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233 Cards in this Set
- Front
- Back
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Primary purposes of the
Vestibular system? |
1. Spatial Orientation of the head and neck
2. Automatic postural control 3. Stabilization of eyes when the head moves |
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THE classic symptom (what is it?)
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Dizziness:
1. 2.6% of visits to family physicians 2. 6.7% of visits to ER 3. >65 y.o. – up to 50% visits to MD |
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Types of Dizziness:
Definition of Vertigo |
Illusion of false motion
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Types of Dizziness:
Definition of Presyncope |
Perception that you are about faint
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Types of Dizziness:
Definition of Dysequilibrium |
Perception that you are losing your balance
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Types of Dizziness:
Definition of Ill-defined Lightheadedness |
Vague sensation, mild, difficult to describe
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Your Vestibular System
has 3 major components. what are they? |
1. A peripheral sensory
apparatus 2. A central processor 3. A mechanism for motor output |
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Vestibular Apparatus consists of? (3 things)
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1. Bony labyrinths
2. Membranous labyrinths (Filled with endolymph) 3. Hair cells (receptors) |
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Semicircular canal stimulus:
____ Velocity of head |
angular velocity of head
anterior semicircular for - YES lateral semicircular - NO posterior semicircular - "tilting head" |
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What is the receptor in ampulla of each semicircular canal?
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Crista
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Firing rate of Hair Cells:
Direction of _____ determines firing rates |
Kinocelium
toward kinocelium = stimulation/depolarization away from kinocelium = inhibition/hyperpolarization |
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Hair cell firing rate.
What happens if head rotation to the R? |
Increase firing rate in R semicircular canal.
Decrease firing rate in left semicircular canal |
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what happens if head turns to L?
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bending of cupula and hairs of receptor hair cells in the excitatory direction on the left
bending of cupula and hairs of receptor hair cells in the inhibitory direction on the right |
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endolymph and cupula at:
rest |
no angular acceleration
no relative motion between canal and endolymph cupula not deflected no perceived angular movement |
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endolymph and cupula at:
acceleration |
angular clockwise acceleration
inertia causes endolymph to lag behind cupula deflected Right perceived clockwise movement |
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endolymph and cupula at:
constant angular motion |
endolymph moving at same speed as canal
no relative motion between canal and endolymph cupula not deflected NO perceived angular movement |
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endolymph and cupula at:
deceleration or stopping of motion |
canal stopped
endolymph momentum keeps it moving clockwise cupula deflected left perceived counterclockwise movement |
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What are the Otoliths?(2)
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1. Utricle
2. Saccule |
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what is Maculae?
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Sensory Receptor in the
Utricle & Saccule |
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Otolith Stimulus:
_______ Acceleration |
Linear Acceleration
Horizontal acceleration - utricle Vertical acceleration – saccule |
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acceleration straight (horizontal) on a jet plane detected by ___
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utricle
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acceleration on Dr. Doom ride at IOA (vertical) detected by ___
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saccule
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Peripheral Vestibular System:
Cranial Nerve ___? |
VIII
CN 8 |
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CN VIII projects directly to _____
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Flocculus
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Motor Output as a
result of sensory integration in ____ |
Vestibular Nuclei
MLF - Eye movements VSP - body movements (postural) |
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Purpose of the VOR
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Acts to maintain stable vision during
head motion. |
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Vestibulo-ocular REFLEX:
Stimulus: _____ Response: _____ |
Stimulus: Head movement (crista)
Response: Eye movement |
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what ratio between head and eye movement for VOR?
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1:1
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what 3 neurons (CN's) are involved in the VOR?
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"LR6" - lateral rectus
CN VIII - vestibulocochlear CN VI - abducens (lateral rectus) CN III - occulomotor (medial rectus) (CN 3,6,8) |
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VOR
stimulus: _____ response: _____ |
stimulus: head movement
response: equal and opposite eye movement |
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Vascular Supply:
Vertebro-basilar arterial system PICA |
Medulla
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Vascular Supply:
Vertebro-basilar arterial system Basilar |
Pons
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Vascular Supply:
Vertebro-basilar arterial system AICA |
Peripheral Vestibular system
Ventrolateral Cerebellum |
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peripheral vestibular
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middle ear
labyrinth CN VIII |
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central vestibular
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brainstem
cerebellum cortex |
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Peripheral
-Middle Ear - What can go wrong? |
1. Infection
2. Fistula 3. Trauma |
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Peripheral
-Labyrinth - What can go wrong? |
1. Infection
2. Fistula 3. Trauma *4. Meniere's *5. Meds (Note: add M's for Labyrinth) |
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Peripheral
-CN VIII - What is the etiology? |
1. Infection
2. Trauma *3. TUMOR (Note: no fistula in CN VIII) |
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Central
-CB-BS-Cortex - What can go wrong? |
stroke
trauma infection disease medications (MS, Cancer, Lupus) |
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Peripheral Vestibular Pathology
Nerve conduction disruption |
“itis”, tumor (AN), trauma (fistula)
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Peripheral Vestibular Pathology
Mechanical disruption |
BPPV
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Peripheral Vestibular Pathology
Fluid pressure/membrane rupture |
Meniere’s, fistula
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Peripheral Vestibular Pathology
Hair cell destruction |
Ototoxicity, aging
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Consider the signs and
symptoms caused by this: History of viral illness (2 diagnoses) |
Neuronitis = Viral Infection of the Vestibular Nerve leads to sudden disruption of signal
Labyrinthitis = Viral Infection of the Labyrinth leads to sudden disruption of signal |
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Mr. Johnson
60 year-old man presents to the ER abrupt-onset, severe vertigo associated with nausea and vomiting that began last night. gait instability and poor vision. spontaneous nystagmus. denies hearing loss, tinnitus, or other neurologic deficits. Significant PMH: Upper respiratory tract infection two weeks ago. |
Diff Dx:
How could you differentiate between neuritis and labyrinthitis? Often cannot. Hearing loss can be associated with labyrinthitis. |
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Consider the signs and symptoms
caused by this: Idiopathic |
Meniere’s Disease (Peripheral, Labyrinth)
Increase in endolymph which leads to fluctuating pressure and disruption |
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55 year-old man
complaint of 1 month of dizziness. pressure in the right ear. symptoms have fluctuated over the last month. Hearing loss right ear. A week ago the patient awakened with spinning vertigo, nausea and vomiting lasting for ~2 hours. By morning, the symptoms were gone except for the right ear pressure. |
Meniere’s Disease
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Consider the signs and symptoms
caused by this: Hx of trauma Pressure trauma |
FISTULA
Perilymphatic Fistula at Round Window with endolymph loss which leads to fluctuating disruption of signal |
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Consider the signs and symptoms
caused by this: Hx of trauma Pressure trauma Congenital |
FISTULA
Superior canal dehiscence of the Labyrinth which leads to fluctuating disruption of signal |
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42 year-old
began having hearing problems shortly after plane landed She thought nothing of it (this often happens after flying) until she found a few hours later that her balance was off, and she was falling to the left. Soon thereafter, she began experiencing vertigo, and tinnitus in left ear. She says if she sits perfectly still the symptoms seem to be better, but they worsen as she moves. |
Diff DX
how could you differentiate between Meniere's disease and Fistula? Often cannot without extensive medical testing - 50% of fistula patients have no +history. History of trauma (plane) with fistula 30% Important just to consider fistula as a possibility. often ignored. |
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Consider the signs and symptoms
caused by this: Facial nerve signs |
Acoustic Neuroma (Shwannoma)
Benign tumor on CN VIII leads to disruption of signal |
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42 y.o.
complaining of unsteadiness and a vague sense of “pressure in my head.” hearing has changed a bit as she has aged, and she does experience occasional ringing in her ears. |
Acoustic Neuroma (Shwannoma)
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____ is a much more common complaint than vertigo
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unsteadiness
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Consider the signs and symptoms
caused by this: Insidious Trauma Aging |
BPPV
Otoconia falling into semicircular canal, leads to quick changes in firing rate of crista - BPPV |
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72 y.o.
upon waking today states that the room began spinning when he rolled onto his side. After about 20 seconds, it stopped, and he sat up. When he sat up the spinning returned, and again stopped after 20-30 seconds of sitting still. experienced nausea, and finds that he is quite unsteady when moving about the house. The spinning returns when he moves his head quickly. |
BPPV
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Central Vestibular Pathology =
Vertebral-basilar Atherothrombotic Disease |
TIA’s and Stroke
Migraine Epilepsy MS ABI Spinocerebellar degeneration Ototoxicity Cerebellar pathology |
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Consider signs & symptoms
caused by this: Transient & permanent ischemic effects 25% of TIA’s occur here |
Vertebrobasilar
Insufficiency circle of willis? |
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74 y.o.
complaint of a “swimmy head” that is constant. unsteady and unsure of himself when moving about. wife reports that he has fallen 3 times in the last 2 months. Each fall has occurred shortly after standing up. |
Vertebrobasilar
Insufficiency Central Vestibular Pathology |
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Peripheral Vestibular Conditions often
seen in the Clinic |
BPPV
CN VIII neuritis or neuronitis Labyrinthitis Acoustic neuroma Meniere’s disease Perilymph Fistula Ototoxicity - bilateral |
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what happens when the peripheral vestibular input from one side is impaired or absent?
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no vestibular input going to central processing = incorrect perception of movement which leads to Vertigo
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Two Primary Functions of the
Vestibular System that VR (vestibular rehab?) addresses: |
1. eye stabilization
-acts to stabilize the eyes in space during head and body movements (VOR) 2. balance (postural control) -contributes to balance during tasks while we are trying to be still, or when we are moving. (Vestibulo-Spinal Reflex) |
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3 Major Impairments of
Unilateral Peripheral Loss |
1. Dizziness/Vertigo
2. Visual disturbances -Impaired gaze stabilization (VOR) -abnormal tracking (visuo-ocular) 3. Disequilibrium -faulty "internal mapping" -faulty interpretation of info from eyes/body/vestibular -faulty balancing movements (VSR) 4. *Nausea |
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Why do you have Vertigo with
unilateral peripheral impairment? |
The brain becomes “confused” regarding the unbalanced signals coming from the inner ear resulting in the perception that you are dizzy.
An “illusion” of movement is created. |
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Why do you have Visual Disturbances
with unilateral peripheral impairment? |
Normal Function:
The VOR (vestibulo-ocular reflex) creates a 1:1 relationship between eye movement speed and head movement speed. Impaired VOR leads to Impaired gaze stabilization which leads to Vertigo and visual disturbances. The reflex (VOR) coordination of eye and head movements is affected causing a minor to major loss in fine tuning. This can result in difficulty focusing, and can also be a source of dizziness or vertigo. |
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Why do you have balance problems with unilateral peripheral impairment?
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Faulty internal mapping
-Where you truly are in space and where your brain perceives that you are is different. Faulty postural response system -Automatic muscle responses can be delayed or inaccurate. (VSP) |
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Signs & Symptoms common to BOTH
Peripheral and Central Pathology (Vestibular) |
1. Vertigo - associated w/ nausea and vomiting
2. Nystagmus 3. Visual Disturbances 4. Postural Instability |
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what is the most important aspect of vestibular differential diagnosis?
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history taking
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What are the keys to history taking and therefore Diagnosis? (3)
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1. Tempo - temporal patterns of symptom onset, duration, and pattern over time
2. Symptoms 3. Circumstance |
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Tempo applied to Vertigo
Acute Dizziness:___ Chronic Dizziness:___ Spells of Dizziness:___ |
Acute Dizziness: 3 days or less
Chronic Dizziness: more than 3 days Spells of Dizziness: do symptoms last seconds, minutes, or hours |
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tempo of BPPV
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daily episodes lasting 30 seconds at each time
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Neuronitits/Labyrinthitis tempo
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Persistent
1-3 days to 3 weeks |
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Meniere's tempo
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fluctuating
inconsistent 2hrs to 3 days |
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Meniere's tempo
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fluctuating
inconsistent 2hrs to 3 days |
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Questions during interview
distinguish between vertigo and lightheadedness visual analog scale ask about related symptoms (what are they?) is there a loss of consciousness? If yes, do what? Dizziness Handicap Inventory |
hearing
tinnitus disequilibrium HA nystagmus N/V Visual disturbances if yes, refer back to MD |
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Differential Dx: Central vs. Peripheral Vertigo
Latency |
Peripheral: 2-40 seconds
Central: None |
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Differential Dx: Central vs. Peripheral Vertigo
Severity |
Peripheral: Severe
Central: Mild to Moderate |
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Differential Dx: Central vs. Peripheral Vertigo
Nystagmus |
Peripheral: < 1 minute
Central: > 1 minute |
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Differential Dx: Central vs. Peripheral Vertigo
Fatigability |
Peripheral: Yes
Central: No |
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Differential Dx: Central vs. Peripheral Vertigo
Habituation |
Peripheral: Yes
Central: No |
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Differential Dx: Central vs. Peripheral Vertigo
Postural Instability |
Peripheral: Able to walk; Unidirectional
Central: Falls easily; Severe instability |
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Differential Dx: Central vs. Peripheral Vertigo
Hearing Loss |
Peripheral: Can be present
Central: Usually absent (usually NO hearing loss with central) |
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Differential Dx: Central vs. Peripheral Vertigo
Tinnitus |
Peripheral: Can be present
Central: Usually absent |
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Differential Dx: Central vs. Peripheral Vertigo
Neuro S & S |
Peripheral: Absent
Central: Usually present |
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Circumstance
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did an event occur close to the time your dizziness began?
-fall, hit to head, diving, antibiotics, illness what brings on symptoms? -spontaneous vs positional Is your dizziness constant, or does it come and go? what makes the dizziness worse/better? -head motion, walking in the dark, position |
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more questions:
do you have hearing loss? (now or in the past) Do you have true vertigo - false sense of motion, floating, bobbing, spinning, etc) short episodes: less than 5 minutes moderate episodes: 5 minutes to 24 hours long episodes: 1 day to 1 week persistent: longer than 1 week If no, do you have any of the following symptoms? |
Dysequilibrum (imbalance)
Near Fainting (feeling you might faint, black out) Spacey (disconnected, panic, tingling) same time frames as vertigo Kentala and Rauch |
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
what are the 2 main questions? |
Do you have hearing loss?
Yes or No If you have True Vertigo, is it -Episodic or -Persistent |
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
If No hearing loss, what could you have? |
BPPV or Vestibular Neuronitis
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
If Yes hearing loss, what could you have? |
Meniere's or Labyrinthitis
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
If Episodic true vertigo, what could you have? |
BPPV or Meniere's
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
If Persistent true vertigo, what could you have? |
Vestibular neuronitis or Labyrinthitis
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
No hearing loss Episodic true vertigo |
BPPV
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
Yes hearing loss Episodic true vertigo |
Meniere's
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
No hearing loss Persistent true vertigo |
Vestibular neuronitis
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Kentala and Rauch 2003 Dx of Dizziness Algorithm
Yes hearing loss Persistent true vertigo |
Labyrinthitis
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what is the hallmark sign of vestibular dysfunction?
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nystagmus
definition- involuntary rhythmic oscillation of the eyes physiologic (normal) versus pathologic |
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nystagmus is named for ____ return phase
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fast
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Types of Nystagmus
Physiologic |
rotational-induced
caloric-induced end point head shake-none |
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Types of Nystagums
Pathologic |
spontaneous
gaze-evoked head shake- present |
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Properties of Nystagmus
1. Increases with visual fixation blocked -Frenzel lenses 2. Beats away from the lesion -R lesion = L beating nystagmus -increases when looking away from lesion side 3. Spontaneous disappears within 24 hours |
Peripheral
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Properties of Nystagmus
1. Remains constant – does not increase with visual fixation blocked -Frenzel lenses 2. Often vertical -persistent down-beating 3. If positional - will not fatigue easily |
Central
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What is Vestibular Rehabilitation?
Exercises designed to alleviate problems caused by damage to the vestibular system. These exercises are used to maximize the brain’s ___ to recover from, or to compensate from the damage. |
NEUROPLASICITY
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Does Vestibular Rehab Work?
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YES! In some cases . . .
Studies unequivocally demonstrate a decrease in symptoms in individuals with unilateral hypofunction with vestibular exercises. |
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Who Needs Vestibular Rehab?
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Individuals who do not demonstrate
spontaneous resolution of symptoms Unresolved inner ear disorders Acute/Abrupt loss of vestibular function |
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#1 reason in >65 for going to doctor is ___
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dizziness
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___% of population will complain to their doctors of dizziness at least once in their lifetime
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42%
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incidence of vestibular dysfunction increases with ___
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age
38% incidence under age 65 50% of older adults have vestibular problems |
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What is the major goal of
Vestibular Rehabilitation? |
The primary goal of treatment is to
restore control over one’s life to the individual with disabling symptoms of dizziness and/or disequilibrium. |
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How does Vestibular
Rehabilitation Work? |
Basis lies in the neuroplastic principles
of adaptation, habituation, and sensory reorganization. |
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Vestibular Examination
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Oculomotor
Vertigo/Dizziness Motion Sensitivity Sensory Organization (computer) -CTSIB (foam and dome) Equilibrium Mobility Quality of Life |
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Oculomotor Tests
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Spontaneous Nystagmus
Gaze-holding Nystagmus Head-shaking Nystagmus Smooth Pursuit Saccadic Eye Movements |
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VOR tests
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Head thrust test
Static and Dynamic Visual Acuity |
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Vertigo Assessment Tool (2)
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VAS (Visual Analog Scale)
-"please mark on the line where you are right now" no dizziness--------------------------Worst possible dizziness Motion Sensitivity Test/Battery -different positions (sitting to supine) and record intensity, duration, and assign a score |
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List
Dysequilibrium Assessment Tools |
Multi-directional Reach Test (dynamic balance)
Berg Balance Scale Dynamic Gait Index Sensory Organization Test Tinetti Balance and Gait Test |
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Intervention strategy for:
Vertigo/Gaze Stabilization |
Adaptation
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Intervention strategy for:
Vertigo/Motion sensitivity |
Habituation
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Intervention strategy for:
Unsteadiness |
Balance Re-training
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Intervention strategies for:
decreased ability to be active |
fitness training
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keys to success with vestibular rehab
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a little bit, often
you will probably feel worse before you feel better |
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The modification of a movement from trial-to trial based on error feedback in which the following criteria are met:
-The movement is a specific action or task (Reaching, walking, throwing, etc.) -Changes occurs with repetition or practice and is gradual over minutes to hours. -Once ___ individuals have “after-effects” when returning to prior behavior. |
Definition of Adaptation
adapted |
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Adaptation in VOR
-Long- term _____ in response to repetitive input in a range of different head velocities and directions. -Exercises that improve gaze stabilization by improving the VOR gain. |
change within neurons
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Definition of Gain
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The amount of increase in signal power expressed as the ratio of output to input.
In the VOR the normal gain is 1:1. The input in the VOR is: -head velocity The output in the VOR is: -eye movement |
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Adaptation
The stimulus to promote adaptation of theVOR is called ___ ___: necessary for adaptation to occur. -Detects the error signal ( retinal slip) and adjusts the gain of the VOR. |
“retinal slip”
Cerebellum |
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Adaptation
Adaptation is context specific: -speed dependent and position dependent. Research indicates that it takes at least ____minutes of movement with sufficient head speed in order for adaptation exercises to work. |
1.5 minutes
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Indications for ____ Exercise: Impaired VOR
1) + complaints of blurred vision/ oscillopsia 2) + DVA test 3) + head thrust test 4) + motion sensitivity to horizontal/vertical head rotation. 5) UVL>BVL>CENTRAL |
Adaptation
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Contraindications for Adaptation Exercise (2)
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1) Poor vision/ blindness
2) Severe cervical dysfunction or c/o pain despite modifications. |
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____ Exercises
Horizontal and Vertical movements Vary speed / amplitude of movement Increase conflict in background *VOR will not “kick in” at very low velocities Business card should be positioned at eye level 1. look straight ahead at a letter/word 2. turn your head 45 degrees R 3. turn your head 45 degrees L |
Adaptation Exercises
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Habituation
definition: |
Habituation is a long term reduction in the neurological response to a particular noxious stimulus
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___ exercises are designed to diminish vertigo/dizziness by repeatedly exposing patient to the stimulus
-Expose frequently to exacerbating movements |
Habituation exercises
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____ exercises are prescribed by choosing motions that provoke mild to moderate symptoms
-Movement Sensitivity Quotient |
Habituation exercises
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Indications for ____ exercises
Unilateral peripheral lesions with motion sensitivity. -+ MSQ Central lesions with motion sensitivity -+MSQ As an alternative treatment for patients with BPPV. |
Habituation exercises
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Contraindications for ___ exercises
1) Severe cervical and/ or lumbar disease 2) Orthostatic Hypotension (common in the elderly) 3) Stop exercises if pain or discharge from the ear, change in hearing occurs with exercise. |
Habituation exercises
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___ exercises
Determine offending movements (motion sensitivity test) -time how long dizziness lasts -grade how intense it is -choose top 2-3 offenders Repeat offending movements several times a day |
Habituation exercises
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Compensation/ Substitution
Exercises definition: |
promoting the use of an alternative strategy or compensation for deficits that are irreversible.
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Compensation/ Substitution
Exercises indicated when? |
Indicated in severe bilateral loss with no remaining vestibular function.
Exercises to promote use of cervical ocular reflexes, eye and head movements, imaginary targets . Balance exercises / Education |
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Eye- Head Coordination
Techniques: |
Visual tracking task
Horizontal and Vertical movements Vary speed / amplitude of movement Vary position: sit, stand, walk… Vary sensory cues: tile, carpet, foam… |
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What intervention for these?
Motor Coordination Problems -Promote ankle, hip, stepping strategies Sensory Organization Problems -Visual dependence -Sensory selection problems Stability Limits |
Balance Re-Training
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What intervention is this?
Manipulate senses: -Vision -Somatosensory -Vestibular Manipulate ML variables: -Progress simple to complex tasks -BOS, Support Surface -Field: progress closed to open -Progress Intra to Extra personal |
Sensory Re-weighting
-"load" weaker sense or senses -Practice a lot example: balance training with airex progression |
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what intervention is this?
Progressive walking program Low impact aerobics Stationary bike Mini-trampoline |
fitness programs
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Intervention strategies
____ is for Vertigo/Gaze Stabilization -restoring the “gain” of the VOR; .e, increasing the threshold of motion sensitivity through repetitive stimulus |
Adaptation
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Intervention strategies
____ is for Vertigo/Motion sensitivity -A learned suppression of a neural response to a repeated stimulus (simplest form of learning) |
Habituation
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Intervention strategies
____ is for Unsteadiness -Changing the perceptual “set” -Stimulating the VSR -Improving motor coordination -Promoting Sensory Reorganization |
Balance Re-training
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Intervention strategies
___ is for decreased ability to be active |
Fitness training
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Frequency and Duration for individuals with Peripheral Lesions
1. Must do exercises often, ___ 2. Results often seen within ___ weeks; on the average 4-6 weeks for maximal results. 3. Good to be “coached” and progressed once a week by professional. |
1. every day
2. 1-2 weeks |
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Delay of Healing due to what (4)
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1. CNS unable to compensate
2. Medication 3. Inactivity 4. Other medical problems/complications |
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typical PT Goals (vestibular)
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Facilitate positive CNS neuroplasticity for vestibular pathology via adaptation,
habituation, and sensory re-weighting. Reduce vertigo using habituation and adaptation exercises Reduce imbalance and ataxia through balance re-training Reduce problems with gaze stabilization through eye-head coordination exercises Improve physical conditioning for long term retention of CNS compensation Restore functional skills and daily life roles. |
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Expected Outcomes: Unilateral Vestibular Lesions
1. ____% of patients rate themselves as no disability or mild disability. 2. May have persistent ___ to rapid head movements 3. Expect ___ balance and gait. 4. Minor residual symptoms, full recovery ___ months. |
1. 90%
2. gaze stability problem/ VOR 3. near normal 4. 3-6 |
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Expected Outcomes: for _____
Expect a considerable amount of improvement but will recover more slowly. Will always have some deficits: slower gait, risk for falls. Bad prognosis if other sensory systems are affected (vision, somatosensory) |
Bilateral Vestibular Lesions
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Expected outcomes for: ____
Variable results with vestibular rehab depending on areas involved. Much less successful than peripheral Longer recovery time |
Central Lesions
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What is this?
A high -tech laboratory test which involves the recording of eye movements using electrical sensors. Used with Oculomotor tests, Hallpike-Dix Tests integrity of peripheral vestibular system; compares Can give some info on peripheral vs central lesion. Useful in telling if patient has a “unilateral weakness ”; 20-30% is significant. |
ENG - Electronystagmography
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Rotary chair testing
1. Tests ___ function 2. Can assist with differential diagnosis between bilateral peripheral and central lesions |
1. Tests VOR function
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What is this?
SOT: Differentiates between 3 primary senses in contribution to balance impairments Evaluates automatic postural response to unexpected perturbations |
Posturography
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Consider the signs and symptoms
caused by this: What is it? Positional vertigo that lasts for seconds Nausea and vomiting VOR dysfunction Unsteadiness *Classic History: -Rolling or sitting up in bed -Looking underneath |
BPPV
Otoconia falling into SCC, leads to quick changes in firing rate of crista - BPPV |
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Mechanism of BPPV:
Canalithiasis versus Cupololithiasis Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia. These crystals are normal and function to tell the brain about the direction of gravity or acceleration. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement and a resultant sensation of vertigo. This more common condition is known as ____. |
canalithiasis
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Mechanism of BPPV:
Canalithiasis versus Cupololithiasis In rare cases, the crystals themselves can adhere to the cupula of the semicircular canal rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerves. This condition is termed ____. |
cupulolithiasis
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Posterior Canal
Particles create “drag” in endolymph, leads to distorted message to brain Particles have only one way in or out; once in the canal – they’re trapped! We can “liberate” these trapped particles and return to ___ by maneuvers that take them back out the way they came. |
utricle
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Diagnosis of Posterior Canal BPPV is by the ____ Maneuver
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Dix-Hallpike Maneuver
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Assessment for Posterior Canal BPPV: Hallpike-Dix Test
Onset of vertigo & nystagmus within ____ seconds - ____ nystagmus toward dependent ear |
5-10 seconds
rotational |
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Assessment for Posterior Canal BPPV: Hallpike-Dix Test
• Symptoms resolve within ____ seconds Return to sitting, symptoms return - ____ of nystagmus Symptoms resolve within 30-90 seconds |
30-90 seconds
reversal |
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___ Maneuver:
Canalith Repositioning Procedure |
Epley Maneuver
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____ maneuver
start with short sitting on plinth, then lie down on R, then lie down on L |
Sement Liberatory Maneuver
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what test(s) is done to detect horizontal canal BPPV
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Supine roll test (Pagnini-McClure maneuver) = lie supine facing up, then look right, then look left
Lempert Roll Maneuver = supine and look R, look up, look left, roll L to prone, roll over L shoulder to sidelying, lie supine again, then sit to long sitting |
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____ Maneuver
Position 1: sidelying with BAD ear down on pillow Position 2: supine Position 3: sidelying with bad ear UP on pillow 4. on hands and knees with butt on ankles, head and chin down |
Horizontal Canal Maneuver
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BPPV Assessment and Intervention
Assessment:____ Treatment:____ If ineffective... ___ and ___ exercises |
Assessment: Dix-Hallpike
Treatment: Epley maneuver, Sement Habituation and Adaptation exercises |
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Describe gross anatomy of cerebellum (3)
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1. cerebellar cortex
2. 3 pairs of peduncles 3. Cerebellar Core: 3 deep nuclei |
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what brain part is this?
Attaches to ventral Brainstem Afferent and Efferent tracts in both directions between Brainstem and CB. |
Cerebellum
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What brain part has-
Projections to & from: Motor Cortex Thalamus Red Nucleus Pontine Nuclei Vestibular Nuclei Olivary Nuclei Deep CB Nuclei |
Cerebellum
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What are the 3 lobes that form the cerebellum?
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1. Flocculonodular lobe
2. Anterior lobe 3. Posterior lobe |
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White matter tracts connecting the cerebellum to the brainstem form the ___
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cerebellar peduncles
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The Superior Cerebellar Peduncle attaches to the ____ and contains most of the cerebellar ____ fibers
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Midbrain
Efferent fibers |
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Superior Cerebella Peduncle
contains most of the cerebellar Efferent fibers. Efferents project to (4) |
1. vestibular nuclei
2. reticular nuclei 3. motor cortex 4. red nucleus |
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The Middle Cerebellar Peduncle receives and projects information between the ____ and cerebellum
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cerebral cortex
"brain to the balls" |
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The Inferior Cerebellar Peduncle
Conveys ____ information from the brainstem and spinal cord to the cerebellum Sends ____ inputs to the vestibular and reticular nuclei |
Afferent
Efferent |
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Name the 4 Anatomical Cerebellar Zones
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1. Medial Zone (includes Flocculonodular)
2. Intermediate Zone 3. Lateral Zone 4. Flocculo-nodular lobe |
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Name the Functional Cerebellar Zones
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1. Spinocerebellum (Medial and Intermediate)
2. Cerebrocerebellum (Lateral) 3. Vestibulocerebellum (flocculo-nodular) |
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Key Point
____ are associated with Functional Divisions of Cerebellum |
deep nuclei
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Deep nuclei are associated with Functional Divisions of Cerebellum
1. Vestibulocerebellum: ____ 2. Spinocerebellum: ___ 3. Cerebrocerebellum:___ Key point: Nuclei are ____ arranged |
1. fastigial nucleus
2. interposed nucleus 3. dentate nucleus Somatotopically |
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Anatomical Functional Divisions
which nuclei? Medial Zone |
Fastigial nucleus
Interpositus nucleus |
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Anatomical Functional Divisions
which nuclei? Intermediate zone |
Interpositus Nucleus
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Anatomical Functional Divisions
which nuclei? Lateral Zone |
Dentate nucleus
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Vertically, the cerebellum can be divided into 3 functional areas
Medial Zone (anatomical) = |
Spinocerebellum (functional area)
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Vertically, the cerebellum can be divided into 3 functional areas
Intermediate Zone (anatomical) |
Spinocerebellum (functional area)
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Vertically, the cerebellum can be divided into 3 functional areas
Lateral Zone (anatomical) |
Cerebrocerebellum (functional area)
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Why do people talk about the
areas differently? |
Motor control research reflects “new” functional areas as we have become more sophisticated in our questions and methods.
The “old” functional areas are still correct. The “new” functional areas explain more complex motor behavior, i.e., walking. |
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_____ Zone
Information directly to and from VN and fastigial nucleus of CB |
Medial Zone
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____ Zone
This area projects to areas of the brain concerned with balance |
Medial Zone
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The Medial Zone is important for control of?(3)
Which CB peduncle(s) do you think is/are heavily involved with this type of traffic? |
1. posture
2. balance 3. Locomotion Inferior CP |
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_____ Zone
Receives info from: Somatosensory receptors in the head and body, as well as info from CPGs |
Intermediate Zone
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_____ Zone (anatomical)
Receives info from: Deep CB nuclei and sends processed info back thru Interpositus Nuclei. |
Intermediate Zone
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The ____ Zone is important for control of:
-Motor Regulation -Discrete, ipsilateral limb movements and reflexes Which CB peduncle(s) do you think is/are heavily involved with this type of traffic? |
Intermediate Zone (same as Lateral Zone)
Middle Cerebellar Peduncle |
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____ Zone
Receives afferent info from the Pons |
Lateral Zone
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_____ Zone (anatomical)
Sends Efferent info via the Dentate nucleus to the contralateral thalamus and frontal lobe |
Lateral Zone
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____ Zone is important for control of:
-Motor Regulation -Discrete, ipsilateral limb movements and reflexes (same as intermediate zone) which CB peduncle do you think is/are heavily involved with this type of traffic? |
Lateral Zone
Superior CB peduncle (?) |
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Name the 3 deep nuclei
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1. Fastigial
2. Interpositus 3. Dentate |
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If the cerebellum is damaged unilaterally, why can it effect motor control bilaterally?
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Descending connections from CB to BS and SC are ipsilateral.
Descending connections from Cerebral cortex are contralateral. When CB is communicating with cortex, must cross prior to ascending to the appropriate neurons in the cortical region. Lateral Zone: "Sends efferent info via the Dentate nucleus to the contralateral thalamus and frontal lobe." |
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According to Melnick,what role
does the ___ play in motor control? Comparator Central Set – Anticipatory postural responses Adaptation Sequencing of simple movements that comprise larger movements Mental Imagery Non-motor/Cognitive tasks |
cerebellum
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Classic Impairments associated
with ___ Dysfunction: Ataxia Dyscontrol of eye movements and gaze Dysmetria Dysdiadochokinesia Decomposition of movement Dysarthria Hypotonia Asthenia Dysequilibrium and Gait Ataxia |
Cerebellar
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definition of Ataxia
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meaning "lack of order" is a neurological sign and symptom consisting of gross lack of coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of parts of the nervous system that coordinate movement, such as the cerebellum
co-activation of antagonist and agonist |
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How can I distinguish between sensory ataxia and cerebellar ataxia?
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cerebellar ataxia (swaying and inability to maintain balance with eyes open or closed)
sensory ataxia (increased swaying and inability to maintain balance with eyes closed) |
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Classic Impairment associated with ____ Dysfunction
Dyscontrol of Eye Movements: Ocular Dysmetria -Impaired smooth pursuit -Saccades -Deviation to involved side at rest Spontaneous nystagmus Impaired VOR -Gaze-evoked nystagmus Impaired Function -Blurred vision, Double vision, visual distortions of movement |
Cerebellar
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what is this cerebellar impairment?
A deficit in reaching a target Target inaccuracy of movement -Overshooting -Undershooting Path inaccuracy of movement -Increasing deviation from the trajectory |
Dysmetria
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Role of agonist/antagonist onset and offset
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causes Dysmetria(?)
loss of agonist-antagonist timing in 4 individuals with CB disorders |
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What about multijoint movements?
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“Interaction torques”
-Reflects the effect of movement at one joint (e.g., the elbow) on another joint (e.g., the shoulder. de-coupling of joints -shoulder and elbow inaccurate targeting -slow - undershooting -fast- over shooting Decomposition -shoulder flexion (vertical) followed by elbow extension (horizontal) |
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____:
Motor Control explanation Abnormality in: -Movement Direction -Extent of trajectory (undershoot or overshoot) -Timing of appropriate force production (hyper) -Timing of “on” and “off” muscle firing Motor Control deficits: -Agonist muscle activity is reduced in magnitude and prolonged in time. (Bastian) -Antagonist muscle active is delayed resulting in delayed deceleration. (Bastian) |
Dysmetria
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What is this cerebellar impairment?
Inability to perform rapidly alternating movements What would you hypothesize is happening to the muscles as they alternate from agonist to antagonist? |
Dysdiadochokinesis
Very similar to motor control problem seen in dysmetria Timing of the “On-Off” cycle of the agonist/antagonist muscles is impaired Inability to cease antagonist activity. Agonist muscle activity is reduced in magnitude and prolonged in time. (Bastian) Antagonist muscle active is delayed resulting in delayed deceleration. (Bastian) |
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Dysdiadochokinesis
Very similar to motor control problem seen in dysmetria... Inability to cease ___ activity |
Antagonist
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What is this cerebellar impairment?
Difficulty performing a movement in one smooth pattern -May perform the movement in a sequence of steps |
Decomposition of movement
Less degrees of freedom, increase accuracy(?) faster is better than slower |
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What cerebellar impairment is this?
“Dysmetria” of the oral musculature -Loss of the melodic quality and rhythm of speech -Slow and awkward pronunciation of words -Monotone -Long pauses within and between phrases |
Dysarthria
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What cerebellar impairment is this?
Generalized “weakness” on ipsilateral side Motor control mechanism unclear: -A decrease in fusimotor activity --Sense of increased effort and fatigue -Loss of CB facilitation to motor cortex |
Asthenia
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What cerebellar impairment is this?
Decreased tone DTRs can be decreased Motor Control mechanism unclear; similar to that for Asthenia. |
Hypotonia
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Review of Functional Zones
____- function Input -Signals changes in head position with respect to gravity -Coordination of eye-head movement Output -Regulates axial muscles used in balance -Controls eye movement for coordination of eye-head movement Damage -Poor regulation of gait and posture due to decreased intersegmental stability (poor balance, ataxia) -Nystagmus, impaired VOR |
Vestibulocerebellum
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Lesions of ___ (Functional Zone)
Impaired postural control (balance) Inability to coordinate eye movements *Secondary deficits in distal limb control due to impaired proximal stability. |
Vestibulocerebellum
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_____(Functional Zone) - Function
Input -DSCT: Carries direct information about the actual effect of the motor commands on limb placements -VSCT: Returns “copies” of of the motor commands that are arriving at the MN pools to the Cerebellum Output -Cerebellum can “compare” what is actually happening to what the original command was, and make adjustments Damage -Abnormal sequence of muscle contraction -Prolonged muscle agonist activity with delayed antagonist deceleration phase -Inaccurate targeting with increased tremor nearer target -Increased sway in standing |
Spinocerebellum
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Lesions of ____ (functional Zone) cause
1. Hypotonia 2. Dysmetria 3. Dysdiadochokinesis 4. Intention tremor |
Spinocerebellum
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____ (functional zone) - Function
Input -Spatio-temporal organization necessary for movement – internal representation model -Feed forward system - role in programming of movement --Receives information from motor, premotor and sensory cortex (info. To be executed) --Sends information back to motor cortex --Effects motor command before execution of motor command Output -Initiation of movement -Muscle tone -Coordination Damage -Impaired control of distal limb musculature -Delays in initiation of movement -Faulty execution of movement – decomposition, irregular path or trajectory -Hypotonia |
Cerebrocerebellum
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Lesions of _____ (functional zone) cause
Decomposition of movement Delayed initiation of movement and RT Perception of timing -Coincident timing deficits *Cognitive and motor learning. |
Cerebrocerebellum
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Functional Anatomy
____ Zone (anatomical) Primary vestibular inputs and outputs Integrates spinal and vestibular inputs which leads to . . . influencing important motor pathways for walking. -vestibu- and reticulo- spinal tracts |
Medial Zone
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Functional Anatomy
____ Zone (anatomical) Primary inputs from SC and Cerebral Cortex Primary outputs to Red N. and Cerebral Cortex Integrates spinal and cortical inputs which leads to . . . influencing walking through projections to motor cortical areas. |
Intermediate Zone
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Functional Anatomy
____ Zone (anatomical) Primary inputs Motor Cortex & Motor Cortex Association areas Primary outputs to Red N. and Cerebral Cortex Integrates spinal and cortical inputs which leads to . . . influencing walking via cortical interactions and may be most important for voluntary modifications to the locomotor cycle. |
Lateral Zone
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Functional Anatomy
____ Zone (anatomical) influencing walking via cortical interactions and may be most important for voluntary modifications to the locomotor cycle. |
Lateral Zone
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Functional Anatomy
___(anatomical) Authors consider as a separate functional region Lesion studies: -Abnormal changes in postural tone -Impairments in maintaining sitting or standing balance -Postural Asymmetry -Impaired automatic postural responses -Ataxic gait with abnormal timing and excursions of limb movement |
Flocculonodular Lobe
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____ + _____ (both anatomical)
1. play a strong role in the control of balance and locomotion 2. controlling extensor tone during upright 3. Modulating flexor/extensor activations in the locomotor pattern -Based on sensory feedback from the limbs |
Medial Zone + Flocculonodular node
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____ Zone (anatomical)
appears to play a minimal role in the control of balance and locomotion. Comes into play during locomotor activities that require precision. More important for directing limb placement and regulating agonist-antagonist muscle pairs. |
Intermediate Zone
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____ Zone (anatomical)
appears to play a unique role in walking. Plays a major role in making adjustments in walking during novel situations, or when strong visual guidance is needed. |
Lateral Zone
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_____ Damage in humans
Increased postural sway Hypermetric automatic postural responses Ataxic gait Decomposition of movement during gait Poor obstacle negotiation during gait |
Cerebellar
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Key Point
____ deficits are primarily responsible for ataxia during gait. NOT limb placement deficits. |
Balance
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definition of motor learning
what does it have to do w/ cerebellum? |
relatively permanent change in behavior due to experience
cerebellar damage affects motor adaptation (error-based learning) Cerebellum strongly implicated as largely responsible for motor learning to occur. -CB must have a mechanism that can alter synaptic efficiency in response to experience - climbing fibers? -increased activation of climbing fibers with with motor learning |
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Cerebellum and motor learning
with damage to cerebellum, unable to do motor task ____ -feedback loop -feedforward loop |
unconsciously
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____ Deficits
Predictive APRs -Unable to adjust with repeated exposure to expected perturbation Gait adjustments to different treadmill speeds -Can adjust to change in speed, but motor strategies are abnormal |
Cerebellar
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SARA
Scale for assessment and rating of ____ Gait & Equilibrium – Items 1-3 Speech – Item 4 UE Dysmetria – Item 5 UE Dysmetria (Intention tremor) – Item 6 Dysdiadochokinesis – Item 7 LE Dysmetria – Item 8 |
ataxia
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_____ for Cerebellar patients, Take home message:
Always some spontaneous recovery acutely The more damage, the poorer the potential for recovery “IF the ___ is not totally destroyed, some adaptation . . . can occur.” |
Prognosis
cerebellum |
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What are special treatment considerations for the patient with Cb lesions?
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Recovery, use Task-specific training
-Many, many, many repetitions -Slow and fast movements -Use complex (multi-joint) movements as well as simple Compensation – Alternate Strategies -Movement Decomposition --Visual – Eye-Head Exercises -Limiting Degrees of Freedom -Assistive Devices -Home Modifications |
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Motor control
Coordination: Trunk, Extremities, Head -Timing --Force --Onset --Sequencing Postural Control leads to Balance & Equilibrium -Motor Learning |
cool
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Injury to the ___ leads to Disturbances of Stability and Mobility
Stability -Ability to maintain a body position or posture Mobility -Ability to produce smooth, coordinated, accurate movement while maintaining dynamic equilibrium |
Cerebellum
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