Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination (Page 18 of 30) in pdf

minutes of observation is required to identify periodic

Smooth Pursuit Testing

alternating nystagmus, a horizontal jerk nystagmus that

Having the patient follow a slowly moving target,

changes direction about every two minutes and that is

no faster than 20

per second, tests smooth pursuit. A

indicative of midline cerebellar lesions

. Spontaneous

marked deficit in smooth pursuit is indicative of a de-

nystagmus may also be congenital. This variant is generally

generative cerebellar process

. Small bilateral saccades in

horizontal; may alternate directions but not at regular

the same direction in both eyes during smooth pursuit

intervals; increases with attention, fixation, and anxiety;

testing are indicative of spinocerebellar lesions, especially

and decreases with convergence

. Pendular nystagmus

Friedreich’s ataxia

. Smooth pursuit testing may also

occurs most commonly in patients with multiple sclerosis

be positive in patients with a severe acute peripheral

and brain stem stroke

. The presence of a pendular, a

vestibular lesion due to superposition of an intense

vertical or torsional jerk, skew, or a periodic alternating

spontaneous nystagmus

. Abnormal findings on smooth

horizontal jerk spontaneous nystagmus indicates the

pursuit testing indicate the need for referral.

need for referral. In fact, any spontaneous nystagmus

requires referral with the exception of the congenital

Hearing Examination

variant noted above.

The clinician then observes for spontaneous nys-

The CN examination may indicate hearing loss. A

tagmus in eccentric positions

. Deviation of the eye

conductive hearing loss results from disorders in the

in the direction of the quick phase will increase the

external or middle ear; lesions in the cochlea or the

frequency and velocity of the nystagmus (Alexander’s

cochlear nerve

cause a sensorineural hearing loss. A

law) in patients with a unilateral peripheral vestibular

sensorineural loss is a symptom of salicylate overdose

lesion, and it may still produce a positional nystagmus

Meniere’s disease produces a sensorineural loss that is

in accommodated patients

. Detection of gaze-evoked

progressive over multiple episodes

. Progressive unilateral

10,19

nystagmus on lateral or upward gaze suggests a central

sensorineural hearing loss is also a typical presentation

lesion

. In fact, a gaze-evoked horizontal nystagmus

of patients with acoustic neuromas

. Otosclerosis can

implies lesions in the cerebellar flocculus and the me-

produce both a conductive and a sensorineural hearing

dial vestibular nucleus-nucleus prepositus hypoglossus

loss

. It is the authors’ experience that many elderly

complex, but it can also be the effect of medications,

patients complaining of dizziness present with an un-

such as hypnotics, sedatives, and anxiolytics or alcohol

diagnosed but unrelated conductive hearing loss. Even

intoxication

. Gaze-evoked nystagmus may also be the

9,72

without associated symptoms, this constitutes a reason

result of extra-ocular muscle weakness as in myasthenia

for referral to an audiologist. The presence of symptoms

gravis

. Unsustained eye movements of low frequency

implicating hearing loss as part of a pathology causing

and amplitude are indicative of end-point nystagmus, a

complaints of dizziness indicates the definite need for

non-pathological variant in normal subjects

. The pres-

medical referral.

ence of gaze-evoked nystagmus (with the exception of

end-point nystagmus) indicates the need for referral.

Weber Test

With the Weber test

, the therapist places a tuning

Saccadic Eye Movements

fork (256 or 512 Hz) on the top of the patient’s skull.

Having the patient look back and forth between two

With unilateral sensorineural hearing loss, the patient

targets tests saccadic eye movements. Overshooting of

will perceive the sound as coming from the normal ear.

the target (saccade overshoot dysmetria) may be observed

With a conductive disorder, the patient perceives the

in cerebellar disorders, such as Friedreich’s ataxia

sound as coming from the abnormal ear. Midline is the

Undershooting of the target or hypometria can occur

normal response for this test

. A non-midline response

in patients with Parkinson’s disease

. Vertical saccadic

indicates the need for referral.

eye movements in patients with Wallenberg syndrome

as a result of vertebrobasilar infarction may result in

Rinne Test

eye lateropulsion requiring a corrective horizontal sac-

The Rinne test

allows the therapist to distinguish

cade

. Uncalled-for saccades during gaze fixation on one

between a sensorineural and a conductive deficit in the

of the targets can occur in patients with viral cerebellar

affected ear. Normally, air conduction of the sound of

infection, paraneoplastic syndrome, and Friedreich’s

a vibrating tuning fork (256 or 512 Hz) is perceived as

ataxia

. Macrosaccadic oscillations, which are horizontal

louder than bone conduction. So holding the tuning fork

saccades occurring in waxing and waning bursts with

next to the external auditory canal produces a louder

200 ms saccadic intervals induced by a gaze shift, are

sound than placing the base of the tuning fork on the

indicative of midline cerebellar disease, spinocerebel-

mastoid bone in patients with normal hearing. The same

lar degenerations, and pontine lesions

. Abnormalities

goes in patients with sensorineural hearing loss. However,

identified during saccadic eye movement tests indicate

in patients with conductive deficits, bone conduction will

the need for referral.

appear louder on the affected side than air conduction.

Dizziness in Orthopaedic Physical Therapy Practice:

History and Physical Examination / 239

Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 18

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