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101 Cards in this Set
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A 37-year-old woman suddenly developed pain and numbness in her right shoulder and fingers after falling while exercising.
general physical exam was unremarkable neurologic exam showed that her mental status and cranial nerves were normal motor exam was notable for diminished right triceps strength reflexes were absent in the right triceps coordination and gait were normal sensation was normal except for diminished pain and temperature sensation in her right index and middle fingers Performing the neurologic exam carefully and presenting findings clearly, are crucial to accurately diagnosing and effectively treating patients. |
C7
Not a plexus avulsion Pain/temp nerve compressed (odd because light touch is usually outside) more distal compression |
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S/S differentiation
Weakness can be caused by Sensory changes can be caused by Loss of balance can be caused by: |
Weakness can be caused by
CNS problem PNS problem Sensory changes can be caused by CNS problem PNS problem Loss of balance can be caused by: Vestibular deficits (PNS vs CNS) Visual deficits (PNS vs CNS) Somatosensory loss (PNS vs CNS) Cardiopulmonary deficits Medication change Coordination deficit |
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Factors that can cause Loss of Balance (LOB)
Intrinsic vs Extrinsic factors Intrinsic physiological factors : Extrinsic: Activity-related factors: |
Factors that can cause Loss of Balance (LOB)
Intrinsic vs Extrinsic factors Intrinsic physiological factors Age Sensory Changes Reduced vision, hearing, sensation and vestibular function Musculoskeletal Changes Increased weakness, decreased ROM, altered postural strategies Neuromotor changes Dizziness and or vertigo, Timing and control problems Slowed reaction and movement times Cardiovascular changes Medications LOB (con’t) Intrinsic psychosocial factors (continued) Mental status/ Cognitive impairment Depression Denial of problems Fear of falling Relocation Extrinsic: Environment – ground surface, lighting, stairs, doorways Activity-related factors Most falls occur during normal daily activities Some falls climbing ladders Assistive devices Yappy little dogs |
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What's included in a neuro exam?
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Patient History
General Physical exam Neurological exam Mental status Cranial Nerves Sensory exam Motor exam Coordination & Balance Gait Reflexes |
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Aspects of cognition - can be tested
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General intellect
Orientation - time Attention - Focused, selective, sustained, alternating, divided Memory - Working, short-term , spatial memory Executive function - Slow processing/initiation, rate of learning, creative thought Praxia - Ideomotor; movement transitions Visual perceptual, spacial processing: Environmental/body spatial localization and processing; interference effects from lack of inhibition Language oral/written - Fluency |
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Mental Status
(big answer) |
Level of alertness, attention and cooperation
Orientation Memory Recent memory Remote memory Language Spontaneous speech Comprehension Naming Repetition Reading Writing Sequencing - for a transfer, for instance Safety awareness (lock brakes? try to stand up, sit on hand) -Neglect -Logic / Abstraction Planning ability - Apraxia (how do you brush teeth? sequence) Affect - response -Low/High -Normal Mood -Steady -Swings (out of the blue) Delusions and Hallucinations |
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History: patient has had a history of a recent MVA (passenger…hit head on windshield) s/p closed head injury and neck pain. The patient has been referred to your out patient clinic for neck pain, has not been able to return to work and is receiving speech therapy for cognitive issues
TASK Find out why the patient is not able to complete your auditory directions for chin tucks (axial extension) without a lot of assistance Tests and measures Auditory damage (CN VII) UMN or LMN damage Apraxia (inability to plan a motor task) Anosognosia (do not recognize anything is wrong) Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) |
Patient (only)
You have minimal motor apraxia (difficulty with sequencing of motor (movement) activities You are aware that something is wrong “I know what you want me to do but I get mixed up when I try to do it” Your hearing is normal You do not have any signs of UMN or LMN lesion You get mixed up easily with the order of the task but with demonstration, tactile and verbal cues, and repetition, you get it right (minimally mixed up) |
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Cranial Nerves:
Olfactory Opthalmic Pupillary response Extraocular movements Facial Sensation and muscles of mastication Muscles of facial expression and taste Hearing and vestibular sense Palate elevation and gag reflex Muscles or articulation Sternocleidomastoid and trapezius muscles Tongue Muscles |
Olfactory (CN I)
Opthalmic (CN II) vision Pupillary response (CN II, III) Extraocular movements (CN III,IV, VI) Facial Sensation and muscles of mastication (CN V) Muscles of facial expression and taste (CN VII) Hearing and vestibular sense (CN VIII) Palate elevation and gag reflex (CN IX, X) Muscles or articulation (CN V, VII,IX, X, XII) Sternocleidomastoid and trapezius muscles (CNXI) Tongue Muscles (CN XII) |
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Sensation
Primary sensation (TBI vs SCI) Cortical sensation other sensation |
Primary sensation (TBI vs SCI)
-Asymmetry -Light touch (2 point discrimination) -Pain & Temperature -Proprioception (joint position sense) - move wrist up/down, in/out -Kinesthesia - match other arm's movement Cortical sensation -Graphesthesia - trace letter on hand -Stereognosis - recognize objects Extinction Protective sensation |
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Neuro exam - Motor Exam (by MD)
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Observation
Involuntary movements Tremor Hypokinesia Inspection Muscle wasting Fasiculations Palpation Tenderness Fasciculations Muscle tone (low, high, or normal) Functional testing Quick testing Drift, Fine Finger tapping, Rapid toe tapping Transitional movement testing sit to stand test Strength of individual muscles groups (pg 65 & 309-311) Sit to stand test: functional strength movement in transitions endurance |
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Motor Exam (by PT)
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Types of Motor Skill (yikes!!!)
Gross motor skill Fine motor skill Closed or open motor skill Simple motor skill Complex motor skill Dual-task skills What PTs need to know about the patient’s abilities What are the normal requirements of the functional activity How successful is the patient’s overall movement in terms of outcomes (are the functional) |
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UE Myotomes
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C5- elbow flexor
C6- Wrist extensors C7- Elbow extension C8- Finger Flexion T1-5th digit abduction |
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LE myotomes
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L2-Hip flexion
L3-Knee extension L4-Ankle Dorsiflexion L5- Long toe extension S1 Ankle plantar Flexion |
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Coordination and balance testing
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Extremity coordination (presents of dyskinesias or ataxia)
Rapid alternating movements Disdiadochokinesia (abnormal alternating mvts) Finger-nose-finger test Heel-shin-test Overshoot Balance Berg or Tinneti Functional reach TUG (timed up and go) Romberg test Tandem stance Single leg stance What is the root of the problem??? |
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Observing gait
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vOrdinary gait
Stance & Swing phase Double limb support time Stride length Cadence Symmetry / Asymmetry Tandem gait Forced gait Walk on heels Walk on toes |
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reflexes
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Deep tendon reflexes
Plantar response Special situation tests Posturing (head injury) -Decorticate vs. decerebrate Dolls eyes (brain stem intact) Pain response -Localization -Withdrawal Infant reflexes ( can return with CNS injury) ATNR STNR Grasp |
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Diagnostic Neuroradiology
CT scans vs. MRI Blumenfeld: pages 83-97 |
CT (5-10 mins)
Head trauma Lower cost Fresh hemorrhage Speed (patient safety) Skull fracture Calcified lesion Claustrophobic or obese Pacemaker or metallic fragments in heart or eye MRI (45 mins) Subtle area Tumor, infarct demyelination etc Brainstem lesion Anatomical detail needed |
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Examination of the low level patient
What if the patient has/is |
What if the patient has/is
Impairments in alertness or attention Uncooperative behaviors Observation of spontaneous speech, movements and responses to your examination Decreased language comprehension Yes or no questions Pictures Deafness Write the questions Inability to speak What if the patient is in a coma? Can a PT still examine them? |
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Coma Exam
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Mental Status
Level of consciousness (response to stimuli) Does the patient Open eyes and turn towards voice Respond to painful stimuli by reaching to it or grimacing Non responsive Do they look like they are in a coma but are just “Locked in” (Syndrome) Consciousness and sensation are normal but the patient is unable to move because of a brainstem lesion Sensory exam Cranial nerves Blink to threat (CN II & III) Pupillary responses (CNII, III) Extraocular movements Vesibulo-occular reflex (CN III, IV, VI, VIII) Oculocephalic reflex or presents of dolls eyes (eyes move opposite of motion, not looking at you, tracking) Reflexes DTNRs Decorticate posture (flexed UEs) Decerebrate posture (extended UEs) more severe…lower in the brainstem |
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Posturing with Brain stem lesion
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ATNR - asymmetric tonic neck reflex
-response Thalamic tracts Diencephalon Decorticate - flexed UE. Rubrospinal Decerebrate - extension. Pons |
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The patient has
Weakness Muscle Atrophy Muscle Fasciculations Decreased Reflexes Decreased Muscle Tone Is it an upper or lower motor neuron lesion |
Lower!
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Are these pathologies CNS or PNS?
Multiple Sclerosis Guillian Barre’ Syndrome Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease Parkinson’s Disease Work toward knowing: What is the disease /syndrome process? What neuroanatomy is involved? What are the symptoms of each? |
Multiple Sclerosis
Central nervous system Guillian Barre’ Syndrome Peripheral nervous system Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease Both peripheral and central nervous system Parkinson’s Disease Unilateral, Tremor, Rigidity and Bradykinesthia What is the disease /syndrome process? What neuroanatomy is involved? What are the symptoms of each? |
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Common S/S of MS
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Motor
Muscle weakness Spasticity Hyperreflexia Sensory Position sense Light touch Pain and temperature General pain Cranial nerves Vision Ocular disturbances Bulbar signs Vertigo Cranial nerves V, VII, VIII Autonomic Bladder dysfunction Bowel dysfunction Sexual dysfunction Sweating and vascular dysfunction Psychiatric Depression Euphoria Cognitive abnormalities Cerebellar Ataxia Tremors Nystagmus (BS or CB) Dysarthria (BS or CB) |
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S/S of brain tumors
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Headache
Visual Changes Nausea Vomiting Cognitive changes Lethargy Behavioral changes Seizures Hemiparesis Sensory impairments apraxia Language deficits Facial Numbness Hearing disturbances Swallowing difficulties Paralysis of outward gaze (CN VI) Papilledema Incoordination Ataxia Enlarged head CN palsies Type of devastation depends on the anatomy the tumor is affecting |
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UE Decreased Sensation:
History: patient has had a R CVA and has mild (minimally involved) Left hemiparesis TASK Find where the patient has decreased UE sensation Tests and measures Decide how involved the patient is for each ( report….intact, min, moderate or maximally involved) Sensory testing Light touch, 2 point discrimination Pain (sharp vs dull) Proprioception & Kinesthesia Stereognosis & Graphesthesia |
History: patient has had a R CVA and has mild (minimally involved) Left hemiparesis
TASK Find where the patient has decreased UE sensation Tests and measures Decide how involved the patient is for each ( report….intact, min, moderate or maximally involved) Sensory testing Light touch, 2 point discrimination Pain (sharp vs dull) Proprioception & Kinesthesia Stereognosis & Graphesthesia Patient (only) Right UE sensation is intact Left arm and hand pain is intact but moderately hypersensitive Left arm proprioception and kinesthesia is minimally involved Patient will be accurate 8/10 times with proprioception and just barely off with kinesthesia Left UE touch and 2 pt discrimination sensation is intact at the Shoulder, elbow and wrist Left hand light touch and 2 point sensation is mildly involved Left hand Stereognosis and Graphesthesia is moderately involved Accurate about 6/10 times or guessing some what close to the letter |
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Decreased LE Sensation
History: patient has had a history of Type II Diabetes for 7 years and has minimal to moderately involved loss of sensation in his bilateral LEs TASK Find where and what type of LE sensation loss the patient has Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Sensory testing Light touch Pain (sharp vs dull) Proprioception & Kinesthesia |
History: patient has had a history of Type II Diabetes for 7 years and has minimal to moderately involved loss of sensation in his bilateral LEs
TASK Find where and what type of LE sensation loss the patient has Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Sensory testing Light touch Pain (sharp vs dull) Proprioception & Kinesthesia Patient (only) Bilateral LE proprioception and kinesthesia is intact Bilateral hip and knee sensation is intact Right LE light touch sensation is minimally involved from just above the ankle to toes (light touch or dull is accurate 8/10 times) Left LE is light touch sensation is moderately involved from just above the ankle to toes (light touch or dull is accurate 5/10 times) Bilateral decreased pain response (patient can tell that you touched every time with sharp… but is not sure if it is sharp or dull |
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Decreased Motor Ability
HX: Patient has experienced a R CVA with L hemiparesis Task: Find out what motor ability the patient has during bedmobility, sitting and transfers (functional tasks). Also assess if patient has issues with safety awareness Test and measures: Sitting balance, transfer ability and level of safety awareness during functional tasks. |
HX: Patient has experienced a R CVA with L hemiparesis
Task: Find out what motor ability the patient has during bedmobility, sitting and transfers (functional tasks). Also assess if patient has issues with safety awareness Test and measures: Sitting balance, transfer ability and level of safety awareness during functional tasks. Patient only: (begin lying on your back) you have a moderate amount of hemi neglect… you don’t look to the left at all unless continually prompted you require minimal assistance to roll towards your left side and moderate assistance to roll to the right leaving behind your left arm You require just minimal assistance to sit and balance (you will fall slowly if they do not hold you) You require minimal assistance to complete the transfer but when asked you are impulsive and begin the transfer right away without safety awareness (legs not set etc) |
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Decreased Balance:
History: a 55 year old patient is referred to you for recent onset of frequent falling. She has a history of a cerebellar tumor removal as an 8 yr old child but just began to fall recently in her home TASK Find out what situations cause her to fall Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Gross LE muscle testing Standing with feet shoulder width apart (eyes open/closed) Standing with feet together (eyes open/closed) Single leg standing (eyes open/closed) Complete same testing on a dense foam surface |
Patient (only…you have recently changed your flooring from tile to dense padded carpet and you fall at night when you can’t see as well)
Your strength is fine (4+/5 ish) You do fine with eyes open for all of the balance tests You have more difficulty with eyes closed and are minimally impaired You stand on the foam and you have moderate difficulty in all cases and can not stand at all with eyes closed on the foam in double stance and you refuse to try single leg stance |
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Increased LBP and decreased balance
History: patient was seeing you for low back pain and now has a bad cold but still wanted to come and be treated because last night he slipped in the shower and tweaked his back again. You notice that his balance is worse. TASK Complete tests and measures that determine why the patient might have decreased balance Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) LE dermatome testing (was normal one week ago) LE gross strength testing (was normal one week ago) Balance & gait Double and single leg balance eyes open and closed |
History: patient was seeing you for low back pain and now has a bad cold but still wanted to come and be treated because last night he slipped in the shower and tweaked his back again. You notice that his balance is worse.
TASK Complete tests and measures that determine why the patient might have decreased balance Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) LE dermatome testing (was normal one week ago) LE gross strength testing (was normal one week ago) Balance & gait Double and single leg balance eyes open and closed Patient (only) You have pinched the Right L5 nerve root when you slipped in the shower L5 dermatome testing in moderately involved L5 musculature is weak (ankle is weak 3+/5) Double limb support in balance you are shifted to the left You are unable to balance in single limb support on the Right due to pain and weakness You walk with a slight hip hike on the right because you ankle is weak |
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Decreased Facial sensation and increased biting of the tongue
History: patient has had a history of Lung Cancer with metastasis to the kidneys. She has recently reported having decreased sensation of the face and has been repeatedly biting her tongue TASK Find where and what type of lesion might be causing this change in sensation and function Tests and measures (CN V, VII, XII) Sensory testing of face (CN V and VII) Light touch Pain (sharp vs dull) Motor testing of face, mastication (biting) and tongue muscles CN V, VII and XII Find out if it is a UMN or LMN lesion |
History: patient has had a history of Lung Cancer with metastasis to the kidneys. She has recently reported having decreased sensation of the face and has been repeatedly biting her tongue
TASK Find where and what type of lesion might be causing this change in sensation and function Tests and measures (CN V, VII, XII) Sensory testing of face (CN V and VII) Light touch Pain (sharp vs dull) Motor testing of face, mastication (biting) and tongue muscles CN V, VII and XII Find out if it is a UMN or LMN lesion Patient (only) (CN V on Lft side of face…LMN injury from mets) Bilateral muscles of facial expression are intact Puff, kiss, smile, frown, close eyes tightly Sensation (sharp and dull) Left side of face is moderately impaired (5/10 accurate) Right side of face is intact Bite Strong on the Right and weak on the Left (tough to fake…just tell the PT this) Tongue strength is minimally involved 4/5, the tongue deviates slightly to the Right… no fasciculation's noted yet |
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Decreased Sequencing and Safety
History: patient has had a history of a R CVA with Left hemiparesis and neglect. He has fallen out of bed in the hospital and is a fall risk TASK Find out how well the patient is at sequencing and safety Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Are they oriented to person, place, time and event Do they know they have a problem? (anosognosia) Test short and long term memory remember these three items (pen, paper, chair) ask again at 1 & 5 mins (30 mins is also a good test) Ask about family history (something you have knowledge of) Test the patients safety and sequencing abilities… have them complete a transfer from mat to chair Check sequencing, impulsivity, thought process, |
Patient (only)
You are alert and oriented x 4 (person, place, time, event) You just think you are all better You have great long term memory but you are impulsive and don’t take time to remember the items ….”ok, ok, I got it” and then you don’t…but if pressured to slow down and notice each object…you can remember (intact memory but not paying attention) When you are asked to do the transfer you are impulsive, your feet are all tangled and you rush to get to the chair…unsafely…and don’t realize you were unsafe (maximal safety risk) |
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Inability to follow motor commands
History: patient has had a history of a recent MVA (passenger…hit head on windshield) s/p closed head injury and neck pain. The patient has been referred to your out patient clinic for neck pain, has not been able to return to work and is receiving speech therapy for cognitive issues TASK Find out why the patient is not able to complete your auditory directions for chin tucks (axial extension) without a lot of assistance Tests and measures Auditory damage (CN VII) UMN or LMN damage Apraxia (inability to plan a motor task) Anosognosia (do not recognize anything is wrong) Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) |
History: patient has had a history of a recent MVA (passenger…hit head on windshield) s/p closed head injury and neck pain. The patient has been referred to your out patient clinic for neck pain, has not been able to return to work and is receiving speech therapy for cognitive issues
Patient (only) You have minimal motor apraxia (difficulty with sequencing of motor (movement) activities You are aware that something is wrong “I know what you want me to do but I get mixed up when I try to do it” Your hearing is normal You do not have any signs of UMN or LMN lesions You get mixed up easily with the order of the task but with demonstration, tactile and verbal cues, and repetition, you get it right (minimally mixed up) |
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Decreased orientation, alertness, and cooperation
History: patient has had a history of severe head injury and has been transferred to the rehabilitation floor after 2 weeks in ICU. You are evaluating her for the first time. TASK Find what level of Orientation, Alertness, Attention and Cooperation she is capable of Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Orientation: to person, place, time and event Alertness: is she awake and following you or zoning Attention: able to follow task to completion (spell WORLD fwd & bwd…slower going backward is ok) Cooperation: does she get frustrated |
History: patient has had a history of severe head injury and has been transferred to the rehabilitation floor after 2 weeks in ICU. You are evaluating her for the first time.
TASK Find what level of Orientation, Alertness, Attention and Cooperation she is capable of Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Orientation: to person, place, time and event Alertness: is she awake and following you or zoning Attention: able to follow task to completion (spell WORLD fwd & bwd…slower going backward is ok) Cooperation: does she get frustrated Patient (only) You are oriented to your name and where you are only Alert and oriented to person and place (times 2) You try to pay close attention (so you are alert) Intact alertness You attempt to spell WORLD fwd very slowly and lose the train of thought frequently Attention is moderately impaired You start off each task trying, then get a little frustrated w/ self & PT |
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Facial Asymmetry and Drooling
History: the 70 year old patient you were seeing for neck pain missed one week of PT and has returned to PT just getting over the flue. He is now complaining of a loss of hearing and you notice he drooled while drinking water from a cup. You decide to check his Cranial nerves to see if anything is really wrong or if he is just tired. TASK Find out if he might have something wrong with his hearing and mouth control Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Test hearing (bone and air conduction) Sensory testing to face (CN V) Motor testing of muscles of facial expression (CN VII) Test the muscles of mastication (CN V) |
TASK:Find out if he might have something wrong with his hearing and mouth control
Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Test hearing (bone and air conduction) Sensory testing to face (CN V) Motor testing of muscles of facial expression (CN VII) Test the muscles of mastication (CN V) Patient (only…patient is in the beginning stages of R sided Bells Palsy…CN VII paralysis…LMN injury) You have weak facial musculature on the Right only (you can’t smile evenly and you drool on that side only) Your bite is strong (CNV) Your face sensation is normal Your hearing is decreased on the right |
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Change in alertness and arousal for person in coma
History: patient has had a history severe head injury and is in a coma in ICU at your hospital. The nurse reports the patient had a rough night and is resting presently….you go in to check the patient and find there is a change in the patient’s level of (un) consciousness (it is worse) TASK Find out what levels the patient is at now Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved, non responsive) Response to voice Do they turn towards you and open their eyes (pt did respond previously) Sensory….Response to painful stimuli Sternal rub or pinch under arm (grimace response …CN VII) Cranial nerves (all CN responded previously)) Blink to threat (CN II), Pupillary response to light (CN II, III), gag reflex Posturing (no posturing noted prior) |
TASK
Find out what levels the patient is at now Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved, non responsive) Response to voice Do they turn towards you and open their eyes (pt did respond previously) Sensory….Response to painful stimuli Sternal rub or pinch under arm (grimace response …CN VII) Cranial nerves (all CN responded previously)) Blink to threat (CN II), Pupillary response to light (CN II, III), gag reflex Posturing (no posturing noted prior) Patient (only) Your coma has worsened (the nurse thinks you are just resting well) You do not respond to voice You do not respond to painful stimulus You have dolls eyes You have slight decorticate posturing (UEs are bent at elbows, tight and resting at level of umbilicus) Pupils are not responding, you do have a gag reflex (just have consultant tell them this) |
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Decreased coordination and gait ability
History: patient is similar to Kristen with a Hx of head injury TASK Find out what deficits she has in UEs and LEs Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Sensory testing Sharp and dull of UE and LE is intact Test Proprioception and Kinesthesia of UE and LEs Strength (she is strong…you don’t need to test) Coordination of UE and LE Finger tap, rapid alternating movements, over shoot, finger to nose Balance |
History: patient is similar to Kristen with a Hx of head injury
TASK Find out what deficits she has in UEs and LEs Tests and measures Decide how involved the patient is for each (report… intact, min, moderate or maximally involved) Sensory testing Sharp and dull of UE and LE is intact Test Proprioception and Kinesthesia of UE and LEs Strength (she is strong…you don’t need to test) Coordination of UE and LE Finger tap, rapid alternating movements, over shoot, finger to nose Balance Patient (only) You can send email and text with your UEs…they are fine Rapid alternating activities are intact Your LE coordination in moderately involved Heel to shin is all over the place and you need to use vision Foot tapping is slow and difficult without vision to help Your sitting is intact Your standing static and dynamic balance is moderately impaired in double limb support You can not maintain single limb support on either side |
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Undetermined diagnosis
You are treating your patient for TMJ pain. You have not seen the in 2 weeks because they were sick last week. The patient reports they have fallen 2 times this past week since they have seen you last. What questions do you ask about their falls? After you receive the information about their falls what tests and measures would your like to perform? |
You are treating your patient for TMJ pain. The patient reports they have fallen 2 times this past week since they have seen you last.
What questions do you ask about their falls? After you receive the information about their falls what tests and measures would your like to perform? Patient only You are in the beginning stages of Gullian Barre (you don’t know this). You had the flu last week and you are still not feeling well You are not dizzy and your sensation is normal You are feeling continued weakness from the flu right side more than left You gait is slow and uncoordinated with slight hip hiking on the Right You are just not that coordinated do to loss in strength that you are not aware of You are experiencing moderate weakness in your Right ankle 3/5 and left ankle 4/5, the strength and your knee and hips is only 3+ to 4/5 You cannot complete a single leg stance due to lack of strength No UMN signs are present… the only LMN sign is weakness and slowed reflexes |
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Undetermined diagnosis
You are seeing your patient for an evaluation for dizziness and LOB that began 2 weeks ago after a hard time of “hayfever” (in flagstaff it is pine pollen time”. Your patient reports that they get dizzy rolling over in bed at night but the symptoms subside and then they can go back to sleep. You suspect BPPV and not CNS vestibular problem (why?) Do you start with a Dix Halpike or a horizonal roll test? What other testing do you complete? |
You are seeing your patient for an evaluation for dizziness and LOB that began 2 weeks ago after a hard time of “hayfever” (in flagstaff it is pine pollen time”. Your patient reports that they get dizzy rolling over in bed at night but the symptoms subside and then they can go back to sleep.
You suspect BPPV and not CNS vestibular problem (why?) Do you start with a Dix Halpike or a horizonal roll test? What other testing do you complete? Patient only (you have left horizontal canalathiasis) Negative Dix Hallpike Positive roll : Nystagmus lasting less than 30 secs to the left Negative occulomotor examination (tell the PT you refuse to do the head shake test “no way”) |
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Undetermined diagnosis
During the evaluation you find out that your new patient has balance problems (has fallen 4 times over the past year but 2 of the falls were close to a bout of pneumonia) and neck pain. Your patient has recently began using a walking stick due to complains of unsteady gait and clumbsiness. The patient has slight head forward and rounded shoulders posture with moderate bilateral shoulders elevation (looks stressed) What questions do you ask about the falls and dizziness? (other questions?) What test and measure do you want to perform? |
Patient: you have had multiple sclerosis for about 5 years and you don’t know it… you do not show Nystagmus or have dizziness (no signs of BPPV)
You have had progressing weakness of bilat LEs R > L You have had a weird visual blurriness following the pneumonia ( you have difficulty with smooth pursuit and saccads…if they test it) You have a Right slight foot drop 2+/5 ankle DF (your gait and balance is not good R>L and your coordination is bad… slight ataxic trunk) You have had bladder problems during the “pneumonia bout” (you were just sick and having an MS exacerbation…but did not know it) You have UMN signs in B Les, clonus on the R and hyperactive reflexes Bil |
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An estimated __% of the general population is affected by a vestibular disorder.
At least ___ of the overall United States population is affected by a balance or vestibular disorder sometime during their lives. Approximately __ out of every 1000 individuals consult their family physician each year with complaints of vertigo, dizziness, or imbalance; half the individuals over the age of __ will develop positional vertigo. Of all falls suffered by the elderly, __% are reported to be the result of vestibular problems. |
An estimated 20% of the general population is affected by a vestibular disorder.
At least half of the overall United States population is affected by a balance or vestibular disorder sometime during their lives. Approximately 15 out of every 1000 individuals consult their family physician each year with complaints of vertigo, dizziness, or imbalance; half the individuals over the age of 65 will develop positional vertigo. Of all falls suffered by the elderly, 50% are reported to be the result of vestibular problems. |
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In approximately __% of vestibular patients, the cause cannot be recognized.
Traditional vestibular function tests fail to establish a ____ that can account for a patient's symptoms in a reported 30% to 50% of cases. ____ problems may not be amenable to surgical treatment, and pharmacological treatment of these conditions with vestibular suppressants often retards the recovery process. Vestibular dysfunction is a prominent part of balance disorders, particularly in the elderly, and is a significant source of ______. |
In approximately 15% of vestibular patients, the cause cannot be recognized.
Traditional vestibular function tests fail to establish a localizing diagnosis that can account for a patient's symptoms in a reported 30% to 50% of cases. Inner ear problems may not be amenable to surgical treatment, and pharmacological treatment of these conditions with vestibular suppressants often retards the recovery process. Vestibular dysfunction is a prominent part of balance disorders, particularly in the elderly, and is a significant source of morbidity. |
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Causes of Dizziness
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Systemic
Diabetes Hypoglycemia Infection Medications (polypharmacy) Cardiovascular Hypotension Arrhythmias Multifactorial Postural impairments (cervical posture) Visual impairments Cognitive impairments Emotional /psychological Panic attacks/anxiety Hyperventilation symdrome Depression Social isolation, guilt Peripheral Dysfunction Benign paroxysmal Positional Vertigo Menieres Disease Vestibular Neuritis (unilateral/bilateral) Acoustic Neuroma Perilymph Fistula Central Dysfunction Migraine TBI CVA Cerebellar involvement Degeneration/Tumors Multiple Sclerosis |
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What are the three somatosensory inputs that our body uses (for balance)?
The peripheral vestibular system lies within which part of the ear? What kind of motion do the SCC’s sense? What kind of motion do the otoliths sense? What are the two otolith organs? |
What are the three somatosensory inputs that our body uses?
Vision, vestibular, proprioceptive The peripheral vestibular system lies within which part of the ear? Inner ear What kind of motion do the SCC’s sense? – angular velocity What kind of motion do the otoliths sense? – linear acceleration What are the two otolith organs? -utricle and saccule |
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Endolymphatic fluid moves in the same direction as head movement- true or false
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Endolymphatic fluid moves in the same direction as head movement- true or false
- false |
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This artery is the biggest supplier of the peripheral vestibular system-
What is the primary artery for the central processor of balance? |
This artery is the biggest supplier of the peripheral vestibular system- AICA
Anterior Inferior Cerebellar Artery (AICA): sole blood supply for peripheral vestibular system including ventrolateral cerebellum, lateral tegmentum of inferior 2/3 of pons. What is the primary artery for the central processor of balance? PICA Posterior Inferior Cerebellar Artery (PICA): supplies central vestibular system including inferior cerebellum, dorsolateral medulla which includes inferior vestibular nuclei complex |
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The vestibular nuclei are located in which area of the brain?
The VSR works at the spinal level of the neck to stabilize the head: true or false |
The vestibular nuclei are located in which area of the brain? pons
The VSR works at the spinal level of the neck to stabilize the head: true or false (false) |
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Vestibular nucleii
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Four “major” nuclei located in primarily in pons and extends to the medulla
superior- relays for VOR medial- relays for VOR, involved in VSR and coordinates head and eye movements that occur together lateral- primary nucleus for VSR descending- connected to all nuclei and cerebellum, but no primary outflow |
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What is the purpose of the VOR?
What is the pathway of the VOR from the peripheral vestibular system to the brain? |
What is the purpose of the VOR? -vestibular occular reflex- used to generate eye movement equal and opposite to head movement in order to maintain a fixed gaze.
What is the pathway of the VOR from the peripheral vestibular system to the brain? Vestibular nerve -> increased firing of Medial and superior vestibular nuclei and cerebellum -> MLF -> occulomotor nuclei and abducens nuclei |
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Match the three coplanar Semi Circular Canals.
If there is damage to the peripheral vestibular system, what structure of the body will assist in readjusting central vestibular processing if necessary? The peripheral vestibular system cannot repair after damage and that is the purpose of having the cerebellum as a secondary central processor if necessary- true/false-. |
Match the three coplanar SCC’s. Left Anterior/RightPosterior, LP,/RA, LH/RH
If there is damage to the peripheral vestibular system, what structure of the body will assist in readjusting central vestibular processing if necessary? cerebellum The peripheral vestibular system cannot repair after damage and that is the purpose of having the cerebellum as a secondary central processor if necessary- true/false- false. |
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Evaluation of the vestibular patient
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Subjective:
Current history, Past medical history, symptoms (onset, timing, duration), meds, injuries/falls, hearing/vision changes, imaging/testing, level of function (current/prior), subjective outcome measures: Dizziness Handicap Inventory) Blood pressure and screen for Orthostatic hypotension Screen of VBI Cervical Spine Assessment ROM, pain, reproduction of symptoms occulomotor exam Cerebellar tests Reflexes UMN/LMN signs Strength assessment Sensation and skin integrity Gait assessment Outcome measures Balance: CTSIB/SOT, Romberg, Berg, Dynamic Gait, Functional Gait, functional reach, ABC Other: dynamic visual acuity, motion sensitivity score |
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Occulomotor exam
components |
Occulomotor exam
Spontaneous nystagmus Occular ROM Smooth pursuit Gaze evoked nystagmus Saccades Convergence VOR (slow) Head thrust B VOR cancellation Head shake test |
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Vestibular testing (use ____ if available)
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Vestibular testing (use Frenzel lenses or infrared goggles if available)
Dix-Hallpike B Roll test/Horizontal test |
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Outcome measures for exam of vestibular patient
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Outcome measures
Balance: CTSIB/SOT, Romberg, Berg, Dynamic Gait, Functional Gait, functional reach, ABC Other: dynamic visual acuity, motion sensitivity score |
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Things to rule out FIRST with vestibular patient
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Vertebral Basilar Insufficiency (VBI)
Orthostatic hypotension (OH) |
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Vertebral Basilar Insufficiency (VBI) Test
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Vertebral Basilar Insufficiency (VBI) Test
Pt is interviewed to extract signs and symptoms If remarkable pt is referred out Prior to comprehensive clinical exam, the examiner performs end range cervical rotation to right and left in sitting or supine. Position held for 10 seconds with observation for symptoms of VBI If remarkable pt is referred for appropriate medical consult. Positive test: dizziness, diplopia, dysphasia, dysarthria, drop attacks, nausea, and nystagmus Recommendations: do not perform this test if you suspect VBI based on history as it can be dangerous. There are several variations of this test in the literature including cervical extension, rotation and extension, traction (all are most likely beneficial). Reference: Cook, Chad, Orthopedic Physical Examination Tests, pg 66, 2008 |
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Orthostatic Hypotension
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Definition: (postural hypotension) a form of low blood pressure that happens when you stand/sit up from sitting or lying down. OH can make you feel dizzy or lightheaded, and maybe even faint or fall
The decrease is usually around 20/10 mmHG Why is this important?: need to distinguish difference as symptoms are common to a majority of vestibular disorders. |
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Spontaneous nystagmus
Test: |
Spontaneous nystagmus
Test: patient instructed to sit looking straight ahead, without any head movement. Observe patients eyes Results: Normal: no nystagmus Abnormal: Observable nystagmus Peripheral: will be mainly horizontal, visual fixation decreases nystagmus Central: nystagmus in single plane, visual fixation does not change it or increases it |
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Occular ROM testing
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Occular ROM (screen for symmetry and normal function to check CN integrity Bilateral)
CN 3 Occulomotor: superior rectus: elevates the eye medial rectus: adducts the eye inferior rectus: depresses the eye inferior oblique: causes intorsion-clockwise rotation CN 4 Trochlear: superior oblique: pulls the eye down and in, extorsion, counterclockwise rotation CN 6 Abducens: lateral rectus: abducts the eye |
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Smooth pursuit
Test: |
Smooth pursuit
Test: patient instructed to hold their head stationary. Have the patient follow a slow moving object (finger or pen tip) horizontally and vertically 30 degrees to each direction. Repeat and make sure to not move your finger to fast Results: Normal: smooth conjugate eye movement Abnormal: saccadic (jerky) eye movements, may indicate a central origin |
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Gaze Evoked Nystagmus
Test: |
Gaze Evoked Nystagmus
Test: patient instructed to sit looking straight ahead, then asked to gaze left/right and hold each position ≈ 5-10 seconds while therapist observes for nystagmus. Repeat with up and down Results: Normal: no nystagmus Abnormal: Observable nystagmus Peripheral: nystagmus will increase with gaze toward the direction of quick phase Central: nystagmus either does not change or reverses direction with change of gaze, c/o diplopia, inability to hold http://www.youtube.com/watch?v=mghGeKkNBzQ&feature=related |
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Saccades
Test: |
Saccades
Test: patient instructed to hold head stationary. Therapist holds finger or pen about 15 degrees to one side of nose. Ask the patient to look from finger <> nose horizontally and vertically. Repeat 3-4 times Results: Normal: smooth conjugate eye movements from one target to the other. Eyes move to target in 1 movement Abnormal: Saccadic (jerky) eye movements. Eyes demonstrate undershoot/overshoots and take more than 1-2 movements to get to target. Indicates CNS involvement. http://www.youtube.com/watch?v=gqCgzSSwPLk |
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Convergence test
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Convergence (CN lll)
Patient instructed to hold head stationary. Therapist holds finger or pen approximately 15- 20 inches from patients face and slowly brings object close to patients eyes (3-4 inches from nose) observing for convergence and ability to focus on object. Results: Normal: eyes converge and diverge appropriately focusing on object Abnormal: patient is unable to maintain focus on object because 1 or both eyes cannot perform appropriate movements. May indicate a central problem. |
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VOR (slow)
Test: |
VOR (slow)
Test: Grasp the patients head firmly and tilt forward 30 degrees to align the horizontal SCC’s level. Instruct the patient to maintain gaze on your nose as you rotate their head slowly side to side (30 degrees in each direction). Look for ability to maintain gaze on your nose as well as smoothness of motion or pt c/o bluriness. Results: Normal: gaze is maintained throughout without any reports of symptoms (dizziness, blurred/double vision) Abnormal: inability to maintain gaze, corrective saccade to re-fixate on target. May indicate PNS or CNS vestibular disorder |
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Head thrust test
Test: |
Head thrust test
Test: hold the patients head as in VOR testing. After moving the head slowly side to side, instruct patient that you will be moving their head quickly and to keep looking at your nose. Quickly move head in a small range (5-10 degrees). Perform on other side. Results: Normal: gaze maintained fixed on target Abnormal: corrective saccade to re-fixate on target, indicating a peripheral disorder. Lateralizes ear of hypofunction is the direction the head is turning with abnormal response * Keep element of surprise so patient does not anticipate movement *Use extreme caution or defer test in there is cervical limitations/+VBI http://www.youtube.com/watch?v=j_R0LcPnZ_w&feature=related |
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VOR cancellation
Test: |
VOR cancellation
Test: performed exactly as slow VOR test with exception that now therapist is moving their body at the same time and pace as patients to keep their face directly in front of patient. Results: Normal: gaze maintained with eyes/head in phase with moving target Abnormal: saccadic movements or inability to maintain gaze- indicates a possible central problem |
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Head shake test
Test: |
Head shake test
Test: this test is performed with either Frenzels lenses or infrared goggles (fixation blocked). Grasp patients head firmly and tilt forward 30 degrees. Have patient close their eyes while you move their head side to side 20x. Quickly have patient open their eyes and observe for nystagmus Results: Normal < 3 beats of nystagmus Abnormal: > 3 beats of nystagmus. Nystagmus in 1 direction will indicate a peripheral disorder. Direction changing nystagmus or down/up beating nystagmus indicates central origin. http://www.youtube.com/watch?v=MUxMwtct620 |
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Dynamic Visual Acuity Test (DVA)
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Static vision vs vision with head oscillation at 2 hz
Can use EDTRS chart/Snellen or neurocom + test = > 2-3 line differential Suggests: vestibular imbalance |
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Outcome Measures
ABC DHI MSQ |
ABC
< 80% correlated with reduced activity 67% associated with increased fall risk DHI Self perceived dizziness (has categories of functional, emotional and physical impact). Good content and criterion validity and high internal consistency. Good test-re-test reliability. Significant improvement is 18 points MSQ Abbott: 0-10% = mild; 11-30% = moderate; 31-100% = severe Improvement indicated by: Decreased number of provoking positions Increased number of reps before symptom occurrence Decreased intensity of symptoms Shorter duration of symptoms |
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When do you refer out a patient? (with vestibular issues)
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When you are not comfortable treating a patient based on your clinical skill level
When there are signs or symptoms that are not consistent with any patterns of vestibular diagnosis When you suspect central origin When you have part of picture, but may require additional testing of audiologist to determine need for further skilled PT or further determine diagnosis |
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Audiologic tests
Videonystagmography (VNG) |
Videonystagmography (VNG)
a series of 4 tests used to determine the causes of a patient's dizziness or balance disorders, specifically looking at the inner ear. May be able to determine both a unilateral or bilateral hypofunction. Saccade test: evaluates rapid eye movements Tracking test :evaluates movement of the eyes as they follow a visual target Positional test: measures dizziness associated with positions of the head Caloric test: measures CN Vlll response to warm and cold water circulated through the ear canal. The infrared cameras record the eye movements and display then on a video/computer screen. This allows the examiner to measure nystagmus directly. |
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Peripheral vestibular disorders
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Benign Paroxysmal Positional Vertigo (BPPV)
Meniere’s Disease Vestibular neuritis Vestibular labyrnthitis Ototoxicity Acoustic neuroma Perilymphatic fistula |
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BPPV
symptoms and signs |
Symptoms:
Sudden onset of short duration Vertigo < 60 secs with position changes + DHI + ABC scale Complaints of disequilibrium Possible functional limitations Signs: + positional test such as Dix-Hallpike or Roll/horizontal test Nystagmus + DGI/FGA or Berg Abnormal CTSIB/SOT |
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Meniere's Disease
Definition Symptoms Signs |
Increased amount of endolymph in the inner ear due to malabsorption
Attacks can last 20mins to 24 hours and occur in frequency from days to years Initially recovery occurs after attacks Pt is symptoms free between attacks Over time permanent damage occurs to vestibular and cochlear organs Hearing usually worsens over 5-7 years Symptoms: Episodic flares Ear fullness Tinnitus Vertigo Nausea Anxiety Motion sensitivity Vision disturbance Imbalance Functional limitations Signs: During Attack Hearing loss + Head thrust test + Caloric test > 2 lines DVA test + DGI/FGA/Berg |
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Neuritis/Labyrinthitis
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Infection of the inner ear resulting in inflammation
Caused by either bacterial, viral or vascular Neuritis: effects CN Vlll (vestibular branch only) Labyrnthitis: effects both branches of CN Vlll resulting in impaired or absent hearing Symptoms range from no permanent damage to permanent hearing loss or damage to vestibular system |
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Neuritis/Labyrinthitis
Symptoms and Signs |
Symptoms:
Acutely < 3 days Nausea/vomiting Vertigo Signs: Acute < 3 days Nystagmus (horizontal, gaze evoked + head thrust test + caloric test + DVA > 3 days + head thrust test + calorics Impaired DGI +DVA > 3 days Disequilibrium (worse with movement) Impaired concentration Difficulty with vision Tinnitus/hearing loss (labyrinthitis) Functional limitations |
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Ototoxicity
(Bilateral Vestibular Neuritis) |
Can result in temporary or permanent loss of hearing, balance or both
Exacerbated by head movements due to absent VOR Causes include Antibiotics: “mycin”drugs (gentamicin, streptomycin, kanamycin, tobramycin, neomycin…etc) Anti-neoplastics Environmental chemicals Diuretics Ideopathic (age related or familial) meningitis |
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Ototoxicity
(Bilateral Vestibular Neuritis) Symptoms and Signs |
Symptoms
Severe disequilibrium Oscillopsia (visual disturbance in which objects appear to oscillate) Falls ++ DHI + ABC Functional limitations Signs: + Head thrust test bilaterally > 2 lines DVA Impaired DGI/FGA/Berg |
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Acoustic Neuroma
aka. |
Acoustic Neuroma
Also called vestibular schwannoma, acoustic neurinoma, or neurilemmoma A nonmalignant and usually slow-growing tumor caused by an overproduction of Schwann cells which develop on CN Vlll Rare: only about 2500–3000 new cases are diagnosed in the United States each year Symptoms may develop in individuals at any age, but usually occur between the ages of 30 and 60 years Different degrees of vestibular loss, until tumor removed, then complete vestibular loss |
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Acoustic Neuroma
S/S |
Symptoms:
Dizziness Disequilibrium Unilateral hearing loss Tinnitus Functional limitations Signs: + CN tests (5- facial sensory loss, 7- facial weakness or paralysis) + hearing tests (ABR, BAER, or BSER) + MRI or CT scan |
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Perilymphatic Fistula
Definition Symptoms Signs |
Definition
A tear or defect in the oval window and/or the round window, the small, thin membranes that separate the middle ear from the fluid-filled inner ear Changes the pressure in the middle ear Commonly caused by head trauma or from rapid or profound changes in intracranial or atmospheric pressure such as after Scuba diving, airplane rides, weightlifting, or childbirth Positive diagnosis is confirmed by tympanotomy (operation) Symptoms Dizziness Vertigo Imbalance Nausea Vomiting Tinnitus Fullness/pressure in the ear Signs Hearing loss |
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Single most common cause of dizziness encountered in clinic is...
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BPPV
Single most common cause of dizziness encountered in clinic May account for 20-30% of the patients Incidence in general population 64 / 100,000 50% of individuals over the age of 65 with dizziness |
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Most common cause of BPPV in people under age 50 is
In older people most common cause is Occasionally BPPV follows __% of BPPV idiopathic |
Most common cause of BPPV in people under age 50 is head injury
Direct trauma Whiplash (Dispenza et al, 2011) Migraine (Ishiyama et al, 2000). In older people most common cause is degeneration of the vestibular system of the inner ear. Viruses such as those causing vestibular neuritis and Meniere’s disease Occasionally BPPV follows surgery Dental work Combined prolonged supine position and ear trauma when the surgery is to the inner ear (Atacan et al 2001). Rarely encountered in persons who have been treated with ototoxic medications gentamicin (Black et al, 2004 50% of BPPV idiopathic |
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*______ is no longer a bundled code with NMR and has its own CPT code 95992
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*Canalith repositioining is no longer a bundled code with NMR and has its own CPT code 95992
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Classical Characteristic Symptoms of BPPV
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Brief (typically < 1 minute) episodes of vertigo
associated with changes in head position relative to gravity History: Lying down or rising from horizontal orientation Rolling over in bed Bending over Looking up |
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Dix Hall Pike Test
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A. 45 deg cervical rotation
B. Sit to supine w/ 20 deg cervical extension Look for: Latency Direction of nystagmus: will indicate the involved canal Duration Fatigue Typically: Latency (1-30 seconds) Direction of nystagmus: up beating torsional nystagmus) Duration (<2 min) Fatigue (with repeated testing) |
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To assess R posterior and R anterior canal BPPV
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Dix hall pike with head turned to right
Turn head to left to assess L posterior and L anterior canal BPPV (I guess you can tell whether it's anterior or posterior based on direction of beat?) |
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Clinically what is the difference between canalithiasis and cupulolithiasis?
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Cupulolithiasis: otoconia adhere to the cupula
Symptoms: persistent nystagmus > 1 min Canalithiasis: Otoconia are freely mobile in canal and fall to the lowest point in the canal, induces flow of endolymph and deflection of the cupula Symptoms: nystagmus < 1 min |
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Stimulation of one posterior canal causes
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Stimulation of one posterior canal causes a mixed vertical & torsional nystagmus
Fast component (beat) Rt side – up beating, right torsional nystagmus Lt side – up beating, left torsional nystagmus |
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Case example: Up-beating, left torsional nystagmus of short duration
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Case example: Up-beating, left torsional nystagmus of short duration
Answer: left, posterior canal BPPV (canalithiasis) http://youtu.be/cZlXvRlxrRE http://youtu.be/R5aM5iOc0lc canalithiasis is < 1 min duration |
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Treatment options for BPPV
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Brandt-Daroff Exercise- HEP
Epley Maneuver- indicated for canalithiasis canalith repositioning exercise Semont Maneuver- indicated for cupulolithiasis Libratory or Brisk Maneuver Pts may experience associated imbalance & gait ataxia Generally resolve with successful treatment of the BPPV If not: balance and gait exercises are indicated |
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Brandt-Daroff Exercise
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Home method of treating BPPV, usually used when the side of BPPV is unclear.
These exercises are performed in three sets per day for two weeks. In each set, one performs the maneuver as shown five times. Start in an upright, seated position. Move into the lying position on one side with your nose pointed up at about a 45-degree angle. Remain in this position for about 30 seconds (or until the vertigo subsides, whichever is longer), then move back to the seated position. Repeat on the other side. How Well It Works Relieves 3 to 14 days for almost all people What To Think About Use caution if cervical injuries are involved This exercise may cause vertigo and nausea and vomiting. This can discourage people from continuing the exercise. |
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Epley Maneuver
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Instructions:
Turn head to affected side Tilt head back 20 degrees Transition from sitting upright to supine Hold each of the following positions for 30 seconds after symptoms stop Turn head to the opposite side Have pt roll to side (head should not change position) Have pt sit upright |
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Sermont Maneuver
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Designed to treat cupulolithiasis
Will work for canalithiasisas well Begin with head position analogous to Dix Hall Pike in sidelying (looking up) Hold for 1-2 minutes Change to opposite sidelying with head in same position (looking down) Hold for 1-2 minutes Outcomes: 80-90% success in one treatment session |
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Conservative post treatment instructions:
(for BPPV) |
Conservative post treatment instructions:
avoid laying on affected side for 24 hours. Wear cervical for 48 hours Sleep at 45 degree angle Generally not necessary? |
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Posterior canal treatment effectiveness
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In general have an 80% - 90% success rate with one treatment session
If subsequent treatments are required, the success rate improves even more Brandt-Daroff Initial study 66 of 67 patients w/ BPPV had an alleviation of the signs and symptoms of BPPV w/in 3 – 14 days of Epley Maneuver (Semont) |
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AC – Canalithiasis
Diagnosis and treatment |
Anterior Canal
Diagnosis Dix hall Pike: down beating torsional nystagmus lasting less than 60 sec Treatment Canalith Repositioning Maneuver http://youtu.be/UDfhT3Safj4 |
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AC – Cupulolithiasis
Diagnosis and treatment |
Diagnosis
Dix hall Pike: down beating torsional nystagmus lasting greater than 60 sec Treatment Liberatory maneuver modified for anterior canal Move in the plane of the affected canal start on involved side, head rotated to that side |
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Horizontal canal issues
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Canalithiasis (most common)
Geotrophic- Nystagmus beats towards ground Side affected is the one with worse symptoms Pneumonic device: “up with the cup” Cupulolithiasis Ageotropic Nystagmus beats away from the ground Side affected is the one with lesser symptoms |
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Horizontal canal testing
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Roll Test:
Neck flexed 20-30 degrees throughout Gentle brist rotation to each side look for Nystagmus (horizontal) |
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Horizontal canal treatments
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Canalithiasis
Modified CRM for HC Start with head rotated 90 deg to the affected side 270 – 360 deg roll away from the affected side Canalith Repositioning Maneuver for the Left Horizontal Canal Start supine with head turned to left Supine head facing ceiling Roll body and neck facing right Roll body and head facing down Then sit up somehow Cupulolithiasis Modified Brandt Daroff exercise: no cervical rotation or supine – cervical rotation |
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Log roll treatment for Right horizontal canalithiasis.
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Log roll treatment for Right horizontal canalithiasis.
Hold each position for duration of symptoms plus 30-60 seconds. Start sidelying with bad ear down, roll to supine, roll to other side (bad ear up), hands and knees with head tilted down |
