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Vestibular assessment from the physiotherapy perspective
This document discusses vestibular assessment from a physiotherapy perspective. It begins with anatomy of the extraocular eye muscles and semicircular canals. Vestibular dysfunction can cause vertigo and imbalance, and the cause may be central or peripheral. A subjective history focuses on symptoms, tempo, and circumstances. Objective assessment includes eye movement testing, cerebellar tests, Rhomberg testing, and gait observation. Specific tests like Dix-Hallpike and roll tests evaluate the semicircular canals. Differential diagnoses and treatments like canalith repositioning maneuvers are also reviewed.
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Vestibular assessment from the physiotherapy perspective
- 1. Vestibular Assessment from thePhysiotherapy Perspective Bronwyn Kaiser A.Physiotherapy Coordinator SCGH Care Coordination Team
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- 4. Anatomy: Extra Occular EyeMuscles Muscle Medial Rectus Lateral Rectus Superior Rectus Inferior Oblique Inferior Rectus Superior Oblique CN Pairing Semicircular Canal SCC dyfunction III } Horizontal Abnormal M/L mvt } Posterior vertical + torsional mvt } Anterior vertical + torsional mvt VI III III III IV - Pairing of SCC - SCC paired with 2 Muscles
- 5. Vestibular dysfunction • Vertigoand imbalance – Diagnosis needs to determine central (cerebellum) vs peripheral (labyrinth and semicircular canals of the inner ear) cause – Multiple peripheral causes (not just BPPV)
- 6. Subjective questioning Headache Migraine Head injury Tinnitus HearingLoss Aural fullness Pain Visual changes (blurred/double) Photophobia Recent URTI/LRTI Sinus pain
- 7. Subjective • Symptoms – “dizzy” –vertigo, light headed, faint, drop attacks, nausea, auditory/visual disturbances • Tempo – latency – Duration – episodic • Circumstance – When – Where – Easing factors
- 8. Objective Eyes Assessment • • • • • EyeROM Gaze Stability Saccade Testing Smooth Pursuit Vestibular Ocular Reflex – Screen – Head Thrust – Dynamic Visual Actuity
- 9. Take Home Message Occularmotor testing See something that isn’t suspected – likely to have a central origin. – Exceptions: Non-direction changing gaze evoked nystagmus + ve Head thrust Regardless, +ve to any occulomotor test should to be referred on for Medical (ENT/ neuro) opinion
- 10. Objective Tests • Cerebellartests – Dysdiadokinesia, finger-nose, heel-shin • Rhomberg test – FTEO vs FTEC • Sharpened Rhomberg – Feet in front of each other EO vs EC • Gait – Heel-toe walk
- 11. Objective Tests –Semicircular canals • Dix-Hallpike – anterior and posterior canal – Contra-indications • MSc: disc prolapse, cervical injury/fracture/trauma • Neuro: cervical myelopathy/radiculopathy • Vascular: dissection carotid/vertebral artery – Caution • Cardiac surgery within 3/12 • Severe orthopnoea • Severe back pain
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- 13. Objective tests –horizontal canal • Horizontal roll test
- 14. Differential Diagnoses BPPV Tempo Symptoms Circumstance episodic,<1min Vertigo, N&V headchanges relative to Gravity VBI episodic,<1min Vertigo, N&V, dipolpia, blurred vision, drop attack EOR E/rotation Postural Hypotension episodic Faint, dizzy Vestibular labrythitis crisis, constant for Vertigo, N&V, hearing loss, <4 days dysequilibruim constant, exacerbated with movement, visual disturbance Vestibular neuritis crisis, constant for Vertigo, N&V, No hearing loss, <4 days dysequilibruim constant, exacerbated with movement, visual disturbance Menieres episodic, 20min to Vertigo, N&V, hearing loss, tinnitus, 24 hours fullness in ear spontaneous and episodic CVA constant Migrane spells for minutes Vertigo, motion sensitivity, dizziness spontaneous or motion provoked Gentamycin Toxicity constant post 1 Dose getting up Vertigo, N&V, OTHER NEURO SIGNS constant Vertigo, dysequilibruim,
- 15. Treatments • Post/ant canalBPPV – Epley manoeuvre – Semont Liberatory manoeuvre/ modified Semont • Horizontal canal BPPV – BBQ roll / Appiani manoeuvre – Cassani manoeuvre • Gaze stabilization exercises • Substitution exercises • Habituation exercises
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- 22. POST TREATMENT • PostTreatment Instructions THERE ARE NONE! • Re-Assessment - you can reassess 10 minutes after treatment if the patient is overly symptomatic - treat again if necessary - review as appropriate for your clinical area not
- 23. CONTRAINDICATIONS & RED FLAGS •CONTRAINDICATIONS: neck surgery, recent neck trauma, severe RA, atlantoaxial + occipitoatlantal instability, Cx myelopathy or radicaulopathy, carotid sinus syncope, Chiari malformation or vascular dissection syndromes. • RED FLAGS: - direction changing nystagmus - tinnitus - hearing loss - aural fullness - additional neurological S+S - failure to respond to conservative Rx ***REFER ON to ENT or Neurologist
Editor's Notes
- #5 Paired SCC in planes – coplanar Association between extra occular eye muscles and vestibular appartus important
- #8 This is like telling you to suck eggs. Subjective – as important as Dx any other conplaint – shoudler etc . . . . Guides your objective. 3 domains – hammer out Symptoms tempo Circumstances