Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
70 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
What are the 2 psychological impacts of falls which can be very detrimental?
|
fear of falling:
those who fall are more likely to become fearful of future falls |
Post Fall Anxiety Syndrome
loss of confidence to walk safely resulting in self-imposed limitations (60% of those who have fallen will fall again |
|
|
What is the "long lie" that Tinetti, Liu & Claus report on in the AMA?
|
Lying on the floor for hours before being discovered due to an inability to help themselves up
(about 1/2 of the elderly are unable to do so) |
|
|
|
Falls prevention requires effort in 3 areas. What are they?
|
1-Medical Assessment:often combination of medical & behavioral factors leads to falls
2-Behavioral Changes:"at risk" people push their limits doing something out of the ordinary 3-Education: knowing strengths/weaknesses fives pt. more freedom, can do simple things to improve balance, helps overcome fear |
|
|
|
Name 3 basic balance systems
|
1-Vestibular system: inner ear/labyrinthine, cervicovestibular, cerebellum, vestibulospinal
2-Somatosensory system: proprioceptors in muscles and joints of lower extremities 3-Visual system: vision, eyes ability to move smoothly and accurately (oculomotor function) |
|
|
|
What are ampullopedal and amullofugal movements?
|
Ampulopedal
-fluid in the SSC moves/flows toward the ampulla |
Ampullofugal
-fluid in the SSC moves/flows away from the ampulla |
|
|
What is Alexander's Law?
|
Nystagmus is enhanced when gaze is in the direction of the fast phase
|
|
|
|
What are the 3 things necessary for normal gait and mobility?
|
1-nervous system (sensory & motor) function: parkinsons
2-adequate structural features: lower extremities: deformed lims, arthritis, obesity 3-normal musculature function: myasthenia gravis |
|
|
|
Subjective evaluation of gait should include assessment of what 3 main issues?
|
1-Ease of walking
2-Speed according to body size 3-General stability |
|
|
|
What are the elements of normal gait?
|
Initiation of Gait
Feet Clear the floor Step distance Smooth and continuous Deviation Trunk Stability Stance Turning |
no hesitation, swing foot clears floor, feet about 1 foot apart, heel back rises as heel fron lifts, walks straight, arms at side, trunk doesn't sway, feet almost touch, steps are continuous
|
|
|
Common descriptors of Abnormal Gait....
|
Spastic * Antalgic * Ataxic *
Tabetic * Vertiginous * Orthopedic * Frontal (lobe) * Parkinsonian * Functional * Paretic * Dyskinetic |
|
|
|
5 Common Disorders
|
1- Benign Paroxysmal Positional Vertigo (BPPV)
2-Bilateral Weakness: presbystasis, ototoxicity, vestb. neuritis, nonspecific vestulopathy 3-Somatosensory Disorders 4- Visual disorders: visual acuity, depth perception, contrast vision, eye movement, oscillopsia 5-Neurologic disorders: parkinsons, metabolic, muscular, cardiogenic |
|
|
|
What is Angular Acceleration?
|
-stimulation by turning the head, with the fulcrum/pivot point inside your head
-describes the relative motion between the endolymph and the skull -the relative motion is going to push on the sensory end organ within the ampulla (crista) -the crista is then displaced (bent) by the fluid motion in the SSC provided by the head turn |
|
|
|
What are the mechanical conversions that occur in the vestibular system?
|
1-macro-mechanical: forward transduction converting from the fluid flow
2-micro-mechanical: stereocilla bending 3-Nano-mechanical: ion channel opening and closing |
ALSO
Type 2 hair cells changing length, producing active force which changes mechanics at micromechanical level which influences macromechanical performance, too |
|
|
What are the 2 divisions of the Vestibular portion of the VIIIth nerve?
|
Superior Division
-hair cells in utricle -anterior part of the saccule -horizontal & superior SSC |
Inferior Division
-posterior part of the saccule -posterior SSC |
|
|
What 4 areas of the inner ear does the vestibular nuclei receive input from?
|
1-Cerebellum-inhibitory
2-Spinal cord-postural muscles & neck stretch receptors 3-Pontine reticular formation-processing/feedback loop 4-Contralateral Vestibular Nucleus-communication from other ear/cross talk |
|
|
|
What is the purpose of the VOR?
|
The VOR (Vestibular Ocular Reflex) pulls the eyes in the opposite direction of a head turn so you can maintain gaze on a target of interest in your visual field
|
|
|
|
What are the major components of the eye?
|
Cornea * Iris * Pupil * Lens * Sclera * Vitrous Humor * Retina * Macula * Fovea * Optic Nerve Head
|
|
|
|
What are the Macula and Fovea?
|
Macula
-Point of central vision and better resolution -3x5 mm in diameter, oval in shape |
Fovea
-in the center of the macula -nor rod cells, only cone cells -extremely fine (best resolution) free of blood vessels |
|
|
6 main occulomotor muscles and the CN that innervate them
|
Superior rectus : III oculomotor
Inferior Rectus : III oculomotor Lateral Rectus : VI abducens Medial Rectus : III oculomotor Superior Oblique : IV troclear |
III Oculomotor:
-Superior Rectus -Inferior Rectus -Medial Rectus -Inferior Oblique IV Trochlear -Superior Oblique VI Abducens -Lateral Rectus |
|
|
Saccades are henerated by the inputs to the OCULOMOTOR NUCLEI from BURST cells
|
Burst cell: inhibited by pause cells
Pause cells: momentarily stop inhibiting and the burst cells fire at great rate This is processed in the pontine reticular formation which sends message to oculomotor nuclei to move the eye muscles. when the pause cells resume their inhibition, burst cells return to their very low firing rate |
|
|
|
What is the difference in an "ankle strategy" and a "hip strategy" in fall avoidance?
|
Ankle
-moves center of gravity slowly -produces pressures/forces that are vertical -forceful interface between foot and surface -use ankle strategy on icy/slick sidewalks |
Hip
-moves center of gravity quickly -produces forces that are horizontal -shearing forces at point of contact foot/surface -hip stragegy when about to fall to react quickly |
|
|
What is sensory orgainzation?
|
the process in which your brain can compare, select and combine the information from the 3 separate systems (visual, vestibluar, somatosensory) based on which system is providing accurate information and which system is important fo the task at hand
|
Sensory organizations: three legged stool: visual, somatosensory, vestibular
|
|
|
What are the semicircular canals?
|
-3 membranous tubes embedded within a bony structure
-central cavity of each canal is filled with endolymph -each endolymph-filled canal has an enlarged area near its base called an ampulla |
|
|
|
What are the Ampullae?
|
-parts of the vestublar nerve penetrate the base of each ampulla
-movement of the endolymph causes cupula to bend making sensory hair cells generate nerve impulses to the brain -the signal transmitted throughout the vestibular nerve to the brain is perceived as ANGULAR ACCELERATION |
|
|
|
What is Angular Accelleration?
|
hair cells detect movements of the fluid in the canals caused by angular acceleration about an axis perpendicular to the plane of the canal. Tiny floating particles aid the process of stimulating the hair cells as they move with the fluid. The canals are connected to the auditory nerve
|
|
|
|
What is the primary purpose of the VOR?
|
to elicit rapid compensatory eye movements that maintain stability of images on the fovea during head motion
|
|
|
|
What is the primary purpose of the Vestibulospinal Reflex?
|
to maintain posture and center of mass over ones base support
|
|
|
|
What is the primary purpose of the Vestibulocolic Reflex?
|
to assist in maintaining the head in horizontal gaze orientation relative to gravity, independent of trunk movement, and within the limits of range of motion of the neck in the sagittal and lateral planes
|
|
|
|
Saccades
|
rapid eye movements made to bring a point of regard onto the fovea
|
|
|
|
Fixation
|
the process by which the brain suppresses internally generated eye movements
|
|
|
|
balance
|
the ability to control the center of gravity over the base of support in any given environment
|
|
|
|
Nystagmus
|
oscillatory eye movements
|
|
|
|
What are types of nystagmus
|
Pendular: eyes move at same speed in both directions (sinusoidal)
Jerk: eyes move slowly in one direction of the fast phase or beat |
|
|
|
4 types of eye movement recording techniques
|
1-Electro-oculography (EOG)/Electronystagmography (ENG)
2-Videorecording techniques 3-Sceral search coil techniques 4-Infrared videorecording techniques |
|
|
|
What is the most common contaminant in EOG recordings?
|
eye blink artifact
|
|
|
|
What 2 pathways of the cerebral cortex influence lower motor centers?
|
Pyramidal System
-plays a major role in the control of fine, isolated versatile movements that set the basis for skill acquistion |
Extrapyramidal system
-provides the mechanism for large gross movement patterns that are primarily reflexive and consittute major postural adjustments |
|
|
3 general movement contral systems tha provide the schemea for muscle activation
|
1-Myototic Reflex: regulates muscle force thereby maintaining stability at the joint
2-Automatic Muscle Response: provides for coordinated limb and trunk movements across the joints (hip, ankle, etc) 3- Volitional Movement- responsible for learned, purposeful movements |
|
|
|
Is dizziness more common in men or women?
|
Women 27%
Men 14% |
|
|
|
What is the relationship between the presence of dizziness, unsteadiness, and the significant negative impact on self-rated general health?
|
patients suffering from dizziness/unsteadiness perceived worse psychological and mental health
these results are in agreement with other studies |
|
|
|
Why is prompt identification and treatment of dizziness so critical?
|
-dizziness is the 3rd most common complaint among patients seen in outpatient clinics
-overall incidence is 5-10% (30-40% in elderly) -diagnosis is critical to reducing the tremendous cost to our society from medical fees, missed days of work and falls |
|
|
|
What is the most important critical distinction?
|
-differentiation of "vertigo" and "nonvertigo"
-true vertigo is often caused by diseases the neuro-otologist can treat -nonvertigo symptoms may be due to cardiovascular, neurologic or systemic diseases |
|
|
|
What is the most important factor in determining the cause of vertigo?
|
-a thorough case history
-it provides qualitative invormation that can be confirmed with quantitative vestibular testing |
|
|
|
What is the value in bedside assessment of the vestibular system?
|
-an effort to identify and localize the site of the problem witin the vestibular system
-designed to assess the function of various components of the balance system and aid in distinguishing normal physiologic from pathologically induced responses to test stimuli -have been shown to be clinically useful in the assessment of vestibular disorders -evaluate the VOR and VSR |
|
|
|
What are some common bedside tests?
|
Spontaneous Vest Nystagmus (SN) * Head-Impulse Test * head shake * dynamic visual acuity * hyperventilation-induced nystagmus * ocular tilt reaction/skew deviation * valsalva-induced nystagmus * romberg * fukuda stepping * past-pointing
|
|
|
|
Can we rely solely on bedside tests for diagnosis?
|
No
-results are commonly considered to be well-established criteria for the apprpriate referral of patients fo diagnostic testing -most appropriately used to alert the examiner that special care should be taken during a particular subtest when lab testing is being performed, or that additional testing is warranted |
|
|
|
What is ICIDH?
|
International Classification of Impairments, Disabilities, and Handicaps
-classification system developed by the WHO in 1980 that is used to describe the consequences of health conditions -"health" is a multi-dimensional concept that encompasses 3 domains: physical, social, and mental states |
|
|
|
What is an impairment
|
-temporary or permanet loss of abnormality of a body structure or function, whether physicological or psychological
|
the functional absence of a vestibular end organ
|
|
|
What is Disability
|
-a restriction or inability to perform an activity in a manner or within a range that is considered normal
|
-fear of falling - results in a patient's inability to engage in a vocation that depends on intact vestibular system function
|
|
|
What is handicap
|
-a social, economic, or environmental disadvantage resulting from an impairment or disability
|
self-imposed social isolation that occurs when a patient fears having an incapacitating spell of vertigo in public
|
|
|
What did the WHO do in 2001?
|
-approved a revision to the 1908 system called the International Classificatoin of Functioning Disability and Health
-acknowledges the complexities associated with the definition of diability and handicap -the new system includes a taxonomy that permits the description of the magnitude of the disability and handicap for the diseases and disorders that are identified in the ICD-10 coding system |
|
|
|
What factors regarding teh outcome must be considered when interpreting results obtained from a clinical measure?
|
-baseline level of dysfunction
-presence of significant comorbidities -patient expectations of the intervention -patients perception of quality -cultural or societal influences -progression of change of the disease -course of the interventions themselves |
|
|
|
What are some tools oriented toward assessment of syptoms?
|
Motion Sensitivity Quotient
-represents a method of quantifying the severity of symptoms evoked by Norre and Becker's stereotyped movements of the head and head/body that were designed for vestibular habilitation therapy -uses a quantitative method for documenting dizziness |
Vertigo Symptom Scale (VSS)
-created to address the known relationship between vertigo, anxiety, and emotional disturbance -scale of 36 items in which the patient indicates how often each occurs |
|
|
What are some tools oriented toward assessment of handicap?
|
-Dizziness handicap Inventory
-Vertigo Handicap Questionaire -Subjective Disability Scale and Post-Therapy Sypmtom Score -Activities-Specific Balance Confidence Scale -UCLA Dizziness Questionaire -Vestibular Disorders Activities of DAily Living |
|
|
|
What are some examples of how the DHI can be used to assess outcomes?
|
Can be used with
-self-report handicap in unilateral and bilateral peripheral vestibular system impairment -surgical outcomes: vestibular schwannoma surgery -treatment for BPPV -central vestibular system impairment -meniere's disease -migraine-associated vertigo -head trauma -psychophysiologic phobic vertigo and hyperventilation -drug treatment for vertigo vestibular rehab including tai chi |
|
|
|
Dizziness statistics
|
Accdng to NIH: 90 million americans will experience dizziness or vertigo
9 mill pts annually seek medical health #1 complaint of pts over age 70 #3 complaint by all pts regardless of age- only headach and lower back pain are higher 85% of vertigo and balance problems can be attributed to an inner ear involvement Falls are leading cause of injury deaths among 65+ |
in 2000, falls among the elderly accounted for over 10,000 deaths and more than 1/2 mill ER visits
25% of elderly who sustain a hip fracture will not survive that year 40,000 over age 65 go to ED with TBI as a result of a fall as early as 1995, NIH Strategic Rehab Plan identified dizziness and balance disorders have reached a national healthcare crisis |
|
|
What does Gans say regarding the primary function of Inner Ear?
|
Primary function of Inner Ear is equilibrium, not hearing
|
|
|
|
What are the 5 end organs in the SCC?
|
2 Otolith systems
3 SCC |
|
|
|
Why do astronauts get space sick?
|
VSR relies on otolith system which tells about the pull of gravity, body doesn't get right info about gravity
|
explains what happens during a Tamarkin crisis
-in BPPV patient, when the debris reenters the utricle and slams down onto the macula, the patient has the hallucination that they are being thrown or pushed down to the ground |
|
|
Why does Dr GAns feel that a thorough understanding of dizzines, vest disorders, comorbid disorders, triage of dizzy patient, treatment and appropriate referrals is so important for AuDs?
|
-need to be able to communicate with physicians at high level of sophisitication
-the Dr. title comes with higher expectations -helps to gain respect of physicians |
|
|
|
How does Dr Gans disdinguish between someone who needs med/pharm treatment vs vestibular rehab?
|
-Med/pharm: if collective symptoms that a patient lists is suggestive that they have a condition in which violent attacks persist
|
Vestibular Rehab: functional manifestation of a problem with active rotation tests, provocation of nystagmus, oscillopsia on dynamic visual acuity tests, postural instability, then that means they are an ideal candidate for rehab
|
|
|
What are ideal expectations from vestibular function test according to Dr Barim?
|
-help with dx of abnormality
-know if abnormality is in lybrinth, vest nerve or central structure -localize to specific ear -localize to exact location in CNS -what disease the pt has -provide monitoring function -help with surgical planning --devise a management and optimal treatment plan |
|
|
|
Which vestibualr pathways should be assessed independently?
|
-each SCC
-Each component of otoliths: succule and utricle -each brach of vetib nerve: superior and inferior -each nucleus w/in the vest nuclei complex -each of the vestib ocular and vestibulo-spinal pathways |
|
|
|
What is Dr Barim's view of "best practice" related to vestibular testing?
|
select a few high yield tests and decide in what order these test shoucld be applied in order to maximize the amount of information we get about the patient while at the same time minimizing the cost
|
don't include lab vestibular tests unless there is a high likelihood that the outcome of the test will in some substantive way affect the diagnosis or management of the patient
|
|
|
What are some vestibular tests?
|
ENG/VNG
Rotary Chair Active Head Rotation Dynamic Posturography Vestibular Evoked Myogenic Potentials |
|
|
|
Advantage of ENG/VNG
|
most sensitive test for common vestibular abnormalities such as BPPV, labyrinthitis, vestibular neuritis
-can often localize the lesion and can lateralize it to one ear -ENG is not that expensive |
|
|
|
Rotary Chair
|
-the stimulus is hightly controlled and repeatable
-natural mode of stimulation and is well tolerated by patients -asseses teh VOR over a broader frequency range than the caloric test does |
|
|
|
AHRT
|
-can test both horizontal and vertical VORs
-high frequency responses that are not tested by any other evaluation -it takes very little time to complete the test and costs much less than the rotary chair |
|
|
|
Dynamic Posturography
|
-generalized test of balance and it's really the only test of vestibulo-spinal pathways that we currently have
-very little time to complete and costs much less than the rotary chair |
|
|
|
What are VEMPS?
Vestibular Evoked Myogenic Potentials |
-high intenisity acoustic clicks or tone bursts evoke short latency muscle responses from the sternocleidomastoid muscles in te nect
-responses believed to originate from vestibular system mainly from teh saccule |
-appropriate for evaluating the saccule and its efferent neural connections: the inferior branch of the vestibular nerve
-appropriate for patients wit Tullio phenomena who may have fistual or superior canal dhiscence |
|
|
What is the "contradiction" regarding eh importance of teh role of vestibular testing plays in diagnosing diseases that cause dizziness?
|
-List 63 diseases that cause dizziness (Stockwell Document)
-Ther are only 7 diseases under the category of Ear dieases that include estibular testing as the absolute diagnostic criteria -THESE 7 DISEASES MAY ACCOUNT FOR 75% OF THE DIZZY POPULATION |
|
