Basic Vestibular Function Tests Overview The vestibular system

Basic Vestibular Function Tests

Overview • The vestibular system • Why test the balance system? • What is bedside testing? • The type of tests and what they show • Management

The vestibular system • Helps us to keep upright, maintain posture • Helps us to keep the gaze of our eyes stable when our head moves

Patient Explanation. Discuss how you would explain this to a patient, (review teacher notes at base of each page)

Investigate dizziness Observe responses Onward referral Aim Decide on managemen t Exclude major pathology

What is bedside testing? We don’t need a bed.

Pathway Overview History Taking Bedside Testing Further Investigation Diagnosis Management

Why bedside testing? Pros Quick Cost effective Easy to perform Good co-operation from patients Cons Can be influenced by the examiner Not as specific Incorrect interpretation Not as sensitive

REMEMBER! The patient might feel dizzy, sick and they may fall so ensure you are in a safe working environment with enough space.

Useful Equipment Logmar Chart Clinical Test of Sensory Interaction and Balance (CTSIB) cushion Frenzel goggles

Cerebellar function tests Test type Rebound test Positive How to perform Example symptoms Inability to Arms out and Problems control push down/put opening and contrasting some pressure on closing a muscle groups the arms door so patient will fail resistance to pressure

Cerebellar function tests Test type Positive Dysmetria Inability to judge range of movement and locate target so patient will undershoot or overshoot the target. How to perform Example symptoms Ask the px to Unable to touch their nose put spoon to and then your mouth finger or tip of a pen. Move the location of the pen to the middle, right and left.

Cerebellar function tests Test type Positive How to perform Example symptoms Dysdiadochok Impaired Rapid palm Difficulties inesia ability to supination/pron in changing perform rapid ation (rotation) a light bulb alternating or using a movements, screwdriver becoming irregular and lagging

Vestibular-ocular reflex

Define nystagmus

Ocular motor tests We first need to check that the patient can make conjugate eye movements and also check their range of eye movement. Test type Smooth pursuit How to perform Positive Keep the head still Cogwheeling or and use the tip of catch up saccades finger or pen and indicate a central ask the patient to sign follow the target with their eyes only. Should be a fine movement

Ocular motor tests Test type Random saccades How to perform Keep the head still and use the tip of finger or pen. Ask the px to locate the target. Positive Overshoot or undershoot of target can be a central sign

Ocular motor tests Test type Spontaneous nystagmus How to perform Involuntary eye movememt Positive See Alexanders law, next slide Nystagmus beats opposite to the side of the weakness. Fast beat to the stronger side with a slow phase back. First degree: nystagmus is present in the centre Second degree: nystagmus is present in the centre and right or left Third degree: nystagmus is present in all three directions.

Vestibular-ocular reflex tests Test type Head thrust (halmagyi and Curthoys, 1988) How to perform Relax patient, grip to the sides comfortably, impulse turn to the right or left from centre Positive Catch up saccade

Vestibular-ocular reflex tests Test type Dynamic visual acuity How to perform Keep glasses on. Head shake from behind the patient, Positive Drop in three or more lines indicates bilateral failure or uncompensated peripheral lesion

Vestibular-ocular reflex tests Test type Head shake How to perform Positive 20 seconds shake Catch up saccade with frenzel glasses reveals an acute to avoid peripheral loss. At suppression least three beats. E. g. left beat=right sided weakness

Five Minute Practical

Vestibulo-spinal reflex tests Test type Romberg How to perform Positive Sensitivity Stand with feet Sway towards the 39% sensitve together with eyes affected side. Central to a open and then sign can be an neuroma eyes closed for 30 irregular sway (Moffat et seconds Sway backward-spinal al, 1989). tract sign.

Vestibulo-spinal reflex tests Test How to perform type Sharpen Ask the px to ed/ stand heel to toe Romberg Positive Sensitivity Sway, step or fall poor

Vestibulo-spinal reflex tests Test How to perform Positive Sensitivity type Unterber Ask the patient to More than 45 degrees 71% ger/Fuku put their arms up rotation to one side sensitivity to da and march on the indicates that it is the a unilateral stepping spot with their weaker side. acoustic eyes closed for 30 neuroma seconds or 50 (Moffat et steps al, 1989)

Vestibulo-spinal reflex tests Test type How to perform Postive Tandem walk Arms folded against chest. 10 steps tandem eyes open and then eyes closed Difficult eyes open indicates a cerebellar disorder, with eyes closed, recent unilateral lesion deviation to that side common Sensitivity

Five Minute Practical

Management • Bedside tests can indicate a lesion • Bedside tests aren’t sensitive alone but a useful screening tool before expensive tests are carried out • Also think about postural blood pressure changes, thyroid issues, low iron and other causes of balance problems such as hyperventilation

Management If further information is required then refer for further testing before you make a diagnosis.

Further reading: https: //jnnp. bmj. com/content/jnnp/75/suppl_4/iv 32. full. pdf https: //www. dizziness-and-balance. com/index. html

Image references Source: Open. Stax College. Anatomy & Physiology, Connexions Web site. http: //cnx. org/content/col 11496/1. 6/, Jun 19, 2013 Date 2011 Logmar chart Source Own work Author Crosstemplejay Description Deutsch: Frenzelbrille English: Frenzel goggles Date 2011 Source Own work Author Polarlys Description English: Diagram of a horizontal, right turn, vestibulo-ocular eflex, with English labels. Date 28 May 2008 Source own work, based on Image: Simple_vestibuloocular_reflex. PNG and Image: Three. Neuron. Arc. png Author. Koen

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