Managing Acute Vertigo for the Non-Vestibular PT. Objectives 4/12/2018

Transcription

1 Managing Acute Vertigo for the Non-Vestibular PT Dalerie Lieberz, PT, DPT, GCS Assistant Professor and DCE at The College of St. Scholastica & staff therapist with the Balance & Dizziness Center at Essentia Polinsky Rehabilitation Duluth, MN. Casey Byron, BS, MPT Interim Physical Therapy Supervisor, Teletherapist & CCCE at Hennepin County Medical Center Minneapolis, MN Objectives 1) Demonstrate ability to perform screening tests accurately for differentiating peripheral vs central etiology 2) Understand how to asses an acute patient for vestibular peripheral hypofunction and what is the appropriate course of treatment for this type of patient based on the APTA's Clinical Practice Guidelines (CPG) from ) Recognize different patterns of nystagmus involved with Benign Paroxysmal Positional Vertigo (BPPV) and use this information to formulate a safe and effective treatment for canalith repositioning. 4) Learn 3 different strategies to adapt vestibular tests and interventions based on the unique confines of the acute hospital patient/environment that an acute therapist can use in their own practice. Vestibular System reproduced without permission. 1

2 Semicircular Canals Semicircular canals work as push-pull pairs Right & left horizontal Right anterior & left posterior Left anterior & right posterior NORMAL -- Horizontal VOR excitation Head rotation to Left Ampulopedal (toward) endolymph motion in the left horizontal canal. Ampulofugal (away) endolymph motion on the right horizontal canal. excitation of left vestibular nerve and medial vestibular nucleus. excitation of right abducens nucleus. Contraction of right lateral rectus Contraction of left medial rectus (via abducens internuclear neurons) excitation of right vestibular nerve and medial vestibular nucleus excitation of left abducens nucleus Eyes rotate right (7-13 msec latency) reproduced without permission. 2

3 6 Extraocular Muscles Controlled by 3 Cranial Nerves CN III CN VI CN IV CN III CN III CN III Google images: people.tamu.edu Nystagmus Diagnostic with peripheral & central vestibular lesions Involuntary Named by the direction of the quick phase Nystagmus with UVL results from asymmetry Nystagmus with BPPV results from Excitation of a canal by debris in the canal Summary Vestibular system senses head position and acceleration Function: To develop subjective awareness of head orientation and movement in space To maintain postural stability, especially during head movements To stabilize visual images during head movements To produce vestibular reflexes for equilibrium reproduced without permission. 3

4 Causes of Dizziness Migraine Orthostatic 2% 2% Basal Ganglia 1% Other 14% Anxiety & Depression 2% TIA & CVA 3% Menier's 4% Cerebellar 5% Vestibular 13% BPPV 32% Fear of Falling Disuse Disequilibrium 22% Dizziness in Patients Over 60 Years of Age Tusa, R.J., Pathophysiology, Vestibular Rehabilitation; A Competency-Based Course, 2002 Central vs Peripheral? Oculomotor exam Smooth pursuit Pt.'s head stationary and they track slowly moving target 30 right, left, up, down (Keep finger from pt...'s face) Do: Horizontal, vertical, oblique, H VOR cancellation: Can pt. suppress VOR appropriately? Pt.'s head and the target move together Pt.'s head tilted down 30 with slow, side to side movement 30 Saccades Pt.'s head stationary and they alternate gaze between 2 targets (e.g. PT nose to PT finger 15 to one side of your nose ) Do: right, left, up, down & oblique Abnormality indicates central Acute Central vs Peripheral HINTS exam youtube HINTS HEAD IMPULSE NYSTAGMUS TEST OF SKEW INFARCT = STROKE IN= Impulse Normal FA= Fast Alternating nystagmus RCT= Refixation on Cover Test PT in ED & acute care Edlow & Newman- Toker (2016) Katah et al. (2009) reproduced without permission. 4

5 Observe for OTR & skew deviation OTR involves a triad of signs: Head tilting Skew deviation (i.e. one eye is up and the other down ) Torsion of eyes toward side of tilt Eval Red Flags with Dizzy referrals A central pathology should be suspected if: Horizontal or vertical diplopia >2weeks after onset of suspected UVH Persistent pure vertical positional nystagmus (w/ ant canal r/o) Spontaneous up beating nystagmus (rare) +skew deviation Acute Hearing loss Acute Peripheral Vestibular Screen Chart review: Medications Note Medication: Is the pt on Meclizine (Anti-vert), Lorazepam (Ativan) or Diazepam (Valium)? Mechanism of injury Imaging (head or neck bleed) Activity orders, fractures with precautions, LBP ENT or Audiology notes (usually do not have yet) Any vestibular tests performed by other providers (ED will frequently perform Dix-Hallpike and Epley) Have orthostatics been performed? reproduced without permission. 5

6 Acute Vestibular Screen Subjective from the pt: Ask the following questions Can you describe the dizziness? Does the room spin? When does your dizziness occur? Does it happen when you lay down? Does it happen when you get up? How long does it last? Do you have double vision? Hearing change? Tinnitus? Are you nauseous? PT Evaluation Subjective Clarify nature of symptom description involving vertigo, dizziness, balance, vision & hearing Determine stage of healing (Hall, et al., 2016) acute (first 2 wks) Subacute (2 wks 3 mo) chronic (> 3 mo) Frequency of symptoms episodes per time frame vs continuous symptoms Duration of symptoms when present seconds/ minutes/ hours/ days Episodic Dizziness Duration Seconds Minutes Hours to Days Etiology BPPV Perilymphatic Fistula Orthostatic hypotension TIA Migraine Panic Attacks Meniere s disease & hydrops reproduced without permission. 6

7 Physical Exam Observation for nystagmus: Spontaneous nystagmus in room light Sponstaneous nystagmus with fixation removed Characteristic Central Peripheral Pattern Variable Mixed horizontaltorsional Directionality May change direction Unidirectional Fixation effect Variable Suppression Spontaneous Nystagmus Physical Exam 2. Does the pt have Gaze-evoked Nystagmus? Gaze-evoked Nystagmus (GEN) is the centripetal drift of the eyes. GEN beats in the direction of gaze. GEN is a central vestibular sign but can be caused by medications (sedatives, tranquilizers, ETOH). GEN is different from end range nystagmus. End range nystagmus is nystagmus in the extreme range of eye ROM. End range nystagmus is a weak vestibular sign as it can occur in normal subjects especially as we age.) reproduced without permission. 7

8 Gaze-Evoked Nystagmus Head Thrust can tell you a lot 5. Does the pt have an abnormal head thrust or head impulse test? Pt is instructed to keep eyes fixed on a target. Head is passively and quickly moved in one direction. Pt s eye s should remain on the target. It is done to right, left, up and down. An abnormal test is if the pt requires a refixation, corrective saccade. The direction of positive thrust is the involved side (side of hypofunction). Head thrust is the most effective method of detecting loss of VOR at the bedside and is a peripheral sign. Head Thrust reproduced without permission. 8

9 Head Shaking Nystagmus 6. Does a pt have Head Shaking Nystagmus? Donn video oculography goggles and pitch their head forward 30 degrees and then oscillate their head 20 times back and forth horizontally. Elicitation of more than 3 beats of jerk nystagmus after the oscillation is a positive test. HSN is usually a peripheral sign (nystagmus away from the side of lesion) but can be a central sign (especially if the nystagmus is torsional or vertical). Head Thrust (HT) or head impulse* Head Impulse or Head Thrust Test for Horizontal Canal Good psychometric properties Good Sensitivity UVH: 71% (88% for complete loss) Good Sensitivity BVH: 84% (100% for complete loss Good Specificity, UVH and BVH: 82% Positive Predictive Value (All subjects): 87% Instrumental version Head-Shaking Nystagmus reproduced without permission. 9

10 Physical Exam- Summary Physical Exam- Summary 2016 CPG for Peripheral Vestibular Hypofunction Strong recommendation: vestibular rehab provides substantial benefit for both UVH and BVH Age & Gender do not affect outcomes Earlier rehab is better, but chronic can benefit Vestibular suppressants, comorbidities, and delayed start negatively impact recovery Moderate recommendation for customized supervised exercises Voluntary saccadic and smooth pursuit not recommended in isolation reproduced without permission. 10

11 Treatment Options for Non-BPPV Impairments Gaze stabilization Adaptation : VOR x1, VOR x2 (aka X1, X2) substitution : VOR x3 (aka X3) Habituation Repeated exposure to stimulus provoking symptoms to reduce visual vertigo and / or motion sensitivity) Optokinetic stimulus for visual sensitivity (Pavlou, 2010 & 2012) Virtual reality for visual motion sensitivity (Meldrum, 2015) Balance & Gait training General conditioning with walking for endurance Addresses deconditioning associated with fear avoidance, but not symptoms of hypofunction without head motion BPPV (2017 CPG Bhattacharyya, et al) Canalithiasis Otoconia mobile in SCC Nystagmus & vertigo fatigue <1min w/ provoking position Cupulolithiasis Adhered to cupula of SCC Nystagmus & vertigo do not fatigue with provoking position Positional Testing Dix-Hallpike Maneuver: Rotate 45 Lie down extending head Remain for 1 minute Positive test for BPPV = vertigo with nystagmus Direction of nystagmus tells you Posterior vs Anterior canal BPPV. Upbeat = posterior Downbeat = anterior Torsion in the direction of the involved side reproduced without permission. 11

12 Positional Testing Findings on Dix-Hallpike maneuver: Canalithiasis Latent onset, ~10 sec s of vertigo and nystagmus on assuming position Fatigues within approximately 1 minute Repeat on return to upright Cupliolithiasis Immediate onset, ~ 10 sec s of vertigo and nystagmus on assuming position Continues for more than one minute Eases on return to upright Canalith Repositioning Treatment (CRT) for posterior (or anterior?) canal Left posterior canal BPPV CRT Modified Positional Testing/Treatment reproduced without permission. 12

13 Roll Test for Horizontal Canal BPPV Roll test video Pt lies supine, head elevated 20 Head is quickly rolled to the side Hold seconds and slowly return to start position Note: Vertigo & nystagmus may occur in both left & right positions; assume affected side is the most symptomatic side Treatment- Cases L Dix-Hallpike, Upbeat nystagmus with L rotation. Delayed onset and fatigues over time. L Posterior Canalithiasis Treatment: L Canalith Repositioning Maneuver (L Eply s) Turn head 45 to L Lay back, extending neck 20 Rotate head to 45 to the R (maintain extension) Roll onto R side, maintaining neck rotation (looking toward ground) Sit up Treatment- Cases L Dix-Hallpike, downbeat nystagmus with R rotation. Delayed onset and fatigues over time. R Anterior Canalithiasis Treatment: R Canalith Repositioning Maneuver (R Epley s) Turn head 45 to R Lay back, extending neck 20 Rotate head to 45 to the L (maintain extension) Roll onto L side, maintaining neck rotation (looking toward ground) Sit up reproduced without permission. 13

14 Treatment- Cases R Dix-Hallpike. Downbeat nystagmus with L rotation. Delayed onset and fatigues over time. L Anterior Canalithiasis Treatment: L Canalith Repositioning Technique (L Epley) Turn head 45 to L Lay back, extending neck 20 Rotate head to 45 to the R (maintain extension) Roll onto R side, maintaining neck rotation (looking toward ground) Sit up Treatment- Cases R Dix-Hallpike. Upbeat nystagmus with R rotation. Delayed onset and fatigues over time. R Posterior Canalithiasis Treatment: R Canalith Repositioning Technique (R Eply s) Turn head 45 to R Lay back, extending neck 20 Rotate head to 45 to the L (maintain extension) Roll onto L side, maintaining neck rotation (looking toward ground) Sit up Treatment- Cases L Roll: strong nystagmus. R roll: weak nystagmus. Geotrophic nystagmus with delayed onset that fatigues L Horizontal Canalithiasis reproduced without permission. 14

15 Treatment- Cases R Roll: weak nystagmus. L roll: Strong nystagmus. Apogeotrophic nystagmus with immediate onset that does not fatigue L Horizontal Cupliolithiasis Ant/Post Cupulolithiasis Key point: The testing for Anterior and Posterior Canal Cupulolithiasis looks the same as for Canalithiasis except for ONE KEY FEATURE. The Nystagmus will onset immediately in test position and will NOT fatigue over time. Treatment- Cases R Dix-Hallpike, Downbeat nystagmus with L rotation, Immediate onset that does not fatigue L Anterior Cupulolithiasis Treatment: Liberatory Maneuver (Semont maneuver) Start in sitting. Turn head 45 to the L Quickly lay back onto L shoulder Quickly lay forward onto R shoulder Sit up Left Liberatory reproduced without permission. 15

16 Horizontal Cupulolithiasis Key point: The testing for Horizontal Canal Cupulolithiasis looks the same as for Canalithiasis except for ONE KEY FEATURE. The Nystagmus will beat Apogeotrophic (away from the earth, or up ). The Cup is Up. Treatment- Cases R roll: strong nystagmus, L roll: weak nystagmus. Apogeotrophic with immediate onset that does not fatigue over time R Horizontal Cupulolithiasis Treatment: Gufoni Maneuver (best) Start in sitting head in neutral, facing forward Quickly lay down onto R side As soon as down, rotate head down to R Gufoni maneuver Or Brandt Daroff Horizontal Canal Habituation References 1. Bhattacharyya, N., Gubbels, S. P., Schwartz, S. R., Edlow, J. A., El-Kashlan, H., Fife, T.,... & Seidman, M. D. (2017). Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngology Head and Neck Surgery, 156(3_suppl), S1-S Edlow JA, Newman-Toker D. (2016). Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo. J Emerg Med. 3. Hall, C. D., Herdman, S. J., Whitney, S. L., Cass, S. P., Clendaniel, R. A., Fife, T. D., &... Woodhouse, S. N. (2016). Vestibular rehabilitation for peripheral vestibular hypofunction: An evidence-based clinical practice guideline. Journal Of Neurologic Physical Therapy, 40(2),124. doi: /npt Helminski, J. (2014). Effectiveness of the canalith repositioning procedure in the treatment of benign paroxysmal positional vertigo.physical Ther.apy. 10: doi: /ptj Epub 2014 Jun Herdman, S. J., & Clendaniel, R. (2014). Vestibular rehabilitation. FA Davis. 6. Kattah, J., Talkad, A., Wang, D., Hsieh, Y., Newman-Toker, D., Kattah, J. C., &... Newman- Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: threestep bedside oculomotor examination more sensitive than early MRI diffusionweighted imaging. Stroke ( ),40(11), p. doi: /strokeaha Whitney SL, Alghwiri A, Alghadir A. (2015). Physical therapy for persons with vestibular disorders. Curr Opin Neurol. (1):61-8. doi: /WCO Review. PMID: reproduced without permission. 16