Cervical ROM and VBI - Vertebrobasilar Insufficiency
- Used to determine any ROM deficits, to look for limitations in further tests
- Used to determine if any 3N’s or 5D’s
5 Ds (dizziness, diplopia [double vision], dysarthria, dysphagia [difficulty swallowing], drop attacks)
3 Ns (nystagmus, nausea/vomiting, numbness) - If any positives come out of this test avoid any test involving EOR neck positions. Send for MRA or Carotid Doppler US
Instructions :
- Patient seated gets to move to EOR and hold for 10secs
- Return to centre and hold for 10
- Repeat to the opposite side
- Hold if pat can’t
Spontaneous and Gaze Evoked Nystagmus
Nystagmus is an Involuntary rhythmic oscillation of the eyes (jerk nystagmus). Can be a fast phase or slow phase
Spontaneous nystagmus
- used to see if there is noticeable nystagmus in the central/neutral position
Instructions:
1. So I want you to keep your head still and just look at the pen.
2. Observe for any nystagmus
Gaze Evoked nystagmus
- used to see if there is noticeable nystagmus in the 30deg position. Helps to determine the direction and degree of nystagmus
Instructions:
1. So I want you to keep your head still and just look at the pen.
2. Observe for any nystagmus in central for 10-30 seconds dependent on if happy to
progress
3. Move to left, observe, right, observe, up, observe, down.
Document:
- Left beating nystagmus, drifts to the right and quick beat back to the left
- Right beating nystagmus, drifts to the left and quick beat back to the right
- The opposite direction to nystagmus normally indicates hypofunction, ie left beating has right hypofunction
- Should follow Alexander’s Law (nystagmus intensity increases with gaze in the direction of the fast phase i.e., right beat nystagmus increases with right gaze)
- E.g. second degree right beat nystagmus (present in center and increased on right
gaze) 3rd degree would bee all directions. 1st degree would to the beat side ie right beat nystagmus to the right gaze
Ocular ROM including convergence
Ocular ROM:
- Used to test all visual fields
Ocular ROM instructions:
1. Target 40cm away from target, must be clear
2. Keeping the head still I want you to follow the tip of my pen
3. Following an H shape back to center
4. looking for eyes steady moving and nystagmus/restrictions in movement
Convergence component Instructions:
1. Hold target at nose level, arm’s length away.
2. Focus on the target as you move it toward your nose. Handy to have a target with a line on it to easily be able to tell if doubled vision
3. I want you to look at the tip of the pen, I want you to let me know if you see double to any point, it might go blurry or might not even go double but just tell me if it does
4. Stop when the target turns double.
5. Measure the distance from nose to target.
6. Repeat 2-3 times.
Indications:
- seeing double >10cm is abnormal
- Range – full or reduced
- Conjugate eye movement - smooth or Jerk/saccadic
- bottom of H can indicate Trochlea Palsy
Smooth Pursuit
- Cannot be done with fixation removed
- Aim: to see how well the eyes smoothly follow the target in a vertical and horizontal plane
Instructions: - Instruct patient to keep head still and follow the object with their eyes
- Move pen slowly 30 deg side to side
- Repeat 2 times along plane
- Repeat on vertical plan
- Aim: to see how well the eyes smoothly follow the target in a vertical and horizontal plane
Document:
- Is eye movement smooth and conjugate?
- Normal = Smooth, conjugate, can have a slightly saccadic pursuit in elderly, particularly through the midline
Central = significantly saccadic smooth pursuit (brainstem or cerebellum)
Saccades Testing
- Aim: test coordination of the eyes. How quickly is the move initiated and is the movement direction, overshooting and undershooting the target
Instructions:- Head still or can hold the chin
- Instruct you to look quickly between the target and your nose when I instruct you to
- Target between 15-30 deg from the midline
- Repeat moving the target around in both the horizontal and vertical plane
I want you to change between looking at the pen and my nose and moving on my command. When I say pen – look at my pen, when I say nose – look at my nose - Move-in H shape again, If the patient predicts movement recorrect and say only move when I say
Document:
- Speed: normal or slow (midbrain or pons issue)
- Accuracy: dysmetric (undershoot or overshoot)
○ Hypometric (small = WNL), large = midbrain or pons issue
○ Hypermetric = always an abnormal, likely cerebellar issue
Latency: 10-20msec latency is normal, very latent =? Central vs. cognition/distraction
Test of Skew
- Aim: To determine any vertical and/or diagonal corrective movement
Instructions:- Ask patient to keep head still
- Instruct to look at the target – ie Nose
- Keeping your eyes fully open, Using a black card fully cover one eye then remove and move straight to the other eye
- Repeat 5x each side
Document: - Looking for vertical displacement
- Positive = Move eye will move up or down when uncovered ie central pathology/dysfunction
- Eye will drift and recorrect
Eyes may move to deviate laterally when covered and correct back to midline - not a peripheral dysfunction
VOR - Vestibulo-Ocular Reflex Testing
- Head Impulse Test (HIT)
- DVA test - Dynamic Visual Acuity
Head impulse Test
- Only test that localises the side of pathology
- Aim: to help differentiate between L or R or Bilateral peripheral lesion
Instructions: - Patient is seated on the side of the plinth
- Both pats eyes stay fixed on target, requiring correction is abnormal
- Look at my physios nose
- Start with slow movement – move to quick impulses that are unpredictable
- Move their head from left to right impulses
- Security can help by supporting more with hands
I’m going to slowly move your head to the left and right. If that’s fine, we are going to get quicker. The main point is we want it to be a surprise so you won’t know which direction I move you.
- Aim: to help differentiate between L or R or Bilateral peripheral lesion
Document:
- Patients’ ability to maintain visual fixation
- Any requirement of saccades for refixation on nose/target, not the direction of fixing
○ Ie if left head impulse requires fixation then a left side peripheral lesion
- Tests: Horizontal SSC
- >2 lines = oscillopsia
>3 lines = vestibular hypofunction
Dynamic Visual Acuity (DVA)
- Aim: Functional test of Vestibulo-Ocular Reflex that looks at the function of VOR in day-to-day life
- ETDRS eye chart – 1.2m away but if pat can read, move back chair
- Norm is 1-2 lines between the static reading of the eye chart and the dynamic requirement
Instructions: - Keeping your head still I want you to read down the lines as far down as you can go
- Try and get them to read the next line
- Count the number of lines to the first line of error
- Now what we are going to be doing is completing the test again however I am going to be turning your head whilst you read. Does that sound ok? We are going to stop the test when you make an error or your symptoms get too bad. So let me know if you feel dizzy or nauseous at all. We will also stop if you are too slow in-between letters.
- Head tilting is done at a rate of 2hertz, so 2 cycles per second. We can use a metronome or app to help
Document: - Read out loud = static line 12
- Moving head and getting to read. Head movement at 2 cycles per second, metronome = dynamic line 7
Measure of the chair from the wall and see improvement
BBPV Testing
- Hallpike Dix Test (PSC/ASC)
- Side-lying Test (PSC/ASC)
- Head Roll Test
Hallpike Dix Test (ASC/PSC)
- Aim: To determine if BPPV. torsional nystagmus occurs, and then the test is considered positive for BPPV.
- Tests: It is a test of the peripheral vestibular system and looks for the presence of otoconia in the semicircular canals.
Technique - Patient sits with their head turned 45 degrees toward the test side
- Moves quickly backward to head extended 30 degrees and hold at least 1 minute
- Maintain head rotation and return to sitting
- Ensure you keep your hands on the patient as can feel dizzy or lightheaded on return to sitting
Interpretation - PSC = upbeat + ipsitorsional nystagmus
- ASC = downbeat + ipsitorsional nystagmus
- Can get a reversal of nystagmus and symptoms on return to sitting
- Canalithiasis = latency + nystagmus & symptoms < 1 min + crescendo
- Cupulolithiasis = immediate onset + nystagmus & symptoms > 1-2 min
Posterior Canal - Head turn to the Left side = looking for a left upbeat torsional nystagmus
- Head turn to the Right side = Right torsional upbeat nystagmus
Anterior Canal - Head turn to the Left side = looking for a left downbeat torsional nystagmus
- Head turn to the Right side = Right torsional downbeat nystagmus
Less noticeable due to the orientation of canals
- Tests: It is a test of the peripheral vestibular system and looks for the presence of otoconia in the semicircular canals.
Side-lying Test (PSC/ASC)
- Can be used as an alternative to Hallpike Dix test if
○ Unable to tolerate cervical ext
○ Anxious
○ LBP - Aim: To determine if BPPV. torsional nystagmus occurs, and then the test is considered positive for BPPV.
- Tests: It is a test of the peripheral vestibular system and looks for the presence of otoconia in the semicircular canals.
Technique
- Patient sits on edge of bed with head turned 45 degrees away from test side
- Moves quickly to lie on their test side shoulder looking up at the ceiling – part of the head you are testing should be in contact with the bed
- Hold position for 1 minute
- Maintaining head pos, assist pat back up.
○ Observe nystagmus on return to sit
○ Ensure keep hands on pat as can feel dizzy or lightheaded on return to sitting
Posterior Canal - Head turn to the Left side = looking for a left upbeat torsional nystagmus - Head turn to the Right side = Right torsional upbeat nystagmus Anterior Canal - Head turn to the Left side = looking for a left downbeat torsional nystagmus - Head turn to the Right side = Right torsional downbeat nystagmus - Less noticeable due to orientation of canals
Side-lying Test (PSC/ASC)
- Can be used as an alternative to Hallpike Dix test if
○ Unable to tolerate cervical ext
○ Anxious
○ LBP
Technique- Patient sits on edge of bed with head turned 45 degrees away from test side
- Moves quickly to lie on their test side shoulder looking up at the ceiling – part of the head you are testing should be in contact with the bed
- Hold position for 1 minute
- Maintaining head pos, assist pat back up.
○ Observe nystagmus on return to sit
○ Ensure keep hands on pat as can feel dizzy or lightheaded on return to sitting
- Head turn to the Left side = looking for a left upbeat torsional nystagmus
- Head turn to the Right side = Right torsional upbeat nystagmus
Anterior Canal
- Head turn to the Left side = looking for a left downbeat torsional nystagmus
- Head turn to the Right side = Right torsional downbeat nystagmus
- Less noticeable due to orientation of canals
Head Roll Test
Aim: Determine presence of Horizontal BPPV
The side the patient lies on that elicits the most intense nystagmus is the affected side.
Technique:
- Patient lies in supine with head flexed to 20 degrees (use pillow)
- Turn head quickly to 90 degrees rotation and hold
- Observe for nystagmus and symptoms – ask for rating of intensity
- Roll back to neutral and wait for all symptoms to completely subside
- Repeat on other side
- HSC Canalithiasis = transient geotropic nystagmus (i.e., left head roll, nystagmus should beat down to ground = toward left ear as left ear down) - HSC Cupulolithiasis = sustained ageotropic nystagmus (i.e., left head roll, nystagmus should beat away from ground = toward right ear, as right ear up). ○ Geotropic = toward the ground/earth ○ Ageotropic = away from the ground/earth § ** if HSC BPPV should have nystagmus on head roll to both sides - Cupulolithiasis = Ageotropic, Canalithiasis = Geotropic - Cupulolithiasis = worse to unaffected side, Canalithiasis = worse to affected side - Hint: Up is Cup is Least (ageotropic is Cupulolithiasis, least symptomatic side = affected side - Ie down beating on both sides = Canalithiasis right side is most symotomatic = Affected side Diagnosis = Right horizontal Canalithiasis
Treatments/Repositioning for BPPV
Must complete Cervical ROM and VBI testing prior to any BPPV Assessment or Treatment
** Hands on patient at all times, particularly on completion of the technique **
Canalith Repositioning Manoeuvres (CRM)
1. Modified Epley (PSC + ASC)
2. BBQ Roll (HSC)
- Hold each position for double the duration of nystagmus and symptoms (between 30secs and 2mins) - Position of head is more important that speed CRM – treats the Canalithiasis BPPV. Otoconia are freely moving, we want to flush them out
Liberatory Manoeuvres for Cupulolithiasis BPPV
1. Semont (PSC)
2. Modified Semont (ASC)
3. Gufoni for Ageo (HSC)
- Speed is key - otherwise otoconia will not dislodge
- General rule is to hold each position for about 2 minutes
Modified Epley (PSC + ASC)
- For posterior and anterior semicircular canalithiasis
Treatment:- Patient sits upright on bed in long sitting. Rotate head 45 degrees toward affected side
- Lie back until supine with neck extended 30 degrees and hold 2x symptoms
- Rotate head 90 degrees toward other side, maintaining neck extension and hold 2x symptoms
- Roll onto their unaffected side so they are looking down toward the ground and hold 2x symptoms
- Slowly sit up, maintaining head down (sniff nose to armpit)
- Slowly bring head to center, avoid looking up
Remaining with hands on ensure all symptoms go away and don’t go into next ext as may worsen symptoms
BBQ Roll (HSC)
- For Horizontal semicircular canalithiasis
Treatment:- Patient supine with head on pillow
- Turn head 90 degrees to affected side and hold 2x symptoms
- Rotate to centre and hold 2x symptoms
- Turn 90 degrees to unaffected side and hold 2x symptoms
- Roll 90 degrees onto stomach looking directly down to ground propped on elbows and hold 2x symptoms
- Continue rolling in same direction to end up back on affected side and sit up
Lower bed for pat to have feet on floor
Semont (PSC)
- For posterior semicircular cupulolithiasis BPPV
Treatment: - Patient sits on bed with head turned 45 degrees toward unaffected side
- Patient lies quickly onto affected side maintaining the same head position (looking up toward the ceiling) and hold for 2 minutes
- Patient rapidly sits up and over onto unaffected shoulder maintaining same head position (land on forehead looking to ground) and hold for 2 minutes
Slowly return to sitting up
Modified Semont (ASC)
Modified Semont (ASC)
- For Anterior semicircular cupulolithiasis BPPV
Treatment:
- Patient sits on bed with head turned 45 degrees toward affected side
- Patient lies quickly onto affected side maintaining the same head position (looking to the ground) and hold for 2 minutes
- Patient rapidly sits up and over onto unaffected shoulder maintaining same head position (looking toward the ceiling) and hold for 2 minutes
Slowly return to sitting up
Gufoni for Ageo (HSC)
- For Horizontal semicircular cupulolithiasis BPPV
Treatment: - Patient sits on edge of bed facing forward
- Patient lies quickly onto affected side and hold for 2 minutes
- Rapidly rotate head 45 degrees to look up towards the ceiling and hold for 2 minutes
- Slowly return to sitting up with head facing forward and hold for 2 minutes
Hint: Ageo = Affected side down = turn head Away from ground (A-A-A)
Adaption Exercises
- Requires an error signal = retinal slip
- Brain attempts to reduce error by increasing gain
- Improves active VOR by increasing the number and speed of compensatory saccades
- Adaptation - VOR X1
- Adaptation - VOR X2
- Head impulse training
- Substitution - Two Targets
Adaptation - VOR X1
- used as a Rehab technique for patients with unilateral or bilateral hypofunction- reduced function
- X1 means head is moving but target is not. Head and eyes moving at the same speed
- Preferred to do in standing so that vestibular system is working to stabilize gaze + standing posture. If too difficult then start in sitting and can progress when can
- Distance = 2m from wall at start. Further away is easier
Instructions:
- Keep eyes on target, you are going to rotate your head from side to side. Kind of like you are saying no aiming to go as fast as you can but keeping your eye focussed
- Positioned in front of patient to ensure stays focussed.
- Should be 98% focussed meaning the target might slip, move or blur sometimes because you are on the cusp. Retinol slip is the goal. Retinal slip is: when the image is slipping off the retina. We want the error to be occasional and specific so that you start to make neuroplastic changes.
- If missing the target, slow down, if managing speeded up.
- Horizontally and vertically “yes movement”
Treatment parameters:
- For acute unilateral vestibular hypofunction recommend 12 mins of adaptation per day. 1-2mins horizontally and vertically. 3 times per day.
- For Chronic unilateral vestibular hypofunction recommend 20 mins of adaptation per day. 1-2mins horizontally and vertically. 5 times per day.
- Progress slowly over the weeks.
- Warning: it is normal for these exercises to make you feel dizzy or nauseous or off balance for a bit after woods. It is lasts for longer than 10 mins of >4/10 intensity. Then do less, slower and break it up more over day
Adaptation - VOR X2
- head and eyes are moving in opp directions. As target further away means that the eyes are moving at double the speed of the head to stay on target
- exercise progression for those with unilateral vestibular hypofunction, neuritis, manières disease
- not appropriate for bilateral as too tricky
thumb as target, head and thumb move in opp direction. Speed far slower but eyes moving faster
Head impulse training
- standing, target on the wall.
- Improve gain of affected side
- Combined with X1 and X2
- Impulse to right side, pause on target and slowly back to middle
4 to affected + 1 to unaffected 1-2mins
