VEST REHAB FINAL

85% of ____ cases get better in one treatment

BPPV

vertigo and nystagmus last how long with BPPV?

< 1 min

how does BPPV happen?

spontaneously or after trauma

BPPV occurs in?

adults all ages

when does BPPV complaint happen?

ages 50-70 roughly 25% of dizziness is

BPPV

over age 80 roughly 40-50% of dizziness is

BPPV

what is BPPV more common with?

head and neck trauma

biggest complaint of BPPV?

poor balance

what are the 2 causes of BPPV?

1. Cupulolithiasis
2. Canalolithiasis

what is MC cause of BPPV?

canalolithiasis

cupulolithiasis =

fixed otoconial debris stuck to cupula

vertigo is longer lasting with:

cupulolithiasis

how long does cupulolithiasis last?

until elastic forces of cupula pull it back or until CNS habituates

canalolithiasis =

free floating debris

what has a suction effect as debris moves w/ gravity?

canalolithiasis

BPPV MC % of cases:

Posterior canal is MC with 90

BPPV 2nd MC % of cases:

Horizontal canal (9%)

BPPV least common % of cases:

Anterior canal (1%)

Test for Posterior canal BPPV:

Dix Hallpike

Test for Horizontal canal BPPV:

Roll Test

Test for Anterior canal BPPV:

Rahko test

What are the managements for Posterior BPPV?

- Posterior Semont maneuver
- Epley maneuver
- Brandt Daroff

What are the managements for Horizontal BPPV?

- Horizontal semont maneuver
- Lempert maneuver Bar B Q
- Horizontal Brandt Daroff

What are the managements for Anterior BPPV?

- (-) posterior semont maneuver
- rahko maneuver
- Brandt daroff man.

timing of symptoms w/ BPPV is suggestive of:

canalolithiasis vs cupulolithiasis

what may be used to break up cupulolithiasis?

vibration

Test series for BPPV?

- left hall pike Dix
- right hall pike Dix
- if no vertigo = do roll test to left
- after 30 sec, do right head turn

do you want patients to fixate on something with BPPV?

no and you can use frenzel lenses to observe eye movement

should a patient look around voluntarily with BPPV testing?

no

patient must remain in position until ______

vertigo stops

after CRT how should the patient position themself?

upright 48 hours

after CRT, what maneuver should be done?

Brandt Daroff habituation exercise every 3 hours until its gone for 2 days

CRT =

Canal Repositioning Therapy

Hallpike Dix we see the _____

position of the posterior canal

hall pike dix pic

what does the posterior semont maneuver do?

movement of the head breaks the debris off cupula

horizontal semont the patient drops ____

toward the affected the side

how do you do the horizontal semont ?

With the horizontal Brandt daroff, the patient flexes ____

the neck 30 deg.

how does horizontal Brandt daroff performed?

How do you perform Rahko test for anterior canal?

bend forward 30-40 deg.

2nd step of Rahko test:

closed eyes and extend back quickly

how many times is Rahko test for anterior canal repeated?

3-4 times

what do you note with Rahko test for anterior canal?

initial direction of slow sway on final repetition

what is the affected side with Rahko test for anterior canal?

slow sway side

how do you perform the anterior canal test?

Turn the patient's head 45 deg. away from the side being tested
tilt the patient forward quickly

what do you note w/anterior canal test?

any nystagmus or vertigo

what is the anterior semont maneuver?

essentially reverse of the posterior canal semont maneuver

how to perform Rahko test:

1. patient lies unaffected side down head in lateral flexion 45 deg.
2. Head neutral
3. head 45 deg. off table
4. 30-45 sec. at each position
5. sit back up and remain still for 3 min

if CRT doesn't work, what is most likely cause?

age of patient

elderly patients are more likely to have:

a disuse disequilibrium

patients who have a fear of falling need:

VRT

list of contraindications to CRT:

Recovery Mechanism of vestibular injury, Adaptation:

changing the gain, phase, or direction of the vestibular response via substitution

Recovery Mechanism of vestibular injury, other sensory inputs:

COR replaces VOR, and otolithic responses for canal responses

Recovery Mechanism of vestibular injury, alternative motor response:

saccades and pursuits for absent VOR

vestibular system has what mechanism?

push pull

CNS data storage pic

Normal function pic of head turning left

what are the 3 Vestibular recovery terms?

rehab
adaptation
habituation

what is vestibular rehabilitation?

an exercise based program, designed by a specialty trained vestibularpdhysical therapist, to improve balance and reduce problems related to dizziness

what is vestibular adaptation?

the response of the CNS to asymmetrical peripheral vestibular activity and resolution of sensory conflicts

what is vestibular habituation?

the long term reduction in a neurologic response to a particular stimulus that is facilitated by repeated exposure to stimulus

vestibular rehab brings about:

adaptation

vestibular adaptation brings about:

habituation

balancing neurological response stimulus brings about:

more appropriate responses

what does vestibular adaptation involve?

readjusting the input output relationships in order to restore adequate motor behavior

what has been the model for recovery w/vestibular adaptation?

unilateral labyrinthectomy

What is crucial in adaptation and drives it in unilateral labyrinthectomy?

VOR

what is unilateral labyrinthectomy?

loss of half the input for the push pull (activation-inhibition signal) that determines responses to head movement

normal healthy patient w/sudden loss can be devastating - but recover fully =

unilateral vestibular deafferentation

What is sudden unilateral loss symptoms of unilateral vestibular deafferentation?

- spontaneous nystagmus
- postural instability
- inadequate compensation for head movement
- change in perception of body orientation and movement

neurons in medial vestibular nucleus get input and relay to:

VOR, VSR, and thalamus

vestibular nuclei communicate across the ____

midline

activity of the vestibular nucleus is not only based on input from the receptors, but also ____

from visual, spinal, reticular, and cerebellum

vestibular adaptation 2 types of imbalances:

static and dynamic

what is static imbalance in regard to vestibular adaptation?

- involves change in tonic discharge
- changes while patient is still
- due to change in push-pull mechanism

what is dynamic imbalance in regard to vestibular adaptation?

- how the imbalance affects patient while moving
- due to change in push-pull mechanism

left unilateral lesion static pic:

sensory components of UVD:

patient will feel he is falling, turning, or leaning to the right while sitting still

more pronounced in darkness - vertigo =

sensory components of UVD

what are static symptoms?

How long do static symptoms last?

usually disappears within 1 month

OTR =

ocular tilt reaction

Ocular Tilt Reaction (OTR) is what type of symptom?

static

what are the 2 word static symptoms?

- ocular torsion
- skew deviation
- lateralpulsion

normal tilt reaction =

eyes counter roll (away from side of tilt)

when patient tilts his head:

The eyes must roll, and horizontal & vertical axes must match

with a left lesion, right utricular input makes patient think he is _____

tilted right, so he tilts left

what is ocular torsion?

as the input from the right side is perceived and there is no inhibition from the left side the eyes will roll toward the left as a consequence

what is skew deviation?

left eye must extort
right eye intorts

in regard to skew deviation, the strength of the torsional reaction involves:

the superior and inferior recti whose secondary action is torsion

what is lateralpulsion?

leaning or falling toward the affected side

does lateralpulsion disappear?

yes, with compensation

dynamic disturbance =

decreased amplitude of slow phase of VOR

dynamic disturbance causes:

abnormal responses to head motion

dynamic disturbance can cause:

right and left asymmetry of eye responses due to head rotation

left unilateral lesion dynamic pic:

what happens with the left unilateral lesion?

without inhibition from the left-the right side may activate w/left head motion

what is the result of a left unilateral lesion?

right beating (perverted) nystagmus

with a left unilateral lesion, movement toward the healthy right side may exaggerate _____

response due to increased type II inhibition on the lesioned left side

VOR tests:

- Head thrust test
- Head shaking nystagmus

continuous spin =

dynamic testing

recovery for left unilateral lesion:

left vestibular nuclei are less active
- right vestibular nuclei get no type 2 inhibition

with recovery for left unilateral lesion, the lack of activity in the left vestibular nucleus means:

that the effects of right motion are magnified

recovery pic

the visual system perceives:

the motion of the environment as the head moves

vision input helps to:

increase inhibition of the type I neurons

what is the role of cerebellum?

center for sensory information integration

what does the role of cerebellum contribute to?

VOR suppression and fixation suppression of nystagmus

comparison of mechanoreception (spindles) to:

vestibular inputs

what happens to changes on left lesion side?

Type I neurons become less sensitive to GABA (more difficult to inhibit)

what happens to changes on lesion side with Type I neurons?

Type I neurons grow new sprouts to vestibular sensory receptors

what happens to changes on healthy side of unilateral left lesion side?

type I neurons become more sensitive to GABA (easier to inhibit)
- because type II neurons this side may release less GABA

on the healthy side of a unilateral lesion,

type II neurons become more sensitive to activation from visual and mechanoreceptive stimuli

error signal drives adaptation:

retinal slip

the reason to have a VOR is to:

stabilize images on the retina

is vision necessary for adaptation?

no

what is evidence of adaptation?

loss of nystagmus and counter roll

what is essential for the restoration of dynamic disturbance?

vision

what do animal studies show?

it's images of the environment moving across the retina driving adaptation

vision is necessary for:

dynamic recovery, not static

without retinal slip during head motion:

there is no reliable signal to use for recalibration of dynamic VOR

with static disturbance, the role of _________ are more important

somatosensory cues

with bilateral loss, is VOR recovery possible?

no

what will a patient rely on with Bilateral loss?

- substitution strategies
- anticipatory strategies

strategy of bilateral loss:

patients w/bilateral loss that rely on visual input have difficulty:

with escalators or reading

poor recovery boils down to:

irregularity of symptoms like BPPV or Meniere's

factors inhibiting recovery:

how does "Decompensation" happen?

often patients who have compensated for unilateral vestibular lesion may lose