Vestibular Interventions

Question 1

List intervention techniques for vestibular dysfunction

Answer 1

1. Habitutation
2. Gaze stabilization
3. Balance retraining
4. Endurance training
5. Canalith repositioning → BPVV only

Question 2

what is habituation?

Answer 2

the simplest form of neuroplasticity

decrease in response to a repeated benign stimuli (decrease in the amount our brain notices an unpleasant stimuli)

can be short or long-term

Question 3

what is the difference between short and long term habituation?

Answer 3

1. Short-term
   
   • exposure to stim <30 min
   • results in pre-synaptic changes
   • results are generally transient
2. Long-term
   
   • exposure to stim >30 min
   • results in post-synaptic changes
   • more long-term effects

Question 4

how does habituation relate to vestibular rehab?

Answer 4

in research, habituation has referred to the reduction of behavioral response to repeated exposure to a provocative stimulus, with the goal of reducing symptoms related to the vestibular system

Question 5

what are gaze stabilization exercises?

Answer 5

exercises used to improve control of eye movements so vision remains clear during head movements

• based on assumption that they promote vestibular adaptations involving head movement while maintaining focus on target (may be stationary or moving)
• based on principles of substitution were developed with goal of promoting alternative strategies to substitute for missing vestibular function

Question 6

what is the purpose of balance retraining in vestibular rehab?

Answer 6

1. Balance training exercises are used to improve steadiness on feet, so ADLs can be performed successfully
2. Intended to either strengthen vestibular input to balance integration or to facilitate use of visual and/or somatosensory cues to substitute for missing vestibular function

Question 7

what are the 3 most common types of BPPV?

Answer 7

1. Posterior Canaliathiasis
2. Horizontal Canaliathiasis
3. Horizontal Cupulolithiasis

Question 8

Pair the examination technique with the canal

Answer 8

1. Posterior Canal
   
   • Dix-Hallpike Test → gold standard
   • Side-lying test
2. Horizontal Canal
   
   • Roll test
     
     • Bow and lean test
3. Anterior Canal
   
   • Dix-Hallpike test (contralaterally)

Question 9

Prior to conducting a Dix-Hallpike what test should you perform and why?

Answer 9

Vertebral Artery Screen Test

the dix-hallpike will put them in a position that will compress the vertebral and basilar artery which will put the pt at risk for occluding that artery

Question 10

describe how to perform the dix-hallpike

Answer 10

1. pt in long sitting
2. rotate head 45º towards the testing ear
3. bring pt to supine while maintaining head rotation with either:
   
   • head positioned off edge of plinth and extended 30-40
   • head rests on depressed plinth at 30-45º ext
   • pillow under back to allow for truncal and neck ext
4. hold pt in position ~60 seconds while observing for nystagmus
5. keep head in rotation, bring pt into long sitting
6. observe eyes another 60 seconds
7. allow pt to return to neutral position
8. repeat on other side as appropriate

Question 11

why would you perform a side-lying test over a Dix-Hallpike test?

Answer 11

side-lying test is an alternative to the Dix-Hallpike

useful in pts who cannot tolerate the position required for Dix-Hallpike due to neck or back problems

Question 12

how do you perform the side-lying test?

Answer 12

1. pt sitting on edge of plinth
2. rotate pt’s head 45º away from the testing ear
3. assist pt down onto their side in the direction ipsilateral to testing ear with head remaining rotated
4. hold pt in position for 60 seconds while observing for nystagmus
5. keep head in rotation, bring the pt up to sitting on the edge of the plinth
6. optional:
   
   • observe eyes for another 60 seconds before allowing pt to return to neural positioning

Question 13

describe how nystagmus directional terms differ for horizontal canal

Answer 13

• geotropic → towards ground
• ageotropic → away from the ground

Question 14

what tests are performed for dx of horizontal canalialithasis?

Answer 14

1. ipsilateral roll test
2. contralateral roll test
3. Bow and Lean test

Question 15

describe what occurs during the roll test

Answer 15

1. ipsilateral roll test
   
   • turn head to left → otoconia travel towards cupula = excitatory response
2. contralateral
   
   • turn head to right → otoconia travel away from cupula = inhibitory response

Question 16

what will the results be on the roll test if the patient has horizontal canalithiasis?

Answer 16

geotropic nystagmus with both directions during testing

determine which canal is involved by looking at symptoms severity and folowing up with the bow and lean test

Question 17

describe how to perform the supine roll test

Answer 17

1. assist pt into supine
2. bring neck into 30º flexion
3. bring neck into 90º rotation to one side
4. maintain rotation for at least 60 seconds, observing eye movements
5. after 1 minute, or once symptoms subside, bring pt into 90º rotation to the other side
6. maintain rotation for at least 60 seconds, observing eye movements

Question 18

how does the presence of cupulolithiasis impact the roll test?

Answer 18

the results are opposite

ageotrophic nystagmus to both directions

Question 19

what occurs within the canal during the roll test with horizontal cupulolithiasis?

Answer 19

1. ipsilateral roll test
   
   • turn head ipsilaterally → gravity pulls on cupula, causes to move away from utricle = inhibitory response
2. contralateral roll test
   
   • turn head contralaterally → gravity pulls on cupula, causes to move towards utricle = excitatory response

Question 20

describe the results of the bow and lean test in the presence of horizontal canaliathiasis

Answer 20

1. Bow → pt pitches head forward - otoconia move towards utricle
   
   • excitatory = ipsi nystagmus
2. Lean → pt extends back - otoconia move away from utricle
   
   • inhibatory = contra nystagmus

Question 21

describe the results of the bow and lean test in the presence of horizontal cupulothiasis

Answer 21

1. Bow → pt pitches head forward = otoconia pull cupula away from utricle
   
   • inhibitory = contra nystamus
2. Lean → pt extends back = otoconia pull cupula towards utricle
   
   • excitatory = ipsi nystagmus

Question 22

describe how to perform the bow and lean test

Answer 22

1. pt is sitting on plinth
2. instruct pt to bow/pitch their head forward until the head is parallel to the groun
   
   • use a phone or mirror to observe eyes
3. instruct pt to sit back upright and extend their neck 45º
4. maintain position for 60 seconds and observe for eye movements

Question 23

list treatment manuevers for posterior canal BPVV

Answer 23

1. Modified epley maneuver
2. Semont manever
3. Gans Repositioning maneuver

Question 24

list treatment manuevers for horizontal canal BPVV

Answer 24

1. BBQ roll maneuver
2. Appiani maneuver
3. Casani maneuver (cupulolithiasis)
4. Horizontal hybrid maneuver

Question 25

list treatment maneuvers for anterior canal BPVV

Answer 25

1. Modified Epley Maneuver (contralateral) 2. Deep Head Hanging Maneuver