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NM III vestib, SCI, TBI, concussion - Coggle Diagram

- - - - Description:
        
        Under the umbrella of FND
        
        15-20% of chronic dizziness
        
        No structural damage, problem with software
      - Symptoms and signs:
        
        High Visual dependence
        
        Hypervigilance to vision so they have difficulty with visually demanding tasks
        
        Perceived Somatizations sense of unsteadiness and lightheaded
      - Evaluation:
        
        Oculomotor exam
        
        educate patient
        
        validate
        
        Will have exaggerated sway with Rhomberg
        
        use mCTSIB and FGA
      - Treatment:
        
        Medication
        
        PT
        
        CBT
    - - Description:
        
        this is a diagnosis of exclusion
        
        Spontaneous vertigo that lasts as long as one position
      - Diagnosis:
        
        At least 5 episodes of vestibular symptoms lasting 5min-72h
        
        Hx of of migraines
        
        one or more migraines with one sided location, photophobia, visual aura.
        Slide 54
      - Management:
        
        Gaze Stability
        
        Habitation exercises
        
        Gait and balance training
        
        walking endurance training
        Those with high anxiety benefit the most
    - - Description:
        
        This is when there are low lying cerebellar tonsils that go through the foramen magnum
      - Symptoms:
        
        Exertional headache at base of skull
        
        Neck pain
        
        Imbalance
        
        Weakness in UE
        
        Oscillopsia
  - - - Clinical Manifestations:
        
        dizziness that lasts less than 15s
        
        onset with turning over in bed
        
        Episodic sensation of intense vertigo with head position changes
        
        sensation stops after 30s in static
        
        symptoms during head movement
      - Posterior canal conditions (85%)
        DIX HALLPIKE
        can do sidelying test if they cant do DIX
        
        Dix Hallpike maneuver:
        
        seat them in long sitting, head should hang off table when they lay down
        
        Rotate head 45 degrees toward testing side
        
        recline patient while holding head at 45
        
        position them in 20 degrees of Cervical extension
        
        remain in position for 1min
        
        return to position if negative and try other, if + go to eply
        
        Posterior canal CUpulolinthiasis:
        
        Upbeat torsional to involved side
        
        no latency and lasts over 1m
        
        Treatment: Liberatory maneuver:
        
        start with patient sitting sideways on table
        
        Rotate head 45deg to uninvolved
        
        Lie down on involved shoulder wait for nystagmus to stop
        
        Keep hold of their head in position and quickly arc so they lay down on other shoulder
        
        wait for 1min and then sit up
        Follow with eply
        
        Posterior canalinthiasis:
        
        Upbeat and torsional to involved side
        
        Latency and lasts a few seconds
        
        Treatment:
        
        Eply maneuver
        
        Perform the Dix Hallpike
        
        Rotate 90 degrees to opposite side while maintaining extension
        
        wait 1m
        
        roll onto L shoulder with nose pointing down, can chin tuck if needed
        
        slowly bring them back up maintaining their position
        
        Side lying test if they cant tolerate Dix-
        
        patient seated at edge of table
        
        turn head 45 deg away from tested side
        
        quickly lay them down to tested side with 20 deg of c extension
        
        observe eyes for 1min
      - Horizontal canal conditions (SUPINE ROLL TEST):
        
        increased autonomic symptoms
        
        repeated exams required to confirm
        
        can experience rolling in either direction
        
        Supine roll test:
        
        Patient supine with neck in 20 deg of FLEX
        
        patient is rolled 90 deg to L , can just turn head if they have the range
        
        wait 1 min
        
        roll 90 deg to R, wait 1 min
        
        Slowly roll back to neutral and sit up
        
        Horizontal canal CUpulolinthiasis:
        
        Beat toward tested side and be APOgeotrophic
        
        no latency and lasts over 1
        
        Impacted ear will be INTENSE nystagmus with the unaffected ear down
        
        Apogeotropic Gufoni maneuver
        
        Patient on side of the bed
        
        Lie down on to affected shoulder with that ear down
        
        wait 2min
        
        Quickly turn their head toward the ceiling
        
        wait 2 min
        
        slowly sit up with head in same position then bring to neutral
        
        Horizontal canal Canalinthiasis:
        
        Will beat towards side of involvement and will be GEOtropic
        
        Latency and lasts a few seconds
        
        Impacted ear it is Intense with affected ear down
        
        Geotropic Gufoni maneuver:
        
        patient sits upright and quickly lies down sidewasy onto affected ear
        
        Hold for 2 min
        
        head quickly rotated towards ground
        
        stay there for 2m
        
        slowly sit up with head in same position then slowly back to neutral
    - - Vestibular Neuritis
        
        Description: This is the spontaneous onset of CONTINOUS vertigo for a day to a week .
        
        Usually report having Viral infection
        
        Associated with nausea/ Emesis
        
        Can have lateralpulsion
        
        Vertigo not relieved with rest
        
        After 1w head motion induced imbalance and oscillopsia
      - Labyrinthitis
        
        Description:
        Similar to vestibular neuritis
        
        Can have acute hearing loss and tinnitus
        
        Creates vestibular hypofunction so can be treated similar
      - Vestibular schwannoma resection (acoustic neuroma)
        
        Description:
        
        happens due to a resection of a tumor that was on the 8th CN
        
        can have facial weakness
        
        Presentation:
        
        Progressive sensorineural hearing loss
        
        Tinnitus
        
        Imbalance
      - Meniere's Disease
        
        Diagnostic criteria:
        
        2 or more episodes of spontaneous vertigo lasting 20m-12h
        
        Fluxuating tinnitus or fullness
        
        typically unilateral
        
        Presentation:
        
        Most who are diagnosed do not have it
        
        progressive hearning loss and tinnitus
        
        Events of tumarkin which are conscious violent drop attacks they feel pushed without warning
        
        Management
        
        Low Na diet
        
        can have gentimicin injections to treat
        
        vestibular suppressants in acute attacks
        
        vestibular therapy if not acute attack
      - Superior Canal Dehiscence
        
        Description:
        
        This is an opening of the bone overlying upper portion of the superior canal
        
        Patient presentation:
        
        Pressure sensitivity during coughing, valsalva, BM
        
        Sound sensitivity
        
        Tulio phenomenon where loud sounds cause vertigo
        
        Hearing heartbeat in ear, hear eye movement
        
        Hearing loss and aural fullness
    - - Description:
        
        most commonly caused by gentamicin use
        
        can be caused by aging
        
        Head impulse may be diminished
  - - - Purpose:
        developed to induce long term changes in neuronal response to head movements
        GOAL: reducing symptoms and normalizing gaze and postural stability
        
        VOR x 1:
        angular acceleration of the head stabilize on target
        Keep your eyes on X and turn your head
        2Hz is the goal
        
        VOR x 2:
        Both head moves and the target moves
    - - Purpose:
        To promote alternative strategies to substitute for impaired vestibular function
      - Substitution Exercises:
        
        Eye movement between 2 targets - both thumbs in front, eyes move, then head moves to one, then do the same for the other
        
        remembered target exercise - thumb in front and keep eyes on it with eyes closed and a head turn
        
        walk with head turns
        
        balance on different surfaces
    - - Purpose: Use movements that are provocative to the patient in increasing repetitions to lead to a reduction in symptoms.
- - - - Exam:
        
        Canadian c spine rules
        
        Ligamentous stability (alar, sharp purser, transverse)
        
        UQS
        
        joint position error ( over 4.5 deg is meaningful error)
        
        Smooth pursuit
        
        Cervical torsion
        
        H and N differentiation
      - Cervical torsion test:
        
        patient is seated on swivel chair
        
        close eyes
        
        Pt holds head in neutral
        
        patient rotates their trunk and holds for 30s
        positive is symptom provocation or nystagmus
      - head and neck differentiation test:
        
        seated on swivel
        
        eyes closed
        
        PT holds head in neutral
        
        Patient rotates trunk to 45deg at 60bpm
        Positive is symptoms or nystagmus
      - Interventions are impairment based
        
        Manips only AFTER acute
    - - Exam:
        -VOMS which includes
        
        smooth pursuit
        
        saccades (eyes between 2ts)
        
        near point convergence( abnormal if target doubles at or over 6cm )
        
        VOR ( 180bpm only 20deg of movement)
        
        VOR C( 50bpm 80deg trunk rot)
        
        also check
        
        BPPV
      - Intervention:
        Impairment based where you try to have it be as difficult as possible before inducing the symptoms
        
        Only introduce new activities one at a time
        
        encourage rest breaks
        
        VOR 1 and 2 IF eyes slip off target or it blurs with test (need adaptation)
        
        Habituation if eyes remain on target and are stable but it causes symptoms
        
        if visual motion sensitivity can go graded progression starting in sitting
        
        brock strings in concergance/ divergance, can also do pencil push ups
    - - Buffalo treadmill /bike test for exertional tolerance:
        stop if symp worsening more than 3pt (worsening symp 1t, new symp 1pt), stop if over 17 RPE, at 90 age predicted
      - Intervention:
        
        we should implement graded progressive aerobic
        
        Buffalo- prescribe aerobic at 60-80% of test max for same duration 5-6 days a week
    - - BESS test can evaluate static balance
        
        CB & M- higher level balance and mobility based on environment
        
        HiMAT- running and jumping skipping
        
        DGI
        
        FGA
        
        CTSIB
    - - returning to sport guidelines
        
        relative rest in first 48h
        
        Must have medical clearance to progress from stage 3-4
        
        if they have symptoms over a 2pt increase then scale back
      - Return to learn:
        
        Same 24-48h relative rest
        
        encourage sub symptom daily activity
        
        reduce screen time
- - - - 14% expected to regain walking function
    - - 75% expected to regain walking function
    - - 33% expected to regain walking function
    - - 100% expected walking recovery
    - - Walking 4 neuroplastic principles:
        
        Specificity matters
        
        Intensity matters (BDNF)- over 15 on borg
        
        Repetition matters
        
        Salience matters
        
        NO BWSTT or robotic assisted or pregait activities after 6m
  - - - Prevention/ Tx of OH
        
        maintain ROM
        
        avoid aggressive stretching in inflammatory stage
        
        optimize W/C position
    - - Pressure relief by turning in bed every 2h
        every 20min for 2 min in wheelchair
- - - - Team roles
        
        continuous monitoring
        
        Family roles
        
        Stay calm
        
        receive medical info
        
        basic comfort
    - - Team roles
        
        document baseline responsiveness
        
        Family Actions
        
        calm gentile speech
        
        avoid complex medical talk
        
        watch for any purposeful movement
        
        Levels 1-3 main goals
        
        position and pressure reduction to prevent skin breakdown, contractures, and pneumonia. Recommend amounts of stimulation and caregiver education
    - - Team roles
        
        Deliver brief varied stimulation
        
        Deliver early cognitive engagement
        
        Family roles
        
        explain to them what you are about to do
        
        Talk in normal tone
        
        keep comments and commands short and simple
    - - Team roles
        
        1:1 supervision
        
        use specialized beds/ equipment for safety
        
        manage agitation
        
        simple familiar tasks
        
        frequent rest breaks
        
        Family roles
        
        Reassure them that they are safe
        
        experiment to find familiar calming activities
        
        PT main goals for levels 4-5
        
        encourage patient to be more active participant in therapy
        
        regain functional ability and allow for cognitive, behavioral and memory challenges.
        
        PT locomotion action statements for TBI and SCI OVER 6m
        
        Should do mod-H intensity walking training at 60-85% HRm
        
        Should used VR
        
        Strength training should be used
        
        MAY circuit train
        
        DO NOT use the following
        
        use BWSTT after 6m
        
        Robitic assted
    - - Team Roles
        
        Work on sustained attention
        
        errorless learning
        
        Limit number of visitors to 2-3
        
        help them organize
        
        Family Roles
        
        Repeat things
        
        repeat orientation cues
        
        have consistent routine
        
        short relevant interactions
    - - Team Roles
        
        can start challenging memory, attention
        
        physical deficits can be adressed
        - Awareness training
        
        Family roles
        
        Use memory aids
        
        keep daily schedule
        
        Allow extra processing time
        
        PT goals for 6-10
        
        facilitate patient to initiate more activities and ask for assistance or guidance
        
        provide structure
        
        new learning
        
        gaining independence
        
        return to optimal functioning
    - - Team roles
        
        Focus on real world ALDs
        
        Role training
        
        Vocational training
        - Awareness training
        
        Family roles
        
        encourage independent routine
        
        offer some supervision
        
        reminders for compensatory tools
    - - Team Roles
        
        work on executive function
        
        physical conditioning
        - Awareness training
        
        Family Roles
        
        Promote consistent use of memory aids
        
        watch for irritability, low tolerance and fatigue
    - - Team Roles
        
        Work on complex task sequencing
        
        work on dual tasking
        
        Family Roles
        
        Be available for assistance
        
        community entry planning
    - - Team Roles
        
        Ongoing OP therapy
        
        refine skills
        
        Return to work
        
        Family roles
        
        Promote autonomy
        
        reinforce sustained memory