Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 15
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30cardiovascular disorder. Palpitations, the presence of an
Unilateral cerebellar lesions result in a deviation to-
irregular heartbeat, may indicate a disturbance in the
wards the side of the lesion when the patient attempts
heart’s ability to normally conduct electrical impulses
to walk in a straight line. Patients with cerebellar
36
and may be benign or quite dangerous. Palpitations
ataxia are unable to walk in a tandem gait. In patients
lasting for hours or irregular heartbeats accompanied
with sensory ataxia, gait is also wide-based. Impaired
by pain, shortness of breath, or lightheadedness re-
proprioception may cause steppage gait: The patient
quire referral to a physician for medical evaluation
.
lifts the feet excessively high off the ground and slaps
36
Similarly, tachycardia (>100 bpm) and bradycardia (<60
them down rather heavily. Using a cane or a railing
bpm) may indicate relatively benign conditions, such
often dramatically improves gait
. Difficulty walking
10
as mitral valve prolapse and “athlete’s heart” but may
with concurrent rotation of the head in the horizontal
also occur in more serious conditions such as coronary
plane may indicate a peripheral vestibular deficit. Gait
artery disease and aneurysm
. Monitoring pulse rate
unsteadiness may also be a complaint in patients with
36,57
during a sit-to-stand test may also be helpful for diag-
psychiatric or factitious disorders. Simon, Aminoff, and
nosing orthostatic hypotension: Witting and Gallagher
Greenberg
noted that wildly reeling or lurching move-
59
10
established a normative value of a pulse rate increase
ments from which the patient is able to recover without
of 5.3 ± 6.6 bpm in normal subjects and suggested an
loss of balance may be indicative of conversion disorder
increase of ≥ 20 bpm as a positive test for orthostatic
or malingering: Recovery of balance from self-imposed
hypotension based on a sensitivity of 0.98. Combined
extreme positions and movements in fact demonstrates
with a complaint of presyncopal dizziness, this finding
well-developed balance function. Gait assessment can
warrants referral.
also be done quantitatively with measures such as the
Tinetti Balance Scale and Berg Balance Scale, both with
Auscultation
established predictive validity with regards to fall risk.
Auscultation tests can provide information on a
The former has been reported to identify 7 out 10 fallers
possible cardiovascular disorder responsible for a pa-
with 70% sensitivity and 52% specificity
, whereas the
62
tient complaint of presyncopal dizziness. Lok, Morgan,
latter was able to correctly identify fallers from non-fall-
and Ranganathan
found poor accuracy and inter-rater
ers with 91% sensitivity and 82% specificity
. A score
60
63
agreement for identification of some cardiac ausculta-
on either measure indicative of a low fall risk despite a
tion parameters. Listening for carotid bruits has been
complaint of dizziness and dysequilibrium may indicate
suggested as a screening tool for the likelihood of a
kinesiophobia, which can be classified under other dizzi-
vertebrobasilar incident with cervical manipulation
.
ness and may indicate the need for referral. Titubation,
13
We earlier discussed the role of collateral (i.e., carotid)
oscillation of head and trunk, unilateral deviation when
circulation in the occurrence of VBI
. Terrett
noted that
attempting to walk in a straight line, and wild reeling
1
13
the validity of carotid bruits in the diagnosis of carotid
or lurching motions without loss of balance are less
stenosis or prediction of a vertebrobasilar incident is
likely indicators of musculoskeletal impairments and,
questionable. Negative auscultation results would seem
therefore, indicators for referral.
to provide the therapist with a false sense of doing a
relevant vertebrobasilar screening
. In contrast, Magyar,
13
Vestibulo-Spinal Examination
Nam, Csiba, et al
reported 56% sensitivity and 91%
61
specificity for detection of a 70-99% carotid stenosis
The vestibulo-spinal reflex (VSR) stabilizes the body
when compared with color duplex ultrasound. They also
during head movement; thus, it is responsible for pos-
reported a positive predictive value of 27% of a bruit
tural control. The vestibulospinal tests in general have
found and a 97% negative predictive value for a normal
poor or untested diagnostic accuracy but can serve to
auscultation. They concluded that carotid auscultation
guide further examination by indicating the presence
is a useful screening procedure for carotid occlusion
of postural instability and by implicating the vestibular
or stenosis. In light of the possible contradictory inter-
versus somatosensory system. In isolation, these tests
pretation of these values for diagnostic test accuracy
do not affect a decision to refer or treat.
for auscultation of carotid bruits and the poor values
Single Leg Stance
for accuracy of cardiac auscultation, positive ausculta-
tion findings indicate the need for cautious continued
Single leg stance–with eyes open or closed--can
examination.
be used to screen for decreased postural control. In
the acute stage of vestibular loss, a patient will be
unable to perform this test
; however, patients who
64
Gait Assessment
have a compensated vestibular loss may test normal
.
64
Patients with cerebellar ataxia have a wide-based
This screening test is not specific to vestibular loss,
staggering gait, sometimes with titubation (staggering
as patients with other balance disorders may have dif-
or stumbling gait) or oscillation of head and trunk
.
ficulty performing single leg stance
. A normal single
10
64
236 / The Journal of Manual & Manipulative Therapy, 2005
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