Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 25
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30ear stationary, the vestibular system is not stimulated.
produced significantly more symptoms in patients with
Nystagmus and dizziness with this test are, therefore,
panic disorder than in patients with obsessive-compulsive
interpreted as cervicogenic. However, the therapist still
disorder, depression, or in normals, and they noted that it
needs to differentiate between vascular or somatosensory
might be an easy test to validate panic disorder
. Nakao
124
cervicogenic involvements
. Diagnostic accuracy is ques-
et al
reported 62% sensitivity and 100% specificity for
120
125
tionable: 50% of subjects without cervical pathology tested
this test in the diagnosis of coronary spasm. The authors
positive for nystagmus
, possibly a manifestation of the
have noted clinically that near-immediate reproduction
121
COR
. Fitz-Ritson
found that 47% of patients with cervi-
of symptoms may indicate psychogenic contribution to
26
122
cal trauma demonstrated subjective symptoms of vertigo
dizziness complaints. A positive finding on these tests
or postural instability during the neck torsion test; 90%
implies the need for referral.
improved following therapy. We found no additional data
Valsalva Test
on reliability and validity. A positive response on these
tests in combination with corroborating history findings
In patients with Arnold-Chiari malformation, peri-
in the absence of findings indicative of other pathology
lymphatic fistulae, and other abnormalities of the os-
implies that sole PT management may be indicated.
sicles (e.g., otosclerosis), oval window, and saccule, a
Valsalva maneuver may produce nystagmus. Changes
of middle ear pressure due to loud noises, application
Breathing-Related Tests
of positive and negative pressure to the tympanic mem-
Hyperventilation Test
brane (Hennebert’s sign), and opening and closing the
The hyperventilation test requires patients to voluntarily
Eustachian tube may have a similar effect
. The cough
9
hyperventilate, i.e., 30 breaths min
for 3 minutes
. It
test is a variant on the Valsalva test. Having the patient
-1
47
may be a useful and simple test for validating a diagnosis
cough to increase intrathoracic pressure may be useful
of panic disorder or dizziness related to hyperventilation
in detecting dizziness due to cough presyncope
. We
10
presyncope. In these patients, this test will produce diz-
found no data on reliability and validity. Positive tests
ziness but no nystagmus
. Patients with demyelinating
indicate the need for referral.
9
lesions of the vestibulocochlear nerve due to an acoustic
neuroma, compression by a small blood vessel, or cen-
History and Physical Examination
tral demyelinating lesions (multiple sclerosis) may show
nystagmus on the hyperventilation test
. Hyperventila-
About 50% of dizziness is vestibular and benign
.
9
69
tion may accentuate downbeating nystagmus in patients
More serious causes, e.g., brain tumors and cerebrovas-
with Arnold-Chiari malformation and evoke a nystagmus
cular disorders, account for about 1% and 5% of cases
towards the lesion in patients with vestibular schwanno-
respectively
. Froehling et al
studied diagnostic ac-
69
126
mas
. Nardi et al
found that the hyperventilation test
curacy of symptoms and signs in distinguishing benign
109
123,124
from serious causes:
Vertigo or vomiting combined with a positive Hall-
•
pike-Dix test demonstrated 85% positive predictive
value and a 7.6 positive likelihood ratio (LR) for a
benign cause.
A negative Hallpike-Dix maneuver and absence of
•
vertigo or vomiting had a 68% negative predictive
value for peripheral vertigo.
Age <69, absence of neurological deficits, and/or the
•
presence of vertigo have a negative predictive value
of 88% with a negative LR of 0.3 for a serious cause
of dizziness.
Age >69, presence of neurological deficit, and/or
•
absence of vertigo carry a positive predictive value
of 40% and positive LR of 1.5 for a serious cause of
dizziness.
Discussion
There is emerging evidence that PT management may
suffice for patients with BPPV, cervicogenic dizziness,
and musculoskeletal impairments leading to dysequilib-
rium
. Table 5 provides signs and symptoms indicative
1-7
Fig. 9:
Fig. 9:
F
Alternate neck torsion test
246 / The Journal of Manual & Manipulative Therapy, 2005
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