CVT Patient Safety & Clinical Decision-Making 3 — Questions and Answers
Question 1: Before initiating cervical BPPV maneuvers, which pre-screening test helps identify vertebrobasilar insufficiency risk?
- Romberg test with eyes closed
- Cervical arterial insufficiency screen (Hautant's/VBI testing) (Correct answer)
- Head impulse test (HIT)
- Fukuda stepping test
Correct answer: Cervical arterial insufficiency screen (Hautant's/VBI testing)
Cervical arterial insufficiency screening (e.g., Hautant's test or sustained rotation/extension positions) helps identify patients at risk for vertebrobasilar compromise during repositioning maneuvers.
Question 2: A patient on vestibular rehabilitation is also taking meclizine daily. The therapist should anticipate which effect on treatment outcomes?
- Accelerated vestibular compensation due to reduced nausea
- Reduced central nervous system plasticity potentially slowing compensation (Correct answer)
- Enhanced gaze stabilization due to oculomotor suppression
- No clinically meaningful effect on rehabilitation progress
Correct answer: Reduced central nervous system plasticity potentially slowing compensation
Meclizine is a vestibular suppressant that reduces central compensation mechanisms, potentially slowing the neuroplasticity-dependent recovery process in vestibular rehabilitation.
Question 3: During the modified HINTS exam (Head Impulse, Nystagmus, Test of Skew), which combination is most reassuring for a BENIGN peripheral cause of acute vestibular syndrome?
- Normal head impulse, direction-changing nystagmus, skew deviation present
- Abnormal head impulse, unidirectional nystagmus, no skew deviation (Correct answer)
- Normal head impulse, unidirectional nystagmus, skew deviation present
- Abnormal head impulse, direction-changing nystagmus, no skew deviation
Correct answer: Abnormal head impulse, unidirectional nystagmus, no skew deviation
In peripheral vestibular neuritis, the head impulse test is abnormal (catch-up saccade), nystagmus is unidirectional and suppressed by fixation, and skew deviation is absent.
Question 4: A therapist notices a patient's Romberg test is significantly worse with foam padding than on firm surface. What does this most likely indicate?
- Primarily visual system compensation for balance deficits
- Primarily somatosensory system compensation for vestibular loss (Correct answer)
- Normal aging-related balance changes requiring no intervention
- Central cerebellar dysfunction requiring immediate referral
Correct answer: Primarily somatosensory system compensation for vestibular loss
Marked worsening on foam (which reduces somatosensory input) compared to firm surface indicates the patient is relying heavily on somatosensory cues to compensate for vestibular deficits.
Question 5: Which scenario requires IMMEDIATE discontinuation of vestibular exercises and physician notification?
- Temporary increase in dizziness lasting 30 seconds after head movement exercise
- New onset of severe headache, vomiting, and ataxia during treatment (Correct answer)
- Mild fatigue reported after 20 minutes of balance training
- Patient reports feeling slightly off-balance when walking on uneven surfaces
Correct answer: New onset of severe headache, vomiting, and ataxia during treatment
Severe headache, vomiting, and ataxia during treatment are red flags for a posterior fossa event such as cerebellar hemorrhage requiring emergency evaluation.
Question 6: A patient with bilateral vestibular hypofunction asks about return to driving. Which objective assessment most directly informs this clinical decision?
- Dizziness Handicap Inventory score below 16
- Dynamic Visual Acuity testing showing less than 2-line loss (Correct answer)
- Vestibulo-ocular reflex gain above 0.8 on video head impulse testing
- Functional Gait Assessment score above 22/30
Correct answer: Dynamic Visual Acuity testing showing less than 2-line loss
Dynamic Visual Acuity testing directly measures the ability to maintain clear vision during head movement, which is the key vestibular function required for safe driving.
Question 7: When documenting informed consent for vestibular rehabilitation, which element is MOST important to include for a patient with cervical spondylosis?
- Estimated cost of the full treatment course
- Risks of cervical manipulation techniques and alternatives discussed (Correct answer)
- Names of all exercises that will be performed
- Projected number of sessions required for full recovery
Correct answer: Risks of cervical manipulation techniques and alternatives discussed
Patients with cervical spondylosis face elevated risk with cervical mobilization; documenting that risks were discussed and alternatives offered is a critical medico-legal requirement.
CVT Patient Safety & Clinical Decision-Making 3
Before initiating cervical BPPV maneuvers, which pre-screening test helps identify vertebrobasilar insufficiency risk?