Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 19
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30Burkey et al
reported that the sensitivity of the Rinne
test, the patient attempts to touch his or her finger to
79
test was sufficient to be used as part of a screening
the therapist’s finger. Horizontal overshooting implicates
protocol in the hands of an experienced examiner and
a unilateral labyrinthine lesion; vertical overshooting
when interpreting equivocal results as indicative of a
occurs in patients with midline lesions to the medulla
conductive loss. The finding of bone greater than air
oblongata or the bilateral cerebellar flocculus
. Having
34
conduction indicates the need for referral.
the supine patient track the heel of the foot smoothly
up and down the contralateral shin tests for leg ataxia.
Having the seated patient touch the great toe to the
Active Range of Motion Tests
examiner’s finger is another test for leg ataxia
. Dysdiado-
82
Musculoskeletal impairments (i.e., decreased muscle
chokinesia is the inability to perform rapidly alternating
strength and endurance, joint stability and mobility, and
movements, and in adults it is usually caused by multiple
posture) are implicated in patients with the dysequilibrium
sclerosis; in children, it frequently results from cerebellar
subtype of dizziness and may be amenable to sole PT
tumors. Patients with other movement disorders such
management. Range of motion limitations, specifically
as Parkinson’s disease may have also have difficulty with
trunk, hip, and knee flexion and ankle plantar flexion
rapid alternating movements but this is due to akinesia
contractures, will adversely influence the location of the
or rigidity rather true dysdiadochokinesia
. Dysdiado-
83
center of gravity in relation to the base of support. Ac-
chokinesia can be tested with rapid alternating finger
tive range of motion (AROM) testing should, therefore,
tapping, forearm pronation-supination, and toe tapping
concentrate on assessing trunk, hip, and knee extension
movements, for example
. With the Barre test, the
82,83
and ankle dorsiflexion. Assessing neck motions allows
standing or sitting patient holds the hands outstretched
the clinician to observe possible adverse responses in the
with the forearms supinated and eyes closed. Sinking
sense of ischaemic reactions during patient-controlled
of one arm with simultaneous pronation may indicate
AROM. It also serves to see if patients will be able to as-
a central neurological, likely cerebellar, dysfunction
.
84
sume the test positions needed in further tests. Cervical
The finger-to-nose test has poor test-retest and inter-
AROM tests may also reveal upper cervical hypomobility
rater reliability for dysmetria and tremor, but excellent
implicated in cervicogenic dizziness
. AROM tests also
reliability for time of execution
. Simon, Aminoff, and
80, 81
85
provide indications on strength and coordination deficits
Greenberg
reported a positive heel-to-shin test in
10
in the form of ataxia or abnormal involuntary motions.
80% of patients with alcoholic cerebellar degeneration.
Asterixis is an episodic cessation of muscular activity
We found no further data on reliability and validity for
in patients with hepatic encephalopathy, hepatocerebral
these ataxia tests. Positive limb ataxia tests (including
degeneration, and other metabolic encephalopathies
.
seeming dysdiadochokinesia due to akinesia or rigidity)
10
Episodic cessation of extensor muscle activity occurs when
indicate the need for referral.
the patient holds the arms outstretched with wrists and
fingers extended causing the hands to fall into flexion
Passive Range of Motion Tests
followed by a return to the extended position
. Myoc-
10
lonus is a rapid twitch-like muscle contraction: It can
Passive range of motion (PROM) testing includes
result from the same conditions causing asterixis or with
passive physiological (PPM) and accessory motion (PAM)
Creutzfeldt-Jakob disease
. Chorea can occur in patients
and instability tests. In the spine, they include passive
10
with Wilson’s disease, acquired hepatocerebral degenera-
physiological (PPIVM) and accessory intervertebral mo-
tion, and ataxia-telangiectasia
. Chorea is characterized
tion (PAIVM) and segmental stability tests. Upper cervical
10
by rapid, irregular muscle jerks, occurring unpredictably
segmental motion abnormalities may be the cause for
and involuntarily in different body parts
. An ischaemic
cervicogenic dizziness. In the case of a hypomobility
10
response during cervical AROM testing or the presence
found on AROM testing, PROM tests may determine
of abnormal involuntary motions during AROM testing
cause and subsequent intervention. Instability tests of
of the limbs indicates the need for referral.
the upper cervical spine are especially relevant prior to
tests involving regional passive rotation of the neck or
PPIVM/PAIVM testing: Inadvertent shear forces produced
Limb Ataxia Tests
during these tests due to ligamentous insufficiency may
These tests serve to confirm possible limb ataxia
damage the cord and vertebral arteries
. The therapist
29
observed during AROM testing. During the finger-to-
may want to postpone PPIVM/PAIVM tests to the cervi-
nose test, the quality of arm motion is observed as the
cal spine until both the segmental stability tests and
patient moves the index finger to the tip of the nose or
the VBI tests (see below) have provided a negative re-
the chin. Closing the eyes eliminates visual substitution.
sponse. Intrarater reliability of PPIVM/PAIVM tests has
Mild cerebellar ataxia results in an intention tremor near
consistently been shown to be greater than interrater
the beginning and end of the movement with possible
reliability with the latter varying from generally poor
overshooting of the target
. With the finger-to-finger
to (at times) perfect
. Jull, Bogduk, and Marsland
10
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87
240 / The Journal of Manual & Manipulative Therapy, 2005
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