Picture this: You log onto your computer to check tomorrow’s schedule and you see that you have a vestibular evaluation. Maybe you’re unsure of what to do, because your clinic doesn’t see vestibular cases often. Or maybe you just feel somewhat intimidated by the number of different possible vestibular pathologies. Whether you’re new to the vestibular rehabilitation world or a seasoned pro- have a look through this post to review a thing or two and some helpful information.
Many of us are familiar and comfortable working with the older adult population so it’s important to keep in mind:
Take a Good Subjective History
For vestibular evaluations, the subjective history is one of the most important aspects of the evaluation, but also one of the most difficult. Often, patients have a hard time explaining their symptoms, so it’s important to help guide them as the clinician.
Considerations for subjective history:
Perform a Bedside Evaluation: Objective Findings
This portion of the blog is more of a generalized overview tailored to those who do not have infrared or frenzel equipment available during examination. There’s a huge amount of power in your simple bedside evaluation! See our blog post “Is Bedside Testing Reliable” to discover how a simple 6-test bedside protocol is 77% sensitive for identifying vestibular disorders, as well as the site and side of the lesion.
1. Always start with a solid oculomotor examination, this will help to steer the direction of your evaluation. Some oculomotor abnormalities can be a sign of central dysfunction. So, if you start getting central findings during the oculomotor examination, keep that in mind throughout the duration of your evaluation. Also, if a patient has nystagmus at baseline it can interfere with positioning tests later in the evaluation, so it is important to know what you’re working with from the beginning.
Checkpoint: If you’re seeing nystagmus during oculomotor testing, what does it look like?
Nystagmus can get complicated, so without getting into very specific details, this is a very basic review:
2. Assess cervical range of motion to see if positioning tests will need to be modified.
3. Balance evaluation
Checkpoint: always assess lower extremity sensation, especially if all other tests are checking out to be normal. Many times, patients do not even realize they have diminished sensation in their feet, which can really impact balance and cause the unsteadiness they came to see you for.
Lastly, you’ll want to check positioning tests. Personally, I choose to assess these at the end because individuals can become very symptomatic with these tests which includes increased anxiety, nausea, and sometimes vomiting. Quick Tip: always have a trash can handy!
I saw nystagmus during a positioning test, now what do I do?
Checkpoint: What does the nystagmus look like? Do the eye movements match the canal being stimulated?
PSCC: Posterior Semi-Circular Canal
HSCC: Horizontal Semi-Circular Canal
If your positioning test shows nystagmus that matches one of the above, try performing a canalith repositioning maneuver (CRM) for the appropriate canal.
Be sure to observe the nystagmus! Just because the patient is dizzy in a Dix-Hallpike, it doesn’t necessarily mean that the Posterior Canal is the culprit. Remember Ewald’s First Law: The direction of the nystagmus is directly correlated to the canal that is being stimulated… not the position of the head. So if you see pure horizontal nystagmus in a Dix-Hallpike, you may want to perform a roll test to test for Horizontal Canal BPPV.
Choose Your Treatment
CRMs to choose from:
Bonus checkpoint: Now, how should this be documented?
All other objective findings can be documented accordingly, however positive positioning tests may require a little extra clarification. It’s important to name the eye movements and characteristics thereof to ensure others reading your document will know exactly what was observed upon evaluation.
Ex: (for right, posterior semicircular canal BPPV): R Dix Hallpike (x2 cycles): R torsional, upbeat nystagmus, x7 seconds, with subjective report of vertigo, latency of nystagmus appreciated.
Ex: (for treatment of right, posterior semicircular canal BPPV): CRM performed for R posterior canal (x1 cycle), no reversal of nystagmus noted with return to sit following treatment.
In conclusion, this is a very basic guide. Every patient is different and there are times that additional tests or measures will need to be performed. However, this a good general outline to help simplify or organize your vestibular evaluation.
If you have any questions about specific tests or techniques or would like to have a discussion regarding a vestibular case feel free to comment below, or email any questions to firstname.lastname@example.org
Kelly Keener, PT, DPT
Certificate in Vestibular Rehabilitation, 2019
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