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173 Cards in this Set
- Front
- Back
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what are the components of sensory input
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-vestibular
-vision and proprioception |
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where is the central processor located
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vestibular nuclei and CB
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what are the reflexes for motor output
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-eye moment
-postural-body & head |
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where does most of the vestibular "stuff" take place
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CB
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How do you tell where you are in space
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-the head couples with proprioceptron and vision
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what does the motor output focus on
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-motor, coordinating eyes and temp
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where is the membraneous labyrinth located
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within the bone labyrinth and supported by perilymph
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what is perilymph similar to
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CSF with increase Na:K ratio
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what are the saccule and utricles sensitive to
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gravity and some linear acceleration
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T/F: some of the SCC are in True horizontal or verticle
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FALSE
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where does endolymphatic sac
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-produces endolymph
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what is the snail
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-coclea= purpose is for hearing also contains endolymph
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what is the stapes
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bone that is located between the SCC and coclea that virbrates. If any fistulas form, can cause problems
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what are the peripheral (sensory) components
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-3 SCC (anterior, posterior, horizontal)
-otolith organs: utricle and saccule located within the vestibule |
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what are other important landmarks are important for peripheral (sensory) components
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-8th CN, endolymphatic sac, round & oval windows
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Describe the utricle/saccule
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-hair is in "jello" with peas embedded on top that give resting fire rate
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how does the canal hair cells
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-the tallest hair cells is the kinocilla which is in the middle.
-as movement towards the kinocilla there is excitation (displacement of cupula away from utricle) -as movement away from kinocilla there is inhibition (displacement of cupula towards utricle) |
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How do you get the most stimulation for the R posterior SCC
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-turn to the right at 45 and bend forward and back. this way the R ant and L post will be in the same line
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T/F: there is slight anatomical variations the SCC
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-FALSE
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Example of the push-pull phenomenon: Turn head to Right in normals
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-L 80, R120
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Example for push-pull phenomenon in pts with vestibular pathology turning right to head
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- Left 60, right 120, so feels like turning really fast to Right
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what do the otoliths detected
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-detect linear acceleration, tilt
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T/F: otoliths are oreinted in one plane
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-false, oriented in 2 planes
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What is the vesticular nerve considered part of
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peripheral
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what is the pathway of the afferent signals
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-project from scarps ganglion through the internal auditory canal with cochlear & facial N and labyrinthine artery and enters brain stem at ponto-medullary junction: root entry zone
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what is the role of the Cerebellum
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-modulates vestibular reflex
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what is the purpose of flocculus
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-adjusts/maintains gain of VOR
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what is the purpose of the nodulus
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-adjusts duration of VOR and processes otolith information
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what is the anterior-superior vermis is involved in
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-with vestibuls-spinal reflex
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The PICA delivers blood flow to where
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-inferior portion of the CB hemispehere
-dorsolateral medulla |
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The Basilar artery delivers blood flow to
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pons
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The AICA delivers blood flow to
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-peripheral vestibualr system vialabrinthine artery
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what are the reflexes associated with vestibular (3)
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-vestibulo-ocular reflex
-vestibulo-spinal reflex -vestibulo-=collic reflex |
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what is the purpose of the vestibulo-ocular reflex
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stable vision during head motion
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what is the purpose of the vestibulo-spinal reflex
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stable body during head motion
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what is the purpose of the vestibulo-collic reflex
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stable neck during head motion
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how does the VOR work (how do the eyes move in relation to head)
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-velocities of eye movements are equal but opposite of the direction and velocity of the head
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what is VOR gain
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(eye velocity/head velocity =1)
-if eye velocity is greater, >1 -if head velocity is greater, <1 -occurs when pathological situations, in which the excitation and inhibition is not working properly |
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what is the result of VOR gain
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retinal slip
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when does nystagmus occur
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-usually in pathologic vestibular system (i.e L= < 90spikes/sec, R=90spikes/sec, pathology on L)
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what is nystagmus caused by
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-distored vestibular input from one side causing an imbalance in the firing rates which produces a rhythmic oscillatory movement of the eyes
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how many phases of nystagmus
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-fast and slow. Named for direction of fast beating (right beating nystagmus)
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Describe vertigo
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-abnormal sensation of illusion of motion
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what can dizziness be caused by
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-medications
-cardiac -postural hypotension -diabetes mellitus -thyroid condition -renal failure -TIA's -HIV -visual changes -anxiety depression |
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what are general clinical findings for unilateral peripheral
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-dizziness or vertigo with position changes, rapid movement
-N/V that resolves with time -hearing loss or tinnitus -limited to absent head turn and trunk movement during gait, functional tasks -difficulty with eyes closed activities, especially dynamic -difficulty with complex visual environments -oscillopsia reported with driving, rapid head movement |
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what is oscillopsia
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-objects seem to oscillate
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what are causes of vestibular labyrinthitis
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-viral infection of labyrinth, rarely bacterial.
-typically results in gradual in gradual onset spinning, N/V, peaking in 24h -often in bed for a few days -hearing loss and vestibular issues -residual symptoms may take weeks to resolve |
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T/F: if a pt has vestibular issues and decreases movement, than they will have better functional outcomes
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FALSE- the more a pt moves, the more likley they are to get better quicker and have better outcomes. However, if they don't see medical professionals than they may not return to the prior level of function.
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T/F: vestibular neuroitis is synomous with vestibular labyrinthitis
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False- the nerve itself is affected,but can affect labyrinth
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what are symptoms of vestibular neuroitis
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-no hearing loss
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what is theory behind the cause of Meniere's Disease
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-by too much endolymph in the system causing membraneous distention
-endolymphatic sac may be producing too much endolymph or endolymph not being reabsorbed enough within the labyrinth |
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describe the sxs of Meniere's Disease
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-epidodic in nature
-symptoms come on suddenly, lasts from several minutes toa few hours and leaves suddenly -mild to severe spinning (N&V,imbalance & falls) -aural fullness,fluctuating hearing -tinnitus |
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what is the terrible triad for Meniere's Disease
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-mild to severe spinning
-aural fullness,fluctutaing hearing -tinnitus |
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In Meniere's Disease what is the difference between early and late stage of condition
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-early phase the pt is symptom free between episodes
-in late phase the pt may have permanent hearing loss and vestibular impairment |
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what is the presentation of pts with Meniere's Disease
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-most pts limit their overall activities, such as working or driving
-have in decrease in hearing for low frequency -may come in with new dx of balance & in btwn work on postural control |
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what are the clinical findings of Meniere's Disease
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-during an episode will have vestibular testing similar to a unilateral vestibular loss
-btwn spells, testing will be normal -fluctuating hearing w/progressive low frequency hearing loss of audiogram |
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what is the treatment of Meniere's Disease
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-low sodium diet/diuretics to attempt to manage fluid imbalance
-transtympanic gentamycin injections ("kills" vestibular system, so teach pt how to live without) -surgery for endolymphatic shunt, labyrinthectomy |
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what is an acoustic neuroma
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-8th CN nerve sheath tumor
-benign and usually slow growing -located in internal audiotory canal at cerebellopontine angle -third most common intracranial tumor |
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what are the symptoms of acoustic neuroma
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-progressive, unilateral hearing loss
-tinnitus -mild dysequilibrium -vertigo -dx confirmed with MRI |
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what is the tx for acoustic neuroma
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-watchful waiting
-removal via gamma knife radiation or surgical excision -vestibular rehab following surgery -radiation (slow) |
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what are the causes of bilateral vestibular loss
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-ototoxcity
-bilateral acoustic neuroma (neurofibromastosis [tumors grow all over body]) -autoimmune disease -otosclerosis/degenereation (leading cause of decrease hearing and deafness) |
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what are symptoms of bilateral vestibular loss
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-hearing loss
-significant oscillopsia -dysequilibrium in dark, complex visual environment, uneven surfaces -no significant complaints of dizziness if loss is complete |
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what is the typical presentation of a pt with bilateral vestibular loss
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-usually don't drive
-require an assistive device -may have some sparing, if they do, than they will experience spinning |
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T/F: pt may have a delay of symptoms
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True
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what are the clinical findings for Central vestibular
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-moderate to severe dizziness/vertigo that lasts longer, can be worse after activity
-often have impaired balance and gait -may have cerebellar signs and symptoms -mild to severe HA -less nausea than peripheral -dysequilibrium especially in dark or complex visual environments -motion sensitivity -occasionally sensitive to light and sounds -sense of tilting by the pt,loss of midline orientation |
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describe a brainstem concussion
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-a shearing effect on the root enry zone of the 8th cranial nerce may lead to hemorrhage of cell death in the area of the vestibular nuclei
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what are the signs and symptoms of brainstem concussion
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-dizziness/vertigo
-postural instability -may be associated with other CN damage or CNS signs -VOR and oculomotor abnormalities -implicated if compensation does not occur with labyrinthe concussion |
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what is the dx criteria for migrain-related vestibulopathy
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-no documented vestibular pathology
-migraine dx according international headache society criteria -intermittent vertigo or dyseqiuilibrium at least 2 episodes -accompanied by photo or phonophroesis, visual aura, not necessarily HA -episodic |
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what is the approach for migraine-related vestibulopathy
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-multi-disciplinary approach of medical management including vestibular rehab.
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what types of environment to pts struggle to be
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-in wide open spaces, busy visual environments
-px is poorer with peripheral vestibular dysfunction and history of migraine |
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what is multisensory dysequilibrium
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-AKA dysequilibrium of Aging
-primary symptom is imbalance during functional mobility -results from degradation of two or more sensory systems responsible for balance (bilateral vestibular degeneration, peripheral neuropathy, visual deficits) |
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describe cervicogenic dizziness
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-dizziness and dysequilibrium that is associated with neck pain
-dx of exclusion-no vestibular pathology -current theory is that cervical dysfunction causes abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region |
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how is cervicogenic dizziness dx
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-head-fixed body-turned manuever (which is not sensitive)
--close relationship between neck pain and dizziness --previous neck injury or pathology --elimination of other causes --make sure to clear Cervical spine |
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what intervention is most effective for cervicogenic dizziness
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when the cervical (manual for trigger points and hypomobility) and vestibular dysfunction is addressed (to address sensory organization deficits, VOR dysfunction, and/or motion sensitivity
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what is the most common cause of vertigo in pts
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BPPV=Benign Paroxysmal Positional Vertigo
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what population is BPPVmost often seen in
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most adults, iit is rarely seen in children however, there is a childs"version"of BPPV,
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what do we think the pathology of BPPV is
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otoconia from the otolith organs which becomes dislodged and makes its way to the SCC
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T/F: BPPV is not a biomechanical problem
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False- it is a biomechanical problem that one or more of the SCC has become inappropirately excited
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what are the common characteristics of BPPV
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vertigo when the head is moved into various positions or head changes occur, rolling over in bed, bending over, looking up, lying flat or turning the head, sensation of TRUE spinning after position changes that lasts for seconds to minutes, complaints of imbalance or gait problem, especially with head turnes. Pts may feel "yucky" for 24 hours after
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How common is BPPV
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64 out of 100,0000
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T/F: Symptoms of BPPV will fatigue with repeated stimulation
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TRUE
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how long does symptoms of BPPV lasts
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<60 seconds
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what are the symptoms for BPPV
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Usually spinning, as well as nausea, imbalance, neck stiffness
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what SCC do the otoconia usually get stuck in
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posterior canals
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What is the result of the otoconia geting stuck into the canal
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with head movement, the otoconia move within the canal resulting in abnormal, unilateral stimulation of that particular canal causing nystagmus
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what is the most common cause of BPPV in pts
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post traumatic
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what are other causes of BPPV
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post-acute vestibulopathy, idiopathic, Meniere's Disease, Migraine, Diabetes, dehydration (elderly)
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what is the hallmark signs on BPPV
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rotational nystagmus: there are two componenets Torsional (either to left or right) and verticle (either up or down), latency of 10-30 seconds, duration of <60 secibds and spinning sensation with bending over, supine to/from sit, reaching overhead
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T/F: the direction of the nystagmus always indicates the canal involved
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False, usually however the exception to the rule is when there is horizontal involvement then there is horizontal nystagmus
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Describe the two types of horizontal nystagmus
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Geotrophic: beating toward the ground, Ageotrophic: beating away from the ground
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what is the order of most common to least common BPPV
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posterior canal, horizontal canal and anterior canal
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What does the dix-hallpike test assess?
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anterior and posterior canalithiasis (free floating otoconia)
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what does the roll test assess?
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horizonal canalithiasis
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what are some concerns you may have prior to assessment and tx of a pt
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explain the procedure to the pt, Nausea can occur with episodes, beware of pts spine hx, name the nystagmus to ensure appropriate tx and complete all tests prior to tx, pt will probably be anxious and cool down pt to reduce change of vomiting
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describe the dix-hallpike test for a Right problem
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turn pts head 45 degrees to R, move pt into supine, and head extended 30 degrees, look for nystagmus, maintain position for 30 seconds, keep head in position and assist pt to sitting, monitor nystagmus
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For a Right posterior canal issues, what would the Right dix-hallpike show, and would it change in sitting
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upbeat with Right torsional during testing and downbeat with Left torsional in sitting
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For a Right anterior canal issues, what would the Right dix-hallpike show, and would it change in sitting
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Downbeat Right torsional during testing and upbeat left torsional in sitting
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For a Left anterior canal issues, what would the Right dix-hallpike show, and would it change in sitting
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downbeat Left torsional during testing and upbeat right torsional in sitting
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Describe the Roll test
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pt is in supine with neck flexed to 30 degrees, quickly turn head to Left and look for nystagmus, come back to center, quickly turn head to right, look for nystagmus, canal involved will bethe side which the side the nystagmus is the most vigorous.
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what are intervention options for BPPV
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wait and see, Brandt-Daroff exercises(not shown to be effective), Canalith Repositioning maneuver, liberatory maneuver
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Describe the Brandt-Daroff exercises
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pt starts in sitting positions and quickly moves to sideleying with face turned up and counts to 10, keeping the head in the same position the pt moves to sitting and counts to 10, then pt quickly moves to sidelying on the opposite side and counts to 10, is done 5 X 1-2 a day (NOT SHOWN TO BE EFFECTIVE)
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are the interventions for all of the canals similar
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No, for anterior and posterior use Canal Repositioning Maneuver and for Horizonal, use BBQ roll
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describe the canal repositioning manuever for a Left posterior canal problem
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pt goes into Left hallpike positon and holds position for 60 seconds maintaining the extension in the neck rotate the head to be 45 degrees on the right, pt rolls into sidelying and PT maintains head/shoulder relationship so in sidelying the pt's nose should be pointed at the ground, hold for 60 seconds and slowly sit up from sidelying
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Describe the BBQ roll
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pt starts in sitting, with head flexed 20 degrees and turned towad affected as much as possible, put pt in supine then turn head away from affected side to middle, then turn to unaffected side, have pt go prone on elbows and face down, then back to supine
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What post-maneuver instructions are appropriate to give
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don't look up or down for a few hours and the pt may feel off balance after repositioning for a day or so, they may present with as much as 9 degrees from true verticle
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Descirbe the Rolling exercises
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pt rolls to one side and counts to 10, pt repeats to opposite side, complete maneuver is done 5 X 1-2 days. However is NOT shown to be effective for prevention of reoccurence, therefore no longer recommended. Used when think the otoconia are stuck in the cupula
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What are the guidelines for BPPV management
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most effective if perform multiple (2-4 times) repositioning maneuvers in one session, do not tx more than once every other day, do not tx multiple canals in the same session, may tx subjective symptoms if the correlate with typical pattern-latency and duration
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T/F: a Dix-hallpike results do not fluctuate
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False, may fluctuate during the day or day to day. The test can be affected by the speed of the manuever, plane of the occiput and variability.
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what are the overall outcomes for these BPPV
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after 1-2 tx, 91.3% have resolution of sxs- varies from 80-95, reoccurence is 27-44%, also makes difficult with insurance and pts who come in with expectations of quick fix, when isn't always the case
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Can you state the pt has BPPV if Dix-Hallpke is negative
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No, pt you can justify that you are treating the symptoms which are similar to BPPV
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What are the 3 main components of the PT assessment
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subjective hx, functional mobility assessment, ande oculomotor exam
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what are important components in the subjective exam
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quality of "dizziness" (lightheaded, spinning, imbalance), severity (10 point or VAS), frequency, duration. Exacerbating factors (busy visual environments, position changes, quick head movements, walking, reading, visual motion) and relieving factors (rest, medications, visual focus. IF have visual disturbances. Hearing impairment and fall history
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what are some descriptive words that have been used to describe dizziness
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reeling, whirling, fatigued, off balance, sick, floating, confused, swaying, leaning, spinning, vertigo, being pulled, nauseasous, shaky
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what is the symptoms scale of dizziness
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0-10 scale that quantifies the pts level of dizziness. 0 being nothing at all and 10 being maximum
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what types is visual disturbances may a pt have with vestibular issues
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Blurry vision that may be VOR or visual acuity, double vision
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what is double vision usually a sign of
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centrual invovlement
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T/F: symptoms remain constant regardless of complexity of visual environment
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False, often symptoms will exaggerbate with complex visual environment
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Why is hearing an important component of the subjective exam
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Low frequence decrease is used to dx Meniere's Disease, tinnitus and hearing loss usally indicates unilateral peripheral loss.
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What are important components of the fall hx of a pt
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frequency, cuase, symptoms during fall and injuries sustained
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What are tools used for motion sensitivity
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is tool consisting of 16 positional changes which elicit dizziness, this often used for pts with not major symptoms
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What balance tests are appropriate for pts with vestibular deficits
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BBS, Romberg, Foam and Dome (CTSIB), weight shifting, balance reactions
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What gait assessment tools that are appropriate for pts with vestibular issues
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DGI, (FGA is used in place by some vestibular PTs), Best test, Mini-best
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Describe the DGI
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assess pts ability to modify gait in response to changing task demands, 8 items, scale of 0-3, total possible score 24/24
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On the DGI what is the cut off for a pt being a fall risk
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19 or less
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Descrie the FGA
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more advanced gait tasks that address the ceiling effect of the DGI, 10 items, scale 0-3, total score 30/30
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on the FGA what is the cut off for a pt being a fall risk
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22 or less
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what are the components of the oculomotor exam
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smooth pursuit, saccadic eye movements, VOR cancellation, Head trust, Dynamic Visual acuity, spontaneous nystagmus, gaze evoked nystagmus
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Describe smooth pursit
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pt follows pensw with head still in verticle and horizontal directions, look for any jumping of movement (corrective saccades), will see some normal saccades with age
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what structures help with smooth pursuit
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parieto-occipital cortex, pons and cerebellum
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what does a deficit smooth pursuit indicative of?
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central deficit
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describe the test for saccadic eye movements
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pts holds head still and looks alternately from your nose to pen held 15" to the lateral of your nose and repeated on opposing side, up and down, if the pt overshoots or undershoots, there is a deficit present (more problematic for overshooting
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Undershooting during the saccadic eye movements is called
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hypometric saccades
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Overshooting during the saccadic eye movements is called
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hypermetric saccades
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During the test for saccadic eye movements what do you not want the pt to do
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look at the items voluntarily because will be able to adjust
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Describe the test for VOR cancellation
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tilt pts head down 30 degrees and instruct the pt to focus on your nose, rotate pts head L/R as ou move with them, look for corrective saccades, which are a sign on inability to fixate
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what does a deficit of VOR cancellation indicative of
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central deficit
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Describe a head trust test
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**make sure you have checked cervical ROM and tolerance to quick motion prior. Sit in front of the pt, instruct them to relax neck and focus on your nose, tilt head down 30 degree and thrust head rapidly over a small amplitude, look for pt ability to stay focused on your nose. (Pure VOR test)
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what is the head trust test AKA
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head impulse test
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What does a retinal slip to the right during a head trust test indicative of
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Right sided peripheral problem, and nystagmus to L
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Describe the Dynamic Visual Acuity
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have pt sit 10 ft from chart, and read the lowest line possible. Stand behind pt and tilt head down 30 degrees and turn head at 2 rotations a second while they read the lowest line possible. A degradation of 3 or more lines indicates an impaired VOR
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T/F: Dynamic Visual acuity can differentiate between central or a peripheral problem
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FALSE
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T/F: there is NO way to differentiate with spontaneous nystagmus if the lesion is peripheral or central
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False, with a central lesion, the spontaneous nystagmus will change direction with eye movement.
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T/F: For peripheral lesions you will see spontaneous nystagmus with smooth pursit
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False, the nystagmus is suppressed with smooth pursuits
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T/F: for central lesions you will see spontaious nystagmus with Smooth pursuit
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False, you will see correct saccades
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Describe gaze evoked nystagmus
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ask pt to look to L/R/U/D for 15 sec each. Observe for nystagmus in any direction or change in direction.
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What other assessments may need to be included in order to rule out everything non-vestibular
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cerebellar tests (dysdiadokinesia and dysmetria), UMN test (clonus, babinski, tone changes) and OH test
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what are some vestibular function testing
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electronystagmography (ENG), rotational chair test, audiogram, and computerized dynamic posturography
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What does the ENG consists of:
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oculomotor evaluation, positioning testing, caloric stimulation of the vestibular system
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What are components of the positioning testing for ENG
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pt is in supine head L and R in supine, left lateral and right lateral positions, eye movement is recorded in the dark, looking for static positiong nystagmus (nonspecific)
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describe the caloric stimulation for ENG
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warm and cold stimuli are presented at the tympanic membrane to stimulate the horizontal SCC, water or air may be used, temperature gradient causes mvmnt of the endolymph, which causes nystagmus in the NORMAL ear. Pt will likely expereince dizziness and nystagmus, compare strength of response B. change of <25% is considered normal,
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T/F: caloric stimulation can not be used for differentiation of central or peripheral lesion
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False, result is inidicitative of peripheral lesion
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Describe the rotational chair test
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pt sits in a chair with head supported and eye mvmnt recorded from video googles or electrodes. Divided up into 2 parts, oculomotor and VOR testing. Provides a horizontal acceleration to the vestibular accleration to the vestibular system during which eye recordings measure the strength of the VOR, may help with differenitation
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what results are obtained from the rotational chair test
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VOR gain, VOR phase, compares asymmetry
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what are 2 types of computerized dynamic posturography
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sensory organization test (SOT) and motor control test (MCT)
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Describe the sensory organization test (SOT)
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objective computerized test of functional balance, does not localize lesion, capable of distorting propiroceptive and visual inputs, consists of 6 sensory conditions that alter sensory input in order to determine which senses are used effectively for balance. Abnormal conditions help to ID possible lesion sites, but must becomparedto overall clinical picture. Poor performance on conditions 5 and 6 suggests that pt does not use vestibular feedback well (mor may to difficult to pt to manage due to a motor deficit). Can be usefult in ID aphysiologica c/o dizziness and balance deficits
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Describe Motor control test
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assess automatic postural response when standing surface is unexpectedly perturbed forward or backward. Can be useful in ID those with exaggerated volitional responses to a perturbation. Abnormally long latency responses may ID pathology somewhere within the long loop pathway
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Describe findings on objective test for unilateral peripheral:oculomotor
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spontaneous nystagmus in actue stage, fast beat toward INTACT side, positive head trust test toward involved side and impaired dynamic visual acuity more than 3 lines
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Describe findings on objective test for unilateral peripheral: vestibular function test
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caloris reduction on ENG, abnormal rotational chair test, possible abnormal audiogram and abnormal SOT conditions 5 and 6
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Describe findings on objective test for bilateral vestibular: oculomotor
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positive head trust B, dynamic visual acuity of 5 or more lines,
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Describe findings on objective test for bilateral vestibular: vestibular
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absent caloric responses on ENG, very low to absent response on rotational chair test, may or may not have abnormal audiogram
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Describe the findings on objective test for central vestibular: Oculomotor
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smoot pursuit or saccadesmay be impaired, VOR cancellation may be impaired, Dynamic visual acuitymay be impaired, Head trust NOT impaired, downbeat nystagmus, either spontaneous or resulting from mvmnt, spontaneous nystagmus may be in any direction, gaze holding nystagmus usually direction changing, may have increased nystagmus in Hallpike-Dix or wtih any position chnages, duration will be much longer than peripheral deficit, ENG test will be abnormal, caloric test usually normal, rotational test abnormal, audiogram normal
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Describe Adaptation
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change in gain or direction of vestibular reflexes, primary recovery strategy for UVL, reguries intact cerebral and CB hemi, can be used for BVL with SPARING. Using exercise to create a controlled retinal skip with head mvmnt that results in creation of error signal going to brain (CB to change VOR) brain makes long term chnage in reponse to error signal and have a decrease in retinal slip and decrease dizziness
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Describe static adaptation
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initaila spontaneous nystagmus resolves after UVL with or without visual input,
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Describe dynamic adaptation
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VOR won't recover without an error signal created by visual input.
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Describe Compensation
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Working as optimally as possible (achieved adapation) NOT used to described subsitution
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what SCC do the otoconia usually get stuck in
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posterior canals
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T/F: Adaptation is context specific
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TRUE
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What is the result of the otoconia geting stuck into the canal
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with head movement, the otoconia move within the canal resulting in abnormal, unilateral stimulation of that particular canal causing nystagmus
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Describe gaze stabilization
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start intervetions 3-5 ft away, horizontal and vertical directions, goal is 1 minute 3-5 X/day TARGET MUST STAY CLEAR
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Progression of gaze stabiliazation
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sitting to standing to gait; wide to NBS, simple to complex, near to far, large to small target
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What is sensory re-weighting
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training of which ever of the 3 systems (vestibular, somatosensory or visual) in order to optimize pt performance. Key is to enhance vestibular if avaialble
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Describe Habituation
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decrease pt symptoms by provoking symptoms don't do above 5/10 on scale goal is to habituate them to motion, is context specific, used to relieve motion induced dizziness or motion sensitivity, make sure to education and pact pt
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Describe subsitution
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usually used with BVL, use of something other than VOR to keep eyes steady. Gaze stabilization & visual tracking: subsitutes with smooth pursit and saccades for absent VOR, improve vision and somatosensory
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