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