Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 11
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30Physical Examintion
copper deposition in the cornea in patients with Wilson’s
disease
. Children with ataxia-telangiectasia also have
10
Physical examination with the aim of differential
“spider” veins in the corners of the eyes. Vertical and
diagnosis in patients complaining of dizziness requires
horizontal misalignments of the eyes may be caused
a multitude of tests. Table 4 provides a suggested for-
by cranial nerve palsies. A skew deviation is a vertical
mat for the physical examination. The proposed order
misalignment of the eyes that is not the result of ocular
of examination in this format is intended to safeguard
muscle palsy
. Skew deviation is best detected by alter-
9
previously undiagnosed patients from unnecessary and
nately covering the eyes: Patients with skew deviation
potentially harmful physical tests by establishing the need
make a vertical corrective movement in the sense of a
for referral and obviating the need for further testing in
lateral head tilt when switching the cover from the unaf-
case of a positive response to an earlier physical test.
fected to the affected side. Skew deviation, head tilt, and
ocular counter-rolling constitute the ocular tilt reaction
.
9
Observation
Unilateral lesions of the vestibular nucleus, the medial
longitudinal fascicle, and other vestibular centers due
Skin Observation
to vertebrobasilar infarction can produce a full ocular
Children with ataxia-telangiectasia have tiny red
tilt reaction
. A unilateral thalamus lesion or a benign
34
“spider” veins on the ears and cheeks. Dry skin with
otolith dysfunction can produce a partial ocular tilt reac-
brittle hair may indicate hypothyroidism. Vitamin B
12
tion
. In patients with peripheral or vestibular nucleus
34
deficiency can cause a lemon-yellow skin discoloration.
lesions, the lower eye indicates the side of the lesion;
Papilledema due to increased intracranial pressure oc-
lesions above the level of the vestibular nucleus present
curring together with dysequilibrium is indicative of
with the higher eye on the side of the lesion
. Any of
9
an intracranial mass lesion, usually in the posterior
these abnormalities indicate a need for referral.
fossa
. Clubbing of the fingernails, cyanosis of lips,
10
trophic changes of the skin, and peripheral edema could
Vital Signs
suggest a cardiovascular disorder
. All abnormalities
36,57
above in combination with relevant symptoms noted in
Blood Pressure
the history may indicate the need for referral.
In patients with subclavian steal syndrome, a dif-
ference in blood pressure between the affected and
Postural Observation
non-affected arm is virtually always present. On aver-
Postural deviations negatively affecting the location
age, systolic blood pressure is 45 mm Hg lower in the
of the center of gravity in relation to the base of support
arm supplied by the stenotic blood vessel
. Symptoms
10
may result in patients complaining of the dysequilibrium
indicative of subclavian steal syndrome in combination
type of dizziness. These deviations also prompt further
with a ≥45 mm Hg lower systolic blood pressure in the
musculoskeletal examination to determine cause and
symptomatic arm is a reason for referral. Hypertension
potential management strategies. Postural deviations
and hypotension can contribute to dizziness symptoms
.
36
may also indicate possible pathology. Friedreich’s ataxia
Monitoring the patient’s blood pressure response when
typically causes an increased kyphoscoliosis. Neuro-
transferring from a lying to a standing position is used
syphilis frequently leads to hypertrophic or hypermobile
as a diagnostic test for orthostatic hypotension. A drop
joints with subsequent effects on posture. Craniocervical
in systolic blood pressure of ≥ 30mm Hg or a drop of
junction abnormalities can occur with Arnold-Chiari
10 mm Hg in diastolic blood pressure is indicative of
malformation
. A lateral head tilt might indicate an
10
orthostatic hypotension
. Eaton and Roland
considered
10
12
otolith problem (tilting of the environment) or just
a drop of 20 mmHg in systolic or 10mm Hg in diastolic
tightness of the sternocleidomastoid or upper trapezius
blood pressure two minutes after standing indicative
commonly seen in cervicogenic dizziness
, but it may
26,58
of orthostatic hypotension, but they also warned that
also be caused by ischaemia or infarction in the verte-
blood pressure readings in elderly patients might not
brobasilar system
. A forward head posture, with the
34
precisely meet those criteria. Witting and Gallagher
59
head backward bent on the upper cervical spine, may
established normative values: In 176 healthy subjects,
cause external mechanical compression of the vertebral
systolic blood pressure decreased by 1.2 ± 9.8 mm Hg
artery, thus potentially producing symptoms of VBI
,
31,49
after one minute of standing preceded by five minutes
but it may also lead to hypomobility of soft tissue and
of sitting. A drop in systolic blood pressure of ≥ 20 mm
joint structures especially in the upper cervical spine
,
49
Hg had a specificity of 0.97 for detecting orthostatic hy-
an area implicated in cervicogenic dizziness. Craniocer-
potension
. Combined with a complaint of presyncopal
59
vical junction abnormalities and lateral head tilt may
dizziness, this finding warrants referral.
indicate the need for referral.
Heart Rate
Eye Observation
Palpation of pulses may be useful in detecting a
Pigmented corneal Kayser-Fleischer rings are due to
232 / The Journal of Manual & Manipulative Therapy, 2005
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