Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination (Page 2 of 30) in pdf

complaining of dizziness and who:

peripheral lesions is often severe, intermittent in nature,

May respond to conservative interventions within

and of a shorter duration than vertigo due to a central

•

the PT scope of practice, specifically patients with

lesion. A central lesion often produces constant but less

BPPV, cervicogenic dizziness, and musculoskeletal

severe vertigo

. Vertigo is a symptom in patients with

impairments leading to dysequilibrium.

BPPV, Meniere’s disease, acute peripheral vestibulopathy,

Require referral for medical differential diagnosis

otosclerosis, toxic vestibulopathies, and autoimmune

•

and medical-surgical (co)management.

disease of the inner ear

. It is less common in patients

10,11

In keeping with the evidence-based practice paradigm,

with cerebellopontine angle tumors or acoustic neuropa-

we have attempted to provide, where available, data on

thy

. Vertigo may only be episodic in patients with a

reliability and validity of history items and physical tests

perilymphatic fistula in case of a low-volume leak but can

by way of a Medline search over the period 1995- March

be severe in patients with a large fistula

. Vertigo also

2005 of English-language articles with a title contain-

occurs in the diseases causing brainstem hypoperfusion,

ing search terms relevant to these tests and items. The

e.g., vertebrobasilar insufficiency (VBI), vertebrobasilar

complete list of search terms is available upon request

infarction, vertebrobasilar migraine, and subclavian steal

from the authors. In addition, we performed a hand

syndrome

. Any complaint of vertigo other than

10,11,13,14

search of articles in our personal libraries.

intermittent, severe, rotary, short-lasting vertigo likely

indicates a need for referral.

History

Ataxia

Our literature search located no studies that discussed

Ataxia is a dyscoordination or clumsiness of move-

the reliability or validity of history items. History tak-

ment not associated with muscular weakness

. It is a

ing with patients complaining of dizziness is complex.

symptom in patients with cerebellar tumors and subclavian

Table 1 provides a suggested patient self-report intake

steal syndrome

. Ataxia may affect gait in patients with

questionnaire and Table 2 contains a template for a

hypothyroidism, paraneoplastic cerebellar degeneration,

structured interview.

ataxia-telangiectasia, Arnold-Chiari malformation, VBI,

and myelopathy

. Gait ataxia is the presenting

10,13,15-17

symptom in all patients with hereditary spinocerebellar

Symptoms

degenerations

. It is also the most common finding in

patients with alcoholic cerebellar degeneration and the

Symptom Description

presenting complaint in 10-15% of patients with multiple

A description of dizziness symptoms may be helpful

sclerosis

. Trunk ataxia is a symptom in patients with

for initial classification into one of the four dizziness

ataxia-telangiectasia and Creutzfeldt-Jakob disease

;

subtypes of vertigo, presyncope, dysequilibrium, and

these two diseases also produce limb ataxia as does

other dizziness

. Vertigo is often described as a spin-

paraneoplastic cerebellar degeneration

. In addition,

ning or rotating sensation, a sensation of self-movement

10% of patients with Wernicke’s encephalopathy present

or of the environment moving, whereas patients with

with ataxia of the arms while 20% present with ataxia

presyncopal dizziness complain of lightheadedness, a

affecting the legs

. A patient report of ataxia confirmed

sense of impending faint, or tiredness. Patients with

by physical tests indicates a need for referral.

dysequilibrium may complain of unsteadiness and

Hearing Loss

weakness. Patients who fall into the subtype of other

dizziness may report anxiety, depression, or fatigue.

A sudden onset of unilateral deafness may be due

However, patients commonly have difficulty describing

to labyrinthine artery infarction, possibly indicating an

their symptoms. The above classification system is also

infarction in the vertebrobasilar system

. A rapid loss

challenged when an individual complains of symptoms

of perilymphatic fluid due to a perilymphatic fistula

fitting more than one subtype, as may be the case in

will produce hearing loss, but hearing may be normal

older adults with multi-system impairment

. However,

in case of a low-volume leak

. Meniere’s disease pro-

symptom description indicating presyncopal and other

duces a fluctuating low-frequency hearing loss, which

dizziness may indicate the need for referral.

is progressive over multiple episodes

. Autoimmune

10,19

disease of the inner ear also produces a fluctuating

Vertigo

hearing loss

. Progressive unilateral hearing loss is

An illusion of rotary movement implicates the semi-

also a typical presentation of patients with acoustic

circular canals (SCC)

. Rotary vertigo is a symptom in

neuromas

. Hearing loss is also a symptom in patients

most peripheral vestibulopathies. An illusion of linear

with acute labyrinthitis, quinine or quinidine toxicity,

movement, arguably not true vertigo, indicates a lesion

salicylate overdosage, Friedreich’s ataxia, otosclerosis,

involving the otolith organs but can also occur in pa-

vestibulocochlear nerve compression due to bacterial,

tients with a perilymphatic fistula

. Vertigo as a result of

syphilitic, or tuberculous infection or due to sarcoidosis,

Dizziness in Orthopaedic Physical Therapy Practice:

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