Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination (Page 8 of 30) in pdf

symptoms in patients with central vestibular disorders

Vertebrobasilar migraine occurs frequently during the

are the results of slowly progressive pathologies and

menstrual period

. Subclavian steal syndrome produces

thus have an insidious onset. The onset of symptoms in

symptoms with physical activity of the ipsilateral arm

patients complaining of dysequilibrium is also generally

Stress, hyperventilation, and anxiety can all produce the

insidious. The onset of dizziness and other symptoms is

symptoms of dizziness associated with panic disorder

23,24

sudden in patients with acute peripheral vestibulopathy,

Situations commonly associated with other phobic

aminoglycoside toxicity, labyrinthine damage due to head

syndromes (e.g., large crowds, open spaces, driving, or

trauma, in case of large perilymphatic fistulae, and in

crossing a bridge) can precipitate an attack of phobic

patients suffering subsequent attacks of Meniere’s dis-

postural vertigo

. Dizziness described as tilting of the

ease

. Presyncopal dizziness usually is sudden in onset

environment is aggravated by rapid postural changes

10,12

when precipitating activities are performed. An abrupt

Constant vertiginous dizziness or dizziness brought on

onset is also characteristic of patients with symptoms

by factors other than neck or head movement indicate

due to panic disorder

. An insidious onset of vertiginous

a likely need for referral.

dizziness and an abrupt onset of presyncopal or other

Prodromal Symptoms

dizziness indicate a need for referral.

Some pathology is characterized by prodromal symp-

Precipitating Factors

toms, which occur after encountering the precipitating

Dizziness is often constant in patients with central

stimulus but before the symptoms of dizziness. Prodromes

and bilateral peripheral vestibular lesions

. Other

lasting ten seconds to a few minutes and consisting of

9,10

forms of dizziness are intermittent and precipitated by

lightheadedness, pallor, salivation, blurred vision, and

positioning, movement, or other stimuli. Patients with

tachycardia often precede a vasovagal syncope

. A

10,12

posterior SCC BPPV complain of dizziness when they

visual aura may precede migraine and vertebrobasilar

quickly transfer to a supine position, especially when the

migraine

; 10% of patients with migraine report a visual

head is turned to the affected side

. This also occurs in

or other neurological aura

. Any report of prodromal

patients where the anterior SCC is involved, but there

symptoms indicates a need for referral.

is less specificity as to the direction of head rotation

Symptom Latency

Dizziness is brought on in patients with horizontal SCC

BPPV when rolling over in supine but it can also occur

Symptom latency refers to the time lapsed between

with flexion and extension of the head or when trans-

exposure to the precipitating stimulus and onset of

ferring from supine to upright

. Head movement may

symptoms. Symptoms in patients with BPPV occur after

also provoke symptoms in patients with cervicogenic

a 1-5 second latency period

but may last up to 40

22,45

dizziness

seconds. The latency period in patients with VBI is long:

Dizziness in patients with otosclerosis may be po-

Oostendorp

reported a latency period of 55 ± 18 seconds

sitional but can also be constant

. Attacks of familial

after assuming the De Kleyn-Nieuwenhuyse test position.

paroxysmal ataxia can be triggered by exercise, caffeine,

One could assume that patients with subclavian steal

alcohol, or sudden movements

. A vasovagal pre-syncope

syndrome also have a longer latency period; sufficient

can be brought on by emotional stimuli, pain, the sight

ischaemia needs to develop before symptoms occur.

of blood, fatigue, medical instruments, blood loss, or

Depending on the etiology, a vertebrobasilar infarction

prolonged motionless standing

, and it usually occurs

may be rapidly or very slowly progressive

. Onset of

10,12

with the patient in a sitting or standing position; only very

symptoms is immediate in patients with cervicogenic

rarely is the patient recumbent

. A patient complain-

dizziness upon assuming the provoking position

. A

10,19

ing of presyncopal dizziness while recumbent or after

prolonged latency period (>60 sec) indicates a likely

physical exercise should be screened for a cardiovascular

need for referral.

etiology

. Carotid sinus syndrome has been related to

Symptom Duration

wearing collars that are too tight or may be due to local

tumors in the neck pressing on the carotid sinus

. In

As noted before, dizziness symptoms in patients

10,19

patients with Takayasu’s disease, exercise, standing, or

with central vestibulopathies are generally less severe

head movements may bring on dizziness

. Hyperven-

but constant and prolonged; symptoms with peripheral

tilation and coughing may bring on hyperventilation

vestibulopathies are often severe but intermittent

and cough pre-syncope, respectively

. Dizziness due to

Symptoms in patients with BPPV generally last less

micturition syncope may occur before, during, or after

than 30 seconds but may occur for up to 60 seconds

micturition

. Orthostatic hypotension-related dizziness

Vertigo may last from minutes to days in patients with

occurs when rapidly rising from a sitting position, stand-

Meniere’s disease

. In patients with acute peripheral

10,12,19

ing up after prolonged recumbency, or after prolonged

vestibulopathy, vertigo may be constant for up to two

motionless standing

. A position of cervical extension

weeks

. Symptoms in patients with familial paroxysmal

10,12

and rotation is often implicated as a trigger for VBI

ataxia last from 15 minutes to several hours

. Symptoms

Dizziness in Orthopaedic Physical Therapy Practice:

History and Physical Examination / 229

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