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Vestibular Rehab for Nondizzy Patients: Summary
• Concussion/Traumatic Brain Injury (TBI): Commonly see a decline in vestibular acuity and gaze stability, leading to blurred vision and visual intolerance due to deficits in vestibulospinal reflexes and VOR gain • Multiple Sclerosis (MS): Can cause issues at all levels of vestibulospinal chain—vestibular nerve, cerebellar plaques, VOR, and vestibulospinal reflex • Parkinson’s Disease: Leads to deterioration along the vestibular nucleus complex and vestibular nerve: ○ Vestibular dysfunction (decline in VOR and vestibulospinal reflex) is common • Injury after fall • Peripheral Neuropathy: Leads to degradation of both the sensory apparatus of the lower leg/feet and the musculature (loss of somatosensory system involvement in balance) • BPPV: 25% of individuals with BPPV report no sensation of vertigo or dizziness symptoms but still have severely impacted balance; it is always worth screening in balance patients
TESTS AND MEASURES:
BPPV: Posterior Canal • Hallpike Testing: Turn head 45 degrees toward the involved side; lay on back with 10–15 degrees cervical extension (head hanging off the table or using pillows under the back) • + test: Symptom of vertigo and noted nystagmus (caused by excitation of vestibular apparatus as the particle moves through the canal): ○ Symptoms can also include ear pressure; vertigo not always necessary for it to be a positive test; sometimes symptoms worse when sitting up ○ Nystagmus fatigues after a few seconds: Canalithiasis ○ Nystagmus does not fatigue: Cupulolithiasis • Sit back up; nystagmus will typically reverse directions Nystagmus • Quick phase moves toward the more active side (could be due to being the “angry” side or the only side that is working) VOR • Overstimulating the vestibular system to see what is wrong and how the eyes respond Smooth Pursuits • Tracking a moving target: Will be more abnormal toward the dysfunctional side (jumping to estimated target motion, playing catch-up, unable to track) • Will be a little slow in patients age >65 years Gaze Stability • The ability to hold the eyes still after they are moved up, down, right, or left • Eyes will beat toward the more active side Saccades • Ability to more rapidly move from one target to another in one motion • Generated by the brainstem, basal ganglia, and cerebellum; abnormalities indicate a central issue Head Thrust Test • Test for VOR dysfunction • With eyes on a central target, rapidly turn head in a small range; the goal is to keep eyes locked on the target • Positive side indicates peripheral vestibular dysfunction toward that side
LEARNING TIP!
Symptoms: • Poor balance • Trouble walking
• Vertigo (room or person spinning) • Lightheaded (floating, rocking, “not quite there”) • Nausea/vomiting • Sense of tilt (feel like falling forward) • Clumsiness • Frequent tripping or dragging feet • Blurred vision
Subjective Complaints • Furniture surfing: Provide proprioceptive cueing for balance and postural corrections • Unstoppable straight falling: Vestibulospinal reflex being delayed • Bend over and just keep going • Worried people will think they are drunk • Have to move more slowly, especially with transfers (to stabilize with big movements) • Sense of continued motion after they stopped moving • Frequent faller or loss of balance (cannot let go of an AD, worse balance in the dark) • Dragging feet due to difficulty standing on one leg for controlled stepping • With acute BBPV will have vertigo, nausea, and imbalance, most commonly with lying in bed/rolling over; chronically, patients will note an imbalance and more vague sensation (lightheadedness, floating sensation)
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