Vestibular
Epley Maneuver for right-sided posterior canal BPPV
Evaluation: Supine Head-Hanging Test for the Diagnosis of Anterior Canal BPPV.
Clinically, ac-BPPV is characterized by a vertical downbeat nystagmus with a torsional component toward the affected side when the individual is looking straight ahead as evoked by the supine head-hanging test.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497794/#:~:text=Supine%20Head%2DHanging%20Test%20for%20the%20Diagnosis%20of%20Anterior%20Canal,the%20supine%20head%2Dhanging%20test.
Treatment with Yacovino maneuver: Doesn't matter which ear you are treating, the maneuver is the same. (1) supine with head extended 30 deg, (2) supine head flexed 45 deg, (3) seated with head flexed 45 deg. (step two for too long, you risk the otoconia staying in the posterior canal.
Concussion
Habituation Exercises:
-Gaze stabilization
Gaze stabilization protocol:
-3x/day, at least 12 min daily.
-VORx1 (head movements) and VOR x2 (head and arm movements)
-Seated at 1 meter (14 point font) and 3 meter (54 point font)
-Progression:
---Checkered background
---Increase speed and duration
---Balance challenge (firm, foam, walking)
Acoustic Neuroma initial examination
-Gaze stability - Testing includes the following:
----Spontaneous nystagmus: Have patient look straight ahead focusing vision on something.
----Gaze evoked nystagmus: fixating eyes on target at 30 deg of motion with smooth pursuits (horizontally and then vertically holding for 20 sec)
----VOR (head shaking) in horizontal and vertical
----Rapid head thrust (tilt head 30 deg downward)
-Motion sensitivity as indicated
-mCTSIB
Interventions:
Adaptation:
VOR x 1, VOR x 2 for interventions
Habituation:
Motion sensitivity interventions
DHI
Vertigo handicap questionnaire
Vestibular disorders activities of daily living
For improving Saccades:
-https://eyecanlearn.com/tracking/saccades/
-This is a website the patient can access.
Concussions are like snow flakes. They are all different.
Assess for cervicogenic dizziness.
Different profiles that concussions can present as:
-Cognitive profile: Feels best in morning, greater fatigue through the day. Cognitive impairments are a generalized decline.
-Ocular profile: frontal headache with visual work. Visual focussing issues, diplopia, blurry vision.
-Vestibular profile: dizziness, nausea/motion sickness, symptomatic in busy environments, off-balance.
-Migraine profile: variable headaches in severity and frequency. Nausea, photophobia, phonophobia. Stress, anxiety, lack of exercise. Sleep dysregulation. May also present with vestibular migraines.
-Mood/Anxiety profile: hypervigilance, rumination. Depression. Overwhelmed state (poor tolerance of busy environment). Difficulty initiating sleep (inability to turn thoughts off). Difficulty maintaining sleep. Excessive focus on symptoms. Limited socialization.
Profiles rarely occur in isolation. Treat the primary profile, then draw focus to the secondary.
EXAM
Cervical Screen
Cognitive Testing
Dizziness: common symptom in persistent post-concussion syndrome, with prevalence as high as 32.5% at five years. Dizziness often points to vestibular dysfunction. Dizziness was the sole on-field factor predictive of protracted (>21 days) time to recovery.
Visual/Vestibular Exam:
-Spontaneous Nystagmus: Holding pt's head still and looking for nystagmus while they look straight.
-Fixed Gaze Nystagmus: Use pin to take pt's vision up, down, side-to-side only 30 deg and look at nystagmus at end of motion while they hold their vision.
---Alexander’s Law: with unilateral nystagmus, if looking to the right with left issues, it will speed up fast phase toward the right, but looking to the left, you still get fast to the right, but slower. If central, it would be fast no matter where you are looking.
-Occulomotor range of motion: Looking to see if the eyes move conjugately and smoothly. 18-24 in. Small amount of end-range nystagmus is normal. Small jump in eye movement as eyes cross mid-line is normal.
-Smooth pursuits: 24-36 in. from pt. 60 deg of total arc of motion. Small jump in eye movement as eyes cross mid-line is normal. Smooth pursuit eye movements may be slightly saccadic in older people.
-Convergence: Hold finger 2 ft away and bring closer to nose. Eyes should converge and pupils should constrict. Ask when the patient sees 2 fingers (pens) or it becomes blurry.
Convergence should be sustainable <6cm from tip of nose.
-Saccades (vertical and horizontal): Pt looks at 2 objects 15 deg apart. Looking for number of eye movements it takes for patient’s eyes to reach target. Normal is < or equal to 2 movements. Overshoots are always a positive test!!
-Can also assess ocular alignment.
-VOR Cancellation: Head tilted 30 deg. Head and hand moving in same direction. Assessing for saccadic eye movements (central dysfunction).
-VOR (vertical and horizontal): Head tilted 30 deg.
-Head Thrust Test: Tilted 30 deg downward. 10 deg only for the thrust. Looking for corrective saccades back to target. Positive test indicates vestibular hypofunction on ipsilateral side.
-Head Shaking Nystagmus: Tilt pt's head down 30 deg. Close eyes and shake their head 20x at 2 Hz. Have pt open eyes and fixate vision on a target. Look for nystagmus. Works best with VNG goggles or Frenzel lenses. If nystagmus present, positive sign for unilateral vestibular hypofunction.
-Visual Acuity/Dynamic Visual Acuity.
VOMS:
-Smooth pursuit: 2x horizontal and vertical. 3 ft from patient. 1.5 ft each direction. 2 seconds for full end-to-end.
-Saccades: 2 objects 3 ft from head, 3 ft apart. 10 repetitions looking L to R. Perform vertical and horizontal
-Convergence: Corrective lenses are fine to wear if needed. 14 pt font size at arms length and slowly bringing toward tip of nose. Instruct pt to stop moving target when they see two distinct images or if I observe outward deviation of one eye. Ignore blurring of the image. Measure distance from tip of nose to target in centemeters. Repeat 3 total times. Abnormal is greater than 5 cm.
-VOR: Hold 14 pt target 3 ft from head. Pt rotates head 10x in vertical and horizontal at 180 beats/min. With one beat in each direction.
-Visual Motion Sensitivity (VMS) Test (VOR Cancelation): 80 deg to the right and 80 deg to the left. Metronome set at 50 bmp (one beat in each direction). Repeat for 5 repetitions.
Balance Assessment:
-mCTSIB. 30 sec each position.
-FGA
Motion Sensitivity Quotient.
Exertional testing and prescription flow chart in PPT.
TREATMENT:
Anxiety and Mood profiles for someone 3 months post-concussion:
-Consistent wake up and bedtime every night. 7-9 hours (strive for their optimal amount of sleep). No naps as this can interfere with nighttime sleep.
--Regularly participate in your social activities.
-Maintain a consistent routine: work, household chores, sleep, social activities. Limit idle time.
-Exercise. Moderate to heavy non-risk (head impact) exercise.
-Psychiatry consult
Migraine:
-Pt's who are motivated do quite better than pt's who are less motivated.
-Vestibular rehab as indicated. Starting light and progressing.
-Exercise 30 min per day.
-Regular sleep.
-Drink 8 glasses of water per day.
Vestibular migraine isn't fully understood but seems to result from overlapping pathways that modulate pain and vestibular inputs into the brain.
Vestibular:
-If central dysfunction: work on saccades and smooth pursuits as indicated.
-Wonderful visual exercises under semester 5 concussion and TBI folder
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