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Vestibular assessment from the physiotherapy perspective
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Vestibular Assessment from the Physiotherapy Perspective
Bronwyn Kaiser
A.Physiotherapy Coordinator
SCGH Care Coordination Team
Anatomy
Anatomy: Extra Occular Eye Muscles
- Pairing of SCC- SCC paired with 2 Muscles
Muscle CN Pairing Semicircular Canal SCC dyfunction
Medial RectusIII
} HorizontalAbnormal M/L
mvt
Lateral RectusVI
Superior RectusIII
} Posteriorvertical +
torsional mvt
Inferior ObliqueIII
Inferior RectusIII
} Anteriorvertical +
torsional mvt
Superior ObliqueIV
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
Visual changes (blurred/double)Photophobia
TinnitusHearing LossAural fullnessPain Recent
URTI/LRTISinus 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 testingSee 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 Tempo Symptoms Circumstance
BPPV episodic,<1min Vertigo, N&V head changes relative to Gravity
VBI episodic,<1minVertigo, N&V, dipolpia, blurred vision, drop attack EOR E/rotation
Postural Hypotension episodic Faint, dizzy getting up
Vestibular labrythitis
crisis, constant for <4 days
Vertigo, N&V, hearing loss, dysequilibruim
constant, exacerbated with movement, visual disturbance
Vestibular neuritis
crisis, constant for <4 days
Vertigo, N&V, No hearing loss, dysequilibruim
constant, exacerbated with movement, visual disturbance
Menieresepisodic, 20min to 24 hours
Vertigo, N&V, hearing loss, tinnitus, fullness in ear spontaneous and episodic
CVA constant Vertigo, N&V, OTHER NEURO SIGNS constant
Migrane spells for minutes Vertigo, motion sensitivity, dizziness spontaneous or motion provoked
Gentamycin Toxicity constant Vertigo, dysequilibruim, post 1 Dose
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
LIBERATORY MANOUVER
BRANDT-DAROFF
BBQ TREATMENT
APPIANI MANOUVER
CASANI MANOUVER
POST TREATMENT
• Post Treatment Instructions
THERE ARE NONE!
• Re-Assessment- you can reassess 10 minutes after treatment if the patient is not overly symptomatic
- treat again if necessary
- review as appropriate for your clinical area
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