Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination (Page 20 of 30) in pdf

examined construct validity and found 100% sensitivity

and hemiparesis) but also progressive monosegmental

and specificity when comparing cervical PPIVM/PAIVM

paresis indicates the need for referral.

test with single facet blocks. Cattryse et al

found ac-

ceptable interrater reliability only for the supine upper

Reﬂ ex Tests

cervical flexion instability test but not the Sharp-Purser

or atlas lateral displacement test. A positive finding on

Cerebellar disorders cause hypoactive deep tendon

upper cervical segmental stability tests in combination

reflexes with unilateral cerebellar disorders resulting in

with signs and symptoms of cord or vertebral artery

ipsilateral hyporeflexia. Friedreich’s ataxia, neurosyphilis,

compromise indicates the need for referral.

and polyneuropathies cause leg hyporeflexia. Hyperreflexia

PROM tests can also detect muscle tone abnormali-

is present in multiple sclerosis, vitamin B

deficiency,

ties. Hypotonia is indicative of cerebellar disorders with

focal brainstem lesions, and some spinocerebellar and

unilateral cerebellar disorders producing ipsilateral

olivopontocerebellar degenerations

. A positive Babinski

limb hypotonia

. Hypertonia or rigidity may occur in

sign, Hoffman’s reflex, and ankle clonus may occur in

patients with cerebellar ataxia due to Wilson’s disease,

patients with myelopathy, multiple sclerosis, vitamin B

acquired hepatocerebral degeneration, Creutzfeldt-Jakob

deficiency, focal brainstem lesions, and some spinocer-

disease, and some olivopontocerebellar degenerations.

ebellar and olivopontocerebellar degenerations

. Sung

1,9

Spasticity on PROM testing is common in patients with

and Wang

established 100% sensitivity for a positive

multiple sclerosis, posterior fossa tumors, Arnold-Chiari

Hoffman’s reflex for detecting patients with cervical cord

malformation, VBI or infarction, Friedreich’s ataxia and

compression confirmed on X-ray or MRI. We found no

the other hereditary ataxias, olivopontocerebellar degen-

additional data on reliability and validity of reflex tests.

eration, Creutzfeldt-Jakob disease, neurosyphilis, and

Clearly hypoactive or hyperactive deep tendon reflexes

vitamin B

deficiency

. Prochazka et al

showed poor

may indicate a need for referral; the presence of patho-

reliability for a 5-point rating scale for rating rigidity in

logical reflexes is a definite reason for referral.

patients with Parkinson’s disease. Tone abnormalities on

PROM test indicate the need for referral in a previously

Sensation Tests

undiagnosed patient.

Sensation testing may include tests for light touch

perception, sharp/dull discrimination, vibration sense,

Strength Tests

and propriocepsis

. Sensation testing may reveal defi-

The musculoskeletal system is the effector organ

cits in the distribution pattern of single or multiple

of the balance control system. Sufficient strength and

peripheral nerves, a nerve root, or a multi-segmental

endurance in the muscles involved in static and dynamic

pattern providing diagnostic clues for underlying cause

balance is an obvious prerequisite for optimal balance.

or contributing factors to the patient’s complaint of

Loss of strength and endurance in these muscles can be

dizziness. Joint position sense can be tested by asking

the cause of patient complaints of dizziness and dysequi-

the patient to detect the presence and the direction of

librium. The pattern of any weakness present may also

a passive movement in the joints

. Simon, Aminoff,

8,10

provide diagnostic indicators for the underlying dysfunc-

and Greenberg

suggested beginning this type of test-

tion or disease. Single or multiple muscle weakness can

ing distally and moving proximally to establish the

be the result of disuse atrophy, especially in the elderly.

upper level of deficit in each joint. Placing a joint in a

Weakness in a peripheral nerve distribution implies a

position and having the patient reproduce this position

peripheral neuropathy. Monosegmental myotomal weak-

with the contralateral joint can also be used as a test

ness can implicate a nerve root problem. Multisegmental

for abnormality of joint position sense

; the patient’s

weakness can implicate a process affecting cauda equina

eyes are closed during joint position testing to prevent

or spinal cord. Distal neuropathic weakness can be

visual compensation. Joint position sense in the legs

the result of disorders producing sensory ataxia, e.g.,

is always impaired in patients with sensory ataxia; the

polyneuropathies. Multiple sclerosis, foramen magnum

arms may be affected depending on the type and extent

lesions, spinal cord tumors, and vitamin B

deficiency

of pathology responsible. Placing a 128 Hz tuning fork

can cause paraparesis. Ataxic quadriparesis, hemiataxia

over a bony prominence may serve as a test of vibration

and contralateral hemiparesis, or ataxic hemiparesis are

sense. Successively more proximal sites can determine

all diagnostic indicators of a brainstem lesion

. Knepler

the upper level of deficit in limbs or even trunk. Sensory

and Bohannon

and Bohannon and Corrigan

showed

ataxia is often combined with a decrease in vibratory

large interrater variability in the forces used to establish

sensation

. Peters et al

showed limited interrater

manual muscle test (MMT) grades of 3+, 4-, 4+, and 5.

reliability for a quantitative method of assessing vibra-

Herbison et al

recommended the use of a hand-held

tion sense implying even less reliability for the tuning

myometer over MMT to detect strength changes. Multi-

fork method. It is the authors’ experience that elderly

segmental weakness (including paraparesis, quadriparesis,

patients frequently present with undiagnosed decreased

Dizziness in Orthopaedic Physical Therapy Practice:

History and Physical Examination / 241

Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 20

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