Published on February 19, 2014
Vestibular Assessment from the Physiotherapy Perspective Bronwyn Kaiser A.Physiotherapy Coordinator SCGH Care Coordination Team
Anatomy: Extra Occular Eye Muscles Muscle Medial Rectus Lateral Rectus Superior Rectus Inferior Oblique Inferior Rectus Superior Oblique CN Pairing Semicircular Canal SCC dyfunction III } Horizontal Abnormal M/L mvt } Posterior vertical + torsional mvt } Anterior vertical + torsional mvt VI III III III IV - Pairing of SCC - SCC paired with 2 Muscles
Vestibular dysfunction • Vertigo and imbalance – Diagnosis needs to determine central (cerebellum) vs peripheral (labyrinth and semicircular canals of the inner ear) cause – Multiple peripheral causes (not just BPPV)
Subjective questioning Headache Migraine Head injury Tinnitus Hearing Loss Aural fullness Pain Visual changes (blurred/double) Photophobia Recent URTI/LRTI Sinus pain
Subjective • Symptoms – “dizzy” – vertigo, light headed, faint, drop attacks, nausea, auditory/visual disturbances • Tempo – latency – Duration – episodic • Circumstance – When – Where – Easing factors
Objective Eyes Assessment • • • • • Eye ROM Gaze Stability Saccade Testing Smooth Pursuit Vestibular Ocular Reflex – Screen – Head Thrust – Dynamic Visual Actuity
Take Home Message Occular motor testing See something that isn’t suspected – likely to have a central origin. – Exceptions: Non-direction changing gaze evoked nystagmus + ve Head thrust Regardless, +ve to any occulomotor test should to be referred on for Medical (ENT/ neuro) opinion
Objective Tests • Cerebellar tests – Dysdiadokinesia, finger-nose, heel-shin • Rhomberg test – FTEO vs FTEC • Sharpened Rhomberg – Feet in front of each other EO vs EC • Gait – Heel-toe walk
Objective Tests – Semicircular canals • Dix-Hallpike – anterior and posterior canal – Contra-indications • MSc: disc prolapse, cervical injury/fracture/trauma • Neuro: cervical myelopathy/radiculopathy • Vascular: dissection carotid/vertebral artery – Caution • Cardiac surgery within 3/12 • Severe orthopnoea • Severe back pain
Dix Hallpike Manoeuvre
Objective tests – horizontal canal • Horizontal roll test
Differential Diagnoses BPPV Tempo Symptoms Circumstance episodic,<1min Vertigo, N&V head changes relative to Gravity VBI episodic,<1min Vertigo, N&V, dipolpia, blurred vision, drop attack EOR E/rotation Postural Hypotension episodic Faint, dizzy Vestibular labrythitis crisis, constant for Vertigo, N&V, hearing loss, <4 days dysequilibruim constant, exacerbated with movement, visual disturbance Vestibular neuritis crisis, constant for Vertigo, N&V, No hearing loss, <4 days dysequilibruim constant, exacerbated with movement, visual disturbance Menieres episodic, 20min to Vertigo, N&V, hearing loss, tinnitus, 24 hours fullness in ear spontaneous and episodic CVA constant Migrane spells for minutes Vertigo, motion sensitivity, dizziness spontaneous or motion provoked Gentamycin Toxicity constant post 1 Dose getting up Vertigo, N&V, OTHER NEURO SIGNS constant Vertigo, dysequilibruim,
Treatments • Post/ant canal BPPV – Epley manoeuvre – Semont Liberatory manoeuvre/ modified Semont • Horizontal canal BPPV – BBQ roll / Appiani manoeuvre – Cassani manoeuvre • Gaze stabilization exercises • Substitution exercises • Habituation exercises
CANALITH REPOSITIONING TREATMENT
POST TREATMENT • Post Treatment Instructions THERE ARE NONE! • Re-Assessment - you can reassess 10 minutes after treatment if the patient is overly symptomatic - treat again if necessary - review as appropriate for your clinical area not
CONTRAINDICATIONS & RED FLAGS • CONTRAINDICATIONS: neck surgery, recent neck trauma, severe RA, atlantoaxial + occipitoatlantal instability, Cx myelopathy or radicaulopathy, carotid sinus syncope, Chiari malformation or vascular dissection syndromes. • RED FLAGS: - direction changing nystagmus - tinnitus - hearing loss - aural fullness - additional neurological S+S - failure to respond to conservative Rx ***REFER ON to ENT or Neurologist
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