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Vestibular Management (2) - Coggle Diagram
Vestibular Management (2)
Priorities
Thorough screen and assessment to discern cause of vertigo, whether it is treatable by physio or whether need to refer on
Red flags, central signs --> refer on. If suspicious of stroke or neuritis needs further investigation from doctor.
Given the level of detail/specifics required in subjective history I would use a 'vestibular assessment template' to ensure that I didn't miss anything.
Red flag check list:
5D's
- dizziness, drop attack (dysautonomia), dysphagia, dysarthria, diploplia
3N's
- numbness, nausea, nystagmus
Perform thorough assessment to determine probable cause of symptom
Neuritis
Labrynthitis
BPPV
Stroke
Vestibular migrane
Facts
Anatomy
2x otoliths (saccule - vertical, utricle - horizontal)
3x canals (posterior, horizontal, anterior)
Hair cells convert movement to electrical signals, change in cell firing rate in response to movement (excitatory or inhibitory rate depending on acceleration or deceleration). ie. (L) movement = (L) excitatory, (R) inhibitory
Function: vestibular system enables us to maintain and upright posture whilst moving.
Vestibular occular reflex
allows us to maintain our
focus
whilst moving,
vestibulospinal reflex
allows us to maintain an
upright posture
whilst moving
Complex sensory integration to maintain postural control: vision, somatosensory, vestibular, auditory
To be proficient in this area I would need to undertake practical training to familiarise myself with how to perform techniques.
Difficulties
Must screen for red flags (generally indicative of central cause)
Sudden
hearing loss: neuritis, benign tumour
Vestibular neuritis
Vestibular labrynthitis
Sudden
hearing loss,
sudden
onset vertigo = high risk AICA stroke
Prolonged nystagmus (likely central sign)
vertical nystagmus (likely central sign)
Also need to screen for contrary indications to treatment, reduced neck extension etc. consider modified technique
Feelings
Confident with importance of ruling out red flags, discerning whether physio treatment may be indicated, if clear picture. Not confident in treatment techniques due to lack of practice, high velocity often required in older population who often have stiff neck. Would not be confident to attempt high velocity slam required to dislodge crystals if cupulolithiasis present.
Cupulolithiasis: definitely not confident to attempt high velocity slam required to dislodge crystals from cupulo to convert it to a canalithiasis.
I would be happy to trial Dix halpike if I had confirmed that patient presentation was a posterior canal Canalithiasis
If I saw a patient with horizontal canal involvement, I don't feel confident with my ability to discern whether the nystagmus is geotropic or ageotropic. Possible solution would be to undertake a more comprehensive course on vestibular management, discuss with more experienced colleagues, trial vesticam goggles etc.
Despite knowing that for treatment to be effective, we do need to expose patients to a certain degree of discomfort to decrease sensitivity ie. looking at progressively busier patterns for patients experiencing a vestibular migranes I am not confident with what the ideal 'window of exposure' looks like, no doubt this is something that would come with more clinical experience and discussing recommendations with colleagues.
Benetfits/Ideas
Demonstrate and explain technique on myself prior to performing it on patient. Given that 'dizziness' is often accompanied by some level of anxiety/apprehension, this would help put patients at ease.
Advise patient about what they may feel, why and how long it will last for. ie. this test may reproduce your dizzy symptoms when I tip you back, this means we know what we need to treat and it will likely resolve within certain duration once I sit you back up
Have emesis bag on hand incase
Sudden onset of external environment spinning, short duration, provoked by positional change like getting out of bed and hanging the washing out, eased by keeping still and closing eyes often indicative of peripheral issue that will respond to physio Rx. (But still essential thorough Ax performed to rule out any red flags. Light headedness, spinning inside head often more indicative of central issue.)
Creativity
Write a summary table/quick reference guide to consolidate and outline key components: ie. prolonged nystagmus, vertical nystagmus generally indicative of central signs. -ve HIT, no spontaneous nystagmus, -ve DVA, +ve epply provoked sort duration nystagmus <60sec, dizziness provoked likely BPPV.