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What are the (3) treatments for chronic subjective dizziness and PPPD?
1. Vestibular habilitation
2. Cognitive behavioral therapy
3. Medications
Never healed from initial injury; not adapting after an issue and not recovering as expected; habilitation (decreasing response to a non-noxious stimulus) of the vestibular system is the treatment for these patients
Chronic subjective dizziness
- ABCs
- DHI
Outcome measures for activity and participation
What does HINTS Plus stand for?
- HI = head impulse test (VOR assessment)
- N = nystagmus type
- TS = Test of skew
- Plus : acute hearing loss
Area of stroke commonly affected which supplies the labyrinth and close relation to brainstem and cerebellum
AICA
- "Lightheaded"
- Presyncope
- Syncope
- Orthostatic hypotension
- Lightheadedness: stay hydrated
Cardiac issues
- Four square step test
- BBS
- Functional reach/modified functional reach
- CTSIB/mCTSIB
- Mini BESTest
- Romberg/sharpened romberg
- Unipedal stance test (SLS)
Outcome measures for postural stability
- Precipitants: vestibular crisis, medical event, acute anxiety
- Acute adaptation: visual somatosensory dependence, high risk postural control strategies, environmental
- Predisposing factors: introverted temperament, pre existing anxiety
- Recovery: neuro-otologic, medical, behavioral
- Behavioral comorbidity: anxiety disorders, phobic disorders, depression
- Provoking factors: upright posture, motion (self, environment), visual demands (complexity, precision)
Chronic subjective dizziness
- Resting eye position
- Oculomotor testing
- Gaze stability assessment
- Visual acuity tests
- Findings
Evaluation components: oculomotor/VOR
T/F: Fast phase horizontal nystagmus can also be classified as central origin?
TRUE **
Acute moderate to severe sensorineural hearing loss associated with vertigo could mean ______
Labyrinth infarction
- Starts shortly after an acute event that leads to vertigo/balance issues
- Presentation: dizziness without vertigo and fluctuating unsteadiness that is provoked by environmental or social stimuli
Persistent postural perceptual dizziness (CSD?)
Acute hearing loss is a red flag and is NOT always due to a viral infection but could be ischemia/infarct of ______ and _____.
Cochlea; labyrinth
How do you perform an active VOR test?
Holding pencil and turning head as fast as they can while keeping the object in focus
What does the acronym INFARCT mean in HINTS Plus?
- IN = impulse negative
- FA = fast phase alternating
- RCT = refixation during cover test
- Numbness
- Tingling
- Unilateral hearing loss
- Progressive hearing loss
- Slurred speech
- Tremors
- Poor coordination
- UMN s/s: clonus, spasticity
- LOC
- Rigidity
- Visual field loss
- Memory loss
- CN dysfunction
- Spontaneous nystagmus
- Vertical nystagmus without torsional component
Red flags
- DGI
- FGA
- TUG, TUG manual, TUG cognitive
- FTSTS/30 second sit to stand
- Gait speed
Outcome measures for dynamic stability
Clearing tests before VOR and positional testing: (2)
1. VBI
2. Cervical AROM
- Head impulse (thrust) test
- Positive test means VOR is disrupted due to lesions in peripheral afferents, vestibular nucleus or efferent neurons
- If PNS positive, you will see a corrective saccade
- Normal in cerebellar lesions (Neuron arc is normal)
- PICA strokes can also have normal HIT
- Can, however, be positive in some strokes, therefore HIT, skew deviation of eyes and HINTS can assist in PNS vs. CNS differentiation
HINTS plus -- VOR assessment
Acute, spontaneous, continuous vertigo, particularly when they have nystagmus
Who to use HINTS Plus with
- 180 bpm in a 20 degree range
- Horizontal and vertical
- Positive signs is an inability to maintain gaze stability
Active VOR (screen)
Nystagmus is named by which phase of beating?
Fast phase **
- Have patient look at your nose
- Passively rotate patients head, slow to start then fast
- Positive sign is an inability to maintain gaze stabilization on nose
- 20-30 degrees downward facing of the patient... not just looking straight ahead
Passive VOR -- Head impulse test
In general, which two nystagmus are CENTRAL in origin
1. Purely torsional
2. Purely vertical ***
T/F: fast phase is side of dysfunction?
FALSE..
Slow phase is side of dysfunction ***
Nystagmus is named from fast phase