turned over the affected shoulder; once in a final position, clinician rotates the patients head back to the center

cupulolithiasis 2. affected