NPTE Studycast | Physical Therapy

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Vestibular Disorders

Host: Jimmy McKay, PT, DPT

Featured Guest; Alicia Flach, PT, DPT, NCS

Notes by Alexis Lancaster

Vestibular Disorders

 

What is it?

Disruption that can occur from vestibular apparatus (inner ear) through the cranial nerve to the CNS where the information is processed

Any disruption along this path will cause a vestibular disorder

 

Anatomy

Peripheral vestibular system

BPPV: problems within the vestibular apparatus, specifically semicircular canal

Creates sensation of moving, pt feels dizzy

Problem with cranial nerve 8 (before synapse in brain stem)

Problem here= peripheral problem

Central vestibular system

After cranial nerve 8 synapses in brainstem

Travels different pathways to locations within the brain

Problem here= central problem

 

Differential diagnosis

Dizziness can be due to different things

Vertigo: room spinning, could be peripheral or central vestibular problem

Feeling of imbalance or disequilibrium, pt doesnt feel steady on their feet. Could be peripheral or central vestibular problem

Unrelated to vestibular system

Polypharmacy

Orthostatic hypotension (pt complains of feeling light-headed, passing out, fainting)

Low blood sugar (hypoglycemia)

Migraines

Get to the root of how the patient describes their dizziness

 

Special Tests

Subjective interview: try to understand when it happens, how long it has been going on, how long it lasts when it happens, does it come and go or is it constant, is it related to positional changes?

Rule out/in peripheral condition, BPPV: Dix Hallpike, head thrust test, dynamic visual acuity test

Look for central signs throughout exam

Hypermetria with saccades

Abnormal changes in the ability to perform

Vestibulo-occular reflex cancellation: being able to follow a moving object with your eyes and head moving in the same direction

Rule in the vestibular system overall, rule in/out peripheral vs. central

 

Treatment

Common encounter: BPPV

Managed through canalith repositioning maneuvers (otoconia getting stuck in canal): Epley and BBQ Roll

Dysfunction of peripheral nerve/hypofunction

Gaze stabilization Tx

Movement sensitivity/central component

Habituation

Exercise

Graded exposure

 

Sample Question

A physical therapist evaluates a patient who reports dizziness when getting out of bed. The physical therapist suspects the pt is experiencing symptoms related to BPPV. Which of the following would be the most appropriate assessment to confirm the presence of BPPV

Head thrust test

Dynamic visual acuity testing

Dix Hallpike maneuver

Clock drawing test

 

Answer: C. Dix Hallpike: it is an assessment in which an individual is moved into a position and is intended to elicit a response from the presence of otoconia in the semicircular canal. Position the patient and look for the presence of nystagmus to rule in BPPV.

 

Why the others are wrong:

A: Head thrust test looks at the ability of a patient to perform VOR (vestibulo-ocular reflex)--> specifically looks for hypofunction

B: Dynamic visual acuity testing tests for peripheral hypofunction. Perform eye chart and look at visual acuity in static position and then pt will move head side to side to see visual acuity dynamically.

Episode 20: Cauda Equina Syndrome

Host Jimmy McKay

Featured guest Bridget Ripa

Notes Alexis Lancaster

Cauda equina: “horse’s tail”

 

What is it?

Injury to lumbar and sacral spinal nerve roots within the canal

 

Presentation

Variable lower extremity paralysis

Sensory loss

Bowel and bladder dysfunction

 

Causes

Trauma, pelvic crush (MVA), child birth could precede it

 

Differential diagnosis

Other spinal cord syndromes

Transverse myelitis

MS

Spinal infarct

Spinal tumor

 

Special tests

CT, MRI

Clinical presentation & mechanism of injury

 

Treatment

Make sure they are managed medically first

Bowel/bladder program

Motor learning

Task-specific training

ICF model

Weight-bearing

Neuromuscular re-education

Tone management

FES

Aerobic training

Positioning

Bracing/splinting

Locomotion if applicable

Keeping an eye on shoulder pain

Allow compensation in this population when they need to

How will it look on the test?

Mechanism of injury and clinical presentation

Bowel and bladder dysfunction will be present with cauda equina!

Episode 19: Central Cord Syndrome

Host Jimmy McKay

Featured guest Bridget Ripa

Notes Alexis Lancaster

What is it?

Damage to the central portion of the spinal cord

 

How does it happen?

Hyperextension of the cervical spine is the typical cause

Inflammation or pressure on the cord centrally

 

Anatomy/Presentation

Tricky

Damages spinothalamic, corticospinal, and dorsal columns

Upper extremities weaker than lower extremities

Greater motor deficits than sensory deficits

The sensation of the sacral region is present

 

Differential diagnosis

The other spinal cord syndromes

Rely on clinical presentation

Imaging (CT/MRI)

 

Special tests

CT/MRI

Clinical presentations (UE deficits>LE)

 

Treatment

Medically stable first

Bowel/bladder program

Motor learning

Task-specific training

Weight-bearing

Neuromuscular re-education

Strengthening

Tone management

FES

Aerobic training

Positioning

Bracing/splinting

Locomotion if applicable

LE stronger than UE! So you will probably be walking

Keeping an eye on shoulder pain

Allow compensation in this population

 

How it will look on the NPTE

Upper involved more than lower (hallmark sign)

Mechanism of injury→ hyperextension injury

Episode 18: Brown Sequard Syndrome

Notes by Alexis Lancaster, SPT

What is it?

Damage to one side of the spinal cord

 

Mechanism of injury:

MVA, gunshot wound, stab wound

 

Impairments/presentation:

Ipsilateral losses: proprioception, vibration, deep touch, discriminative touch, and voluntary motor control

Contralateral losses: pain, temperature, crude touch

 

Differential diagnosis:

Other spinal cord injuries (see above impairments list and differentiate this way)

MS

Spinal infarct

Spinal tumor

Transverse myelitis

 

Special tests:

CT, MRI

Clinical presentation

 

Treatment:

Medically stable/managed

Bowel/bladder program

Task-specific training

Motor learning

Neuromuscular re-education

Weight-bearing

Tone management

FES

Aerobic training

Positioning, splinting, bracing

Keep an eye on shoulder pain

 

* Allow for compensation!! (This is different, usually with the neurological population you want to use less compensation and aim for recovery of function, but these patients will need to compensate some)

 

 

How it will appear on the test:

Know how it presents clinically

Know the type of injury that may result in Brown-Sequard