Dizzy Diagnostics

To VOR or not to VOR? 👀 That is the question.

VOR x 1 is not a blanket exercise for all dizziness. Patients who have NO gaze stability deficits or complaints may not benefit from VOR exercises.

How to determine if VOR training is needed?
👁️ Dynamic Visual Acuity (DVA) testing can test for a functional gaze stability deficit. A loss of more than 2 lines is considered abnormal.

If DVA is normal but the patient reports dizziness with the test, assess the patient for movement sensitivity (we like to use the Modified Motion Sensitivity Test).

What questions do you have about VOR exercises?

The vestibular system has NO collateral blood flow! 🩸

Changes in blood flow can cause damage to the vestibular and cochlear end organs themselves, leading to symptoms of dizziness, imbalance, hearing loss, or tinnitus.

It is important to be aware of other symptoms that may indicate vascular compromise:
👉🏽 the 4 Ds: diplomas, dysphasia, dizziness, drop attack
👉🏽 cranial nerve palsies
👉🏽 numbness/tingling

If suspicious for vascular involvement be sure to refer out for proper assessment and encourage medical management of comorbidities.

Should your patient still have dizziness 3 YEARS after a vestibular neuritis event? 😱 NO!

This patient’s initial vestibular hypofunction led to a more chronic issue: ✨Persistent Postural-Perceptual Dizziness (3PD)✨

Her symptoms strongly indicate 3PD:
⏰ near constant, non-spinning dizziness
📈 symptoms present for >3 months
👀 movement and visual triggers
👂🏽 symptoms preceded by a vestibular event

After thorough assessment of her balance and movement tolerance, we have a great plan in place to get her feeling better.

Have you had a patient with 3PD??

The FIRST step in diagnosing a patient’s dizziness is listening to their symptom profile.

AVS time pattern:
🌀 sudden onset dizziness
🌀 persists for days

It’s important to know that acutely they will be symptomatic at rest, but over time symptoms will present mostly with movement.

Other common symptoms are nausea, vomiting, and postural instability.

👀 Alexander’s Law 👀

Understanding this law is crucial for diagnosing a unilateral peripheral hypofunction.

Look for these signs to help confirm a peripheral cause of nystagmus:
➡️ unidirectional or direction-fixed nystagmus
➡️ nystagmus intensifies when the eyes are moved toward the direction of the fast phase (i.e. right beat nystagmus, nystagmus is more intense in right gaze)

*note that this is referring to assessment of spontaneous and gaze nystagmus in a seated position, therefore not involving assessment of positional nystagmus due to BPPV

❓what questions do you have about nystagmus presentation for unilateral vestibular hypofunction ❓

Is it really just BPPV❓

‼️Know the clinical signs of BPPV and unilateral vestibular hypofunction (UVH):

BPPV:
👉🏽 nystagmus and dizziness upon positional testing (I.e. Dix Hallpike, roll test, etc)
👉🏽 symptoms resolve with canalith repositioning procedures

UVH:
👉🏽 positive head impulse test
👉🏽 direction fixed spontaneous and gaze nystagmus
👉🏽 functional gaze stability and balance impairments

What questions do you have about assessing and treating BPPV vs. UVH? Leave them in the comments 👇🏼👇🏼👇🏼

Unilateral vestibular hypofunction (UVH) is an umbrella term for a weakness of one peripheral vestibular system.

It can be caused by:
❗️bacterial infection
❗️viral infection
❗️vascular event
❗️concussion or TBI
❗️ototoxicity due to medication
❗️tumor or lesion
❗️breakdown of structures due to aging

Common diagnoses associated with UVH:
🌀 Vestibular neuritis
🌀 Labyrinthitis
🌀 Ménière’s disease
🌀 Acoustic neuroma

Educating your patient on the pathophysiology of a UVH will help them understand why they are doing the exercises you give them!

What determines whether nystagmus is GEOTROPIC or APOGEOTROPIC in horizontal canal BPPV?

In the horizontal canal movement toward the cupula causes excitation ➕ and movement away from the cupula causes inhibition ➖

GEOTROPIC
💫 Right ear 👉🏽 right roll 👉🏽 right beat nystagmus
💫 Right ear 👉🏽 left roll 👉🏽 left beating nystagmus

APOGEOTROPIC
💫 Right ear 👉🏽 right roll 👉🏽 left beat nystagmus
💫 Right ear 👉🏽 left roll 👉🏽 right beat nystagmus

Now is the time to learn how to conquer BPPV!
To get $10 OFF our online course “Current Concepts in BPPV”, DM ‘BPPV’ and we will send you a discount code!

YOU need to be prepared to identify symptoms of
💫vestibular migraine 💫

Ask these questions:
❓ how long do episodes of dizziness last?
❓ any history of migraines?
❓ what other symptoms are present?

This information is vital for formulating an effective treatment plan to improve your patient’s dizziness!

SAVE this post for later! ✅

Keep an 👁️ out for these nystagmus qualities when doing the Dix Hallpike test for posterior canal BPPV

1️⃣ PATTERN - upward torsion toward the ear involved
2️⃣ LATENCY - short time period before the nystagmus begins
3️⃣ TIME PATTERN - nystagmus should gradually increase in intensity, peak, and then gradually slow

DM us if you want more info on diagnosing and treating BPPV!

The vestibulo-ocular reflex (VOR) is the 🔑 to understanding the vestibular system!

The VOR acts as an autofocus, keeping a target in focus while your head or body moves.

HOW IT WORKS:
1️⃣ peripheral vestibular system detects head movement
2️⃣ signal is sent through vestibular nerve to the brain
3️⃣ signal is sent to eyes to adjust in space relative to head movement

During a RIGHTWARD head movement:
⬅️Your eyes are pulled slowly left to stay focused on a target
➡️As the eyes hit the end of the orbit they will “jump” to the right to catch up with the head

This “ear-brain-eye” connection is an essential foundation for vestibular rehab!

It’s all about dizziness!! Or is it…? These 3️⃣ non-dizziness topics are important to discuss in relation to your patient’s symptoms.

Don’t forget to ask about
👂🏽 ear symptoms
🧠 migraine symptoms
😵‍💫 psychosocial factors

This can help clue you in to underlying causes or perpetuating factors contributing to dizziness.

Don’t forget to save this post for later!

April fools! 😅

Treating chronic dizziness involves a comprehensive approach to address your patient’s symptoms. Treatments may include:
💫medical management
💫vestibular therapy
💫lifestyle modifications (diet, exercise, sleep, etc.)
💫management of comorbidities (stress/anxiety, migraines, cardiovascular/autonomic symptoms, etc.)

If your patient is not improving like you’d hoped, make sure you’re treating your patient holistically and thoroughly.

April fools! 😅

Treating chronic dizziness involves a comprehensive approach to address your patient’s symptoms. Treatments may include:
💫medical management
💫vestibular therapy
💫lifestyle modifications (diet, exercise, sleep, etc.)
💫management of comorbidities (stress/anxiety, migraines, cardiovascular/autonomic symptoms, etc.)

If your patient is not improving like you’d hoped make sure you’re treating your patient holistically and thoroughly.

These details are VITAL when discussing dizziness‼️

You can learn important details about your patient’s dizziness just by asking the right questions. Don’t skimp on the subjective!

This week is Facial Palsy Awareness week! Those of you who have treated patients with facial palsy or are impacted in any way by this condition, understand that it is so much more than physical. Our patients often need lots of support for managing their palsy. The smile truly is the thumbprint of the soul 🙂

👂🏽 anatomy 👂🏽

When discussing benign paroxysmal positional vertigo it is important to be familiar with anatomy of the cupula, the sensory organ that is present in the ampulla of each semicircular canal.

We review this and more in our online course “Current Concepts in BPPV”! Course info in bio.

🌀Dizziness is NOT one size fits all!🌀

If a patient’s symptom profile does not seem consistent with one specific vestibular diagnosis, they may have multiple conditions occurring together.

Overlaps can occur with common diagnoses such as:
👉🏽benign paroxysmal positional vertigo (BPPV)
👉🏽unilateral vestibular hypofunction (UVH)
👉🏽vestibular migraine
👉🏽hydrops
👉🏽Meniere’s disease
👉🏽bilateral vestibular hypofunction
👉🏽persistent postural-perceptual dizziness (3PD)
And more.

Follow along to learn more about assessing and treating these conditions!

📣 Current Concepts in BPPV 📣

Our online BPPV course has gotten some 🔥 feedback, and we are so excited! The learning modules make it easy to go at your own pace. The graphics and visuals make understanding BPPV simple!

‼️one of the best parts - the course includes a 12 page PDF printout with diagrams, decision making algorithms, and descriptions of BPPV tests and treatments for easy reference in the clinic.

We have worked tirelessly on this course and cannot wait for you to see it 🎉

🎭 Happy Mardi Gras! 🎭

It’s a special time in Louisiana! If you celebrate Mardi Gras, we hope you have a wonderful (and highly unproductive work) day!

The 🔑 to diagnosing and treating BPPV is the nystagmus pattern. Know these patterns and what canal they indicate!

Posterior canal 👉🏽 upward torsion
Horizontal canal 👉🏽 geotropic or apogeotropic
Anterior canal 👉🏽 downward torsion

Want to learn more about assessing and treating BPPV?? Check the link in bio for our online course, Current Concepts in BPPV!

📄 The DHI is a validated and useful tool to assess your patient’s dizziness. This article identified 5️⃣ items on the DHI that are the most predictive for BPPV.

While it is important to screen most, if not all, patients with dizziness or imbalance for BPPV, if they choose “sometimes” or “always” for these 5 items a positional assessment is definitely warranted!

🎉 GIVEAWAY! 🎉

Our course Current Concepts in Benign Paroxysmal Positional Vertigo (BPPV) is officially launched! To celebrate, we are doing an Instagram giveaway for free course access to ONE lucky clinician!

TO ENTER:
1️⃣ like this post ❤️
2️⃣ tag 3 clinicians in the comments (PT/PTA, OT/COTA, AuD, MD, NP, PA, etc)
3️⃣ follow on Instagram
‼️for a BONUS entry share to your story

Note: CEU approved for Louisiana PT/PTA. State CEU requirements vary. Check with your individual state for approval requirements.

For course info, see the link in our bio (www.advancedneurotherapyed.com)
*course must be taken within 1 calendar year*

There are two main types of BPPV:
1️⃣ Canalithiasis- otoconia are free floating within the canal (most common!)
2️⃣ Cupulolithiasis- otoconia are adhered to the cupula

Nystagmus pattern and length of nystagmus are the main factors used for determining which variant you are treating.

Want to know more about assessing and treating different variants of BPPV? Our fully online BPPV course will be released soon!

Course weekend! 🙌🏼 We are excited to be teaching at LSU Health Sciences Center in New Orleans with Rachel Wellons. She is an associate professor at the LSUHSC physical therapy program and is the chair of the Academy of Neurologic Physical Therapy vestibular special interest group. We are honored to have her teaching with us this weekend!

Did you know?!

A link between bilateral hearing loss and vestibular dysfunction in the pediatric population has been well established in the literature.

It is important to screen kids for vestibular conditions if they have any hx of hearing loss!

TAG a pediatric therapist or clinician in the comments 👇🏼👇🏼👇🏼

Cushing SL, Papsin BC. Cochlear Implants and Children with Vestibular Impairments. Semin Hear. 2018 Aug;39(3):305-320. doi: 10.1055/s-0038-1666820. Epub 2018 Jul 20. PMID: 30038457; PMCID: PMC6054587.

⏪ back to the basics ⏩

We love this chart for referencing different types of vestibular disorders. It’s a great tool for patient education or student/clinician education!

Find this helpful? Click the save button for quick reference!

Need CEUs??? This is a perfect opportunity to meet your CEU requirements AND learn the ins and outs of vestibular therapy.

Don’t miss it! Link in bio.

People still get dizzy on Christmas! THANK YOU to all the healthcare workers who work tirelessly through the holidays to take care of patients with dizziness or any other symptom. We appreciate you!

Merry Christmas everyone! 🎄 🎅

The vestibular nerve fires at a tonic rate at rest. During head movement a paired activation and inhibition from the two vestibular systems occurs.

During a LEFT head turn
⬆️ excitation of left vestibular nerve
⬇️ inhibition of right vestibular nerve

This allows the brain to detect head movement accurately to keep us stable in space!