Exam 2

what is the role of the vestibular system

sensation and perception of self motion

what do the otoliths sense

head tilt and linear acceleration

what do the semicircular canals sens

rotation (angular acceleration)

when we test one side of the peripheral vestibular system…

the other side is also moving

what is the nerve supply to the vestibular system

vestibulocochlear nerve (CN VIII)

what is the vascular supply to the vestibular system

labyrinthine artery (branch of basilar artery)

what is characteristic of the labyrinthine artery

susceptible to ischemia

VOR

vestibular ocular reflex

maintains gaze stability during head movement

VSR

vestibulospinal reflex

controls body posture and muscle tone to maintain and regain postural control

VCR

vestibulocollic reflex

coordinates neck movements to stabilize the head

how does the tonic activation of the vestibular system work

move towards the side of more stimulation

move away from side of decreased stimulation

a symmetrical hypofunction of both sides of the vestibular system will result in…

no movement due to lack of imbalance between the sides

oscillopsia

bouncing with movement

clear sign of VOR dysfunction

what 5 things do you need to ask to clarify symtoms when a pt c/o “dizziness”

1. type

2. tempo

3. onset

4. duration

5. context

what are the 2 vestibular OMs that are widely used

??

nystagmus

rhythmic involuntary oscillation of the eyes

nystagmus is named for

the fast phase (correction of slow drift to the healthy side)

alexander’s law

looking towards the side of the beat will be more robust

looking away will be less or not at all

BUT always beats in the same direction

what is the difference in nystagmus from peripheral vs central

peripheral = direction fixed nystagmus

central = changing nystagmus

what special test is most commonly used to test for peripheral symptoms

head impulse test

what are the types of interventions used to treat vestibular dysfunction

adaptation (using intact components)

substitution (use other strategies) and compensation (external support)

habituation (repeated exposure)

balance/gait training

what are our parameters for vestibular interventions

short bouts of practice for multiple times a day

no more than 2/10 increase in symptoms during interventions

task oriented approach

*think of the PVT exercise

what is the mechanism of BPPV

otoconia from the otoliths are displaced from the utricle into the semicircular canal

in BPPV what direction is the nystagmus

direction of the affected canal

what is the most commonly affected canal in BPPV

posterior

what are the 2 types of BPPV

canalithiasis

cupulolithiasis

canalithiasis definition and characteristics

otoconia are free-floating in the canal (keeps on moving)

brief latency (nothing happens at first)

lasts <60s usually

intensity decreases prior to dissipating

cupulolithiasis definition and characteristics

otoconia are stuck in the cupula of the canal

immediate onset

lasts >60s

may persist until moved out of the position

what is the overall concept of position testing

position the head such that the canal will be in line with gravity upon moving into the test position

describe the Dix-Hallpike test

pt in long sit

rotate head 45 deg toward test side

relative quick movement down to the table w head ext 30-40 deg off the table

hold for at least 1 min or until any symptoms subside (canalithiasis vs cupulolithiasis)

what is a positive finding for posterior canal in Dix Hallpike

up beating and torsional towards the affected side nystagmus

describe the sidelying test

pt seated at EOB

rot 45 deg away from the test side

relatively quick movement into SL

hold for at least 1 min

describe the horizontal roll test

supine

elevate head 20-30 deg

quickly rotate head to one side

hold at least 1 min

return to neutral

repeat on other side

what is a positive finding of horizontal BPPV in the horizontal roll test

horizontal nystagmus

define geotropic nystagmus

towards the symptomatic side

with gravity

usually associated with canalithiasis

define apogeotropic nystagmus

away from the symptomatic side

against gravity

usually associated with cupulolithiasis

in the horizontal roll test, how is canalithiasis and cupulolithiasis different

canalithiasis: geotropic nystagmus and side w GREATEST intensity is the affected side

cupulolithiasis: apogeotropic nystagmus and side w LEAST intensity is the affected side

what is the overall concept of canalith repositioning maneuvers

rotate the head such that gravity moves the otoconia out of hte canal

describe epley’s maneuver (posterior canalithiasis)

long sit

same initial movement as Dix-Hallpike

slowly rotate head 90 degrees to opp side while maintaining ext

cont rolling the body onto the side w head turned down 45 deg towards the floor

maintain head rot while returning to sitting position

describe the semont maneuver (posterior canalithialsis)

seated EOB

same initial movement at SL test with 20 deg of cervical ext

hold for 1-2 min

maintain head rot and rapidly move pt to SL on opp side

hold for 2 min

maintain head rot while returning to sitting

describe BBQ roll (horizontal canalithiasis)

begin supine and rotate 90 deg to affected side

roll head away from affected ear to neutral

rot head another 90 deg away from affected side

cont roll with both head and body another 90 deg until facing down

return to sit while maintaining head position

desribe the gufoni maneuver (horizontal cupulolithiasis)

seated EOB

move quickly onto affected side w neutral head

hold for 30 sec

rapidly rotate head 45 deg downward to the ground

hold for 1-2 min

maintain head position while returning to sitting

define GBS

acute onset inflammatory polyneuropathy

rapidly progressing (days to weeks)

usually symmetrical

autoimmune and inflammatory process of the peripheral nervous system

hypotonic and flaccid

GBS is (upper or lower) motor neuron based

lower

GBS attacks what

myelin or the axon

what kind of GBS has the worse prognosis

axon

what clinical symptoms diagnose GBS

symmetric progressive weakness (ascending) or UE and LE (can affect cranial nerves)

arreflexia/hyporeflexia

possible sensory dysfunction

severe cases: respiratory failure and ANS dysfunction

cranial nerve involvement in 50% of cases

pain

what is interesting about the lumbar puncture study with GBS

normal WBC count

what is the most common type of GBD

(AIDP) acute inflammatory demyelinating polyneuropathy

myelin affected

what 2 GBS types affect the axon

(AMAN) acute motor axonal neuropathy

(AMSAN) acute motor sensory axonal neuropathy

what is the symptom triad of miller-fisher syndrome

ataxia

ophthalmoplegia

areflexia

how long does it take for GBS to get to the nidar (worst point)

4-6 weeks

what are the phases of GBS and when do they occur

acute/ascending > 3-21 days after onset; in ICU, critical care or acute care

plateau > ICU, critical care, acute care, long-term acute care

recovery/descending > acute care, IP rehab, SAR, home-care, OP

how long can recovery of GBS take

up to 2 years

what are the 5 patient experience phases of GBS

1. dependency

2. helplessness

3. wanting to know more of GBS

4. discovering inner strength

5. regaining independence

how are mild cases of GBS treated

conservatively

how are severe cases of GBS treated

acute medical intervention and supportive care

what types of immunotherapy are used to treat GBS

plasma exchange (plasmapheresis)

intravenous immunoglobulin

what do we have to be careful with in GBS patients in the acute + plateau phases

overstretching (especially muscles that cross 2 joints)

what type of strength training do we avoid at first in the recovery phase of GBS

eccentric

chronic inflammatory demylinating polyneuropathy (CDIP)

chronic disorder that is related to GBS

less common

relapsing and progressive forms

motor predominant

what is the difference in time between GBS and CIDP

CIDP nadir is usually >8 weeks after symptom onset

define MS

multiple sclerosis

autoimmune, neuroinflammatory, neurodegenerative disease

MS affects which nervous system

central (brain, SC, optic nerve)

primarily white matter

what is the biggest difference between GBS and MS

GBS = peripheral

MS = central

what is the pathophysiology of MS

acute inflammation > fibrous gliosis (scarring) > sclerotic plaque/lesion

define relapse in MS

acute episode of new inflammation

typically lasts >24 hours

what do lesions of MS look like on MRI

white circles on the cord

what are the risk factors for MS

females

obesity

Hx of other autoimmune disorders

Hx of epstein-barre virus

family Hx (genetic predisposition)

geographical location

vit D deficiency

what are the 2 things we need to meet in MS lesions to get a diagnosis

dissemination in space - lesion in at least 2 distinct CNS regions

dissemination in time - lesions at at least 2 distinct attacks

what are the 5 places of the CNS that an MS lesion can occur

periventricular

juxtacortical

infratentorial

SC

optic nerve

what are the other supporting findings for an MS diagnosis

oligoclonal bands in CSF but not in the blood

central vein sign

paramagnetic rim lesions

what is the life expectancy for MS patients

only 6 years less than the general population

what are the 3 types of MS

relapsing-remitting

secondary progressive

primary progressive

define relapsing remitting MS

episodes of acute inflammation with full or partial recovery

define secondary progressive MS

transitions into a steadily progressive decline

relapses are possible but less freq

define primary progressive MS

progressive decline from initial presentation

relapses are possible but less frequent

CIS

clinically isolated syndrome

one episode of clinical syndrome (does not meet dissemination in time)

60-80% progress to MS

RIS

radiographically isolated syndrome

often incidental finding during imaginf for other reasons (ex: after MVA)

how is MS managed acutely

high dose of corticosteroids

how MS managed long term

DMT (disease modifying therapies)

medications that stop the disease process

what do some DMTs for MS increase the risk for

progressive multifocal leukoencephalopathy (PML) because of the triggering of JC virus

what are the most common initial presenting symptoms of MS

visual impairment

sensory disturbance

what is the difference between relapse and pseudo relapse

relapse = new symptoms or worsening of old symptoms; >24 hours

pseudo-relapse = usually worsening of old symptoms; <24 hours; infection, stress, overheating induced

what are the 2 most common MS symptoms

severe fatigue

heat intolerance

what is important to note about HR in MS patients

autonomic dysfunction causes HR to be unreliable when gauging exercise intensity

what are the common gait impairments in MS patients

flexors compromised (hip, knee, DF)

in the Kurtzke expanded disability scale, what is the difference between earlier and later stages

earlier = based in neurologic function (1.0-4.5)

later = based on ambulation (5.0-9.5)

what do we have to manage with MS patients

lifestyle + behaviors modifications

fatigue

heat sensitivity

pain

spasticity

gait

what is the biggest emerging treatment in MS for functional leg strength

blood flow restriction training

what is the most common diagnostic tool for MS

Mcdonald Criteria

chances of developing parkinson’s increases with what

age

what is secondary parkinsonism

vascular

drug induced

wilson’s disease (excessive copper in the body)

normal pressure hydrocephalus

what is parkinson-plus degenerations

lewy body dementia

multiple system atrophy

corticobasal ganglia degeneration

progressive supranuclear palsy

primary idiopathic parkinson’s disease represents what percent of parkinsonism

90%

define idiopathic parkinson’s disease

cell loss disorder in the substantia nigra pars copacta

death of dopaminergic neurons

what are the 2 subtypes of IPD

tremor dominant

postural instability/gait disturbance

define tremor dominant IPB

most common

slower progression

most favorable prognosis

relatively preserved mental status

define postural instability/gait disturbance IPB

more rapid progression

falls

more severe cognitive dysfunction

poorer prognosis

what are the 4 cardinal signs or parkinsons

bradykinesia**

rigidity*

rest tremor*

postural instability

(need bradykinesia and 2 of the rest of the 3)