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2018-11-20

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Helping the Dizzy PatientDifferential Diagnosis & Clinical Decision-Making

Physiotherapy Alberta Webinar, November 22, 2018

Presented by:Sheelah Woodhouse PT, BScPTCertificate in Vestibular Rehabilitation, 2000National Director of Vestibular Rehabilitation

The Dizziness Dilemma

• Dizziness is one of the most common reasons that people seek medical help, especially in those > 65.

• Differential diagnosis can be very challenging, as one or more of a host of conditions, both serious and benign, can cause dizziness.

• Adding to the challenge is that ‘dizziness’ is used by clients to describe a wide range of sensations.

Why intervene?

• Dizziness can lead to:– Increased fall risk or fear of falling– Decreased activity / function

• deconditioning and isolation

– Increased anxiety and depression– Decreased self-health ratings

• Could be a flag for a serious health problem that you could abort.

• Likely poorer outcomes in whatever else you are treating them for.

Objectives

• Fortunately, vestibular disorders are thought to be responsible for ~half of all cases of dizziness, the vast majority being peripheral.

• We will discuss:– common causes of dizziness, – key questions to guide differential diagnosis,– bed-side screening tests,– looking at nystagmus, and– treat vs. refer on.

Many Possible Causes

• With more than 60 documented causes of dizziness, where does one start?!

• In multiple physiotherapy settings, any of the following causes could easily be encountered:– Vestibular (35-55% of all dizziness)– Psychogenic (10-25%)– Cerebrovascular (5%) / cardiovascular– Neurologic - Central (5%), or Peripheral– Cervicogenic / musculoskeletal– Metabolic– Medication-related– Multifactorial, etc….

Determine what “dizzy” means

• Vertigo – a sense of motion taking place that isn’t – Suggests vestibular involvement– Peripheral vestibular more likely than central

• Lightheadedness– Suggests presyncope– ↓ blood, oxygen or glucose to brain– Possibly cardiovascular, cerebrovascular, hypocapnia /

hyperventilation, hypoglycemia• Dysequilibrium

– Unsteadiness or imbalance– Possibly MSK, peripheral neuropathy, vision Δ

• Vague– Difficult to describe; floaty; woozy– Possibly psychogenic, cervicogenic, meds, central

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Determine duration

• Seconds of dizziness could be:– Benign Paroxysmal Positional Vertigo (BPPV) – the most

common cause of vertigo– Orthostatic Hypotension – Perilymphatic fistula – a opening btw middle and inner

ear. Listen for reports of trauma, & symptoms with strain, sneeze, nose blowing, loud noises (needs to be seen by ENT/Neuro-otologist)

– Sub-acute or chronic uncompensated unilateral vestibular loss, following quick head movement

Determine duration – cont.• Minutes of dizziness could be:

– TIAs– Migraine– Panic Attacks

• Hours of dizziness could be:– Meniere’s disease (endolymphatic hydrops)– Migraine– Cervicogenic

• Constant dizziness could be:– Cerebellar / central– Medication-related– The first few days after unilateral vestibular infection or trauma

• dizziness or vertigo• rocking sensation• a sense of exaggerated

motion• imbalance or falling• nausea or vomiting• visually provoked dizziness

or queasiness with highly textured or busy environments, reading or watching TV

• Trouble in dark/dimly lit environments

• blurring or oscillopsia with head movement– Vestibulo-ocular reflex

(VOR) deficit

Does it sound vestibular? Vestibular Anatomy & Physiology

• The inner ear contains a rate sensor consisting of a membranous labyrinth, suspended by fluid and connective tissue, within the temporal bone.

• It sends information about head position/movement via the 8th cranial nerve into the brain (vestibular nuclei and cerebellum) for processing.

Canals

• It contains three, fluid-filled semicircular canals, which sense angular head velocity in all directions.

Otolith organs

• It also includes organs which contain calcium carbonate crystals (otoconia) in gel. These allow us to sense linear acceleration/deceleration and tilt.

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Vestibular Physiology• Vestibulo-ocular Reflex (VOR)

– The brain sends instructions to the extra-ocular muscles so we can maintain stable focus when we move –

“gaze stability”

• Vestibulo-spinal Reflexes (VSR)– and to the antigravity muscles

throughout the body –“postural stability”

Peripheral Vestibular Dysfunctions• Benign Paroxysmal Positional Vertigo (BPPV)

– The most common cause of vertigo in adults– Lifetime prevalence of 2.4%– Displaced otoconia– Brief dizziness related to change of head position

Peripheral Vestibular Dysfunctions

• Another commonly seen condition is:– Unilateral Vestibular Hypofunction (UVH)

• Vestibular Neuritis / Labyrinthitis• Trauma (labyrinthine concussion, skull fractures

especially transverse temporal bone #s)• Vascular Compromise• Acoustic Neuroma• Peryilymphatic Fistula

Peripheral Vestibular Dysfunctions

And less commonly:• Meniere’s Disease / Endolymphatic Hydrops• Bilateral Vestibular Hypofunction (BVH)

– Ototoxicity• Aminoglycosides• Alcohol• Chronic salicylate overdosage• Cis-platinum

– Bilateral Endolymphatic Hydrops or trauma– Recurrent Bilateral Neuritis– Age-related degeneration– Autoimmune Disease of the inner ear

Central Vestibular Dysfunctions

• Fortunately, these are more rare (~5-15% of all dizziness):– Migraine-Associated Dizziness*– Stroke – Head Injury– Ischemia – Multiple Sclerosis– Vestibular Epilepsy– Cerebellar dysfunctions– Mal de Debarquement (?)– Persistent Postural Perceptual Dizziness or Psychogenic

Nature

• Is it related to head movement?

Related to Head Movement?

Yes

Vestibular

Cervicogenic

No

Central

Other

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If RELATED to head movement/position:

• Is it VESTIBULAR?– BPPV

• Rolling in bed, getting in/out* of bed, looking upward and bending

• *vs. orthostatic hypotension – out only– Unilateral Vestibular Hypofunction

• Head movement, & situa ons of ↓ visual/prop. cues– Bilateral Vestibular Hypofunction

• Significant balance and vision complaints when moving• Highly dependent on visual and tactile cues• Serious infec on → IV an bio cs (aminoglycosides)

– Persistent Postural Perceptual Dizziness (PPPD)

If RELATED to head movement/position:

• Or is it CERVICOGENIC?– Mechanical

• History of neck trauma; cervical motion abnormality• Vague description• Temporal relationship with neck pain, headache, neck

movement• ? Altered mechanoreceptor input influencing postural

control; altered cervical reflexes– VBI

• Potentially in positions of sustained extension &/or rotation• Accompanied by s/s of cerebrovascular compromise: 5 D’s

And 3 N’s

If NOT related to head movement:

• Is it CENTRAL?– Medication-related

• Temporal relationship with starting, stopping or changing a medication

– Cerebrovascular / cardiovascular / TIA• With prolonged standing; after exertion; spontaneously

(respectively)– Central Lesion, Tumor, Degenerative Δs

• Accompanied by other central s/s– Vestibular Migraine

• Aura, photo/phonophobia, nausea &/or vomiting• MAY OR MAY NOT have h/a

If NOT related to head movement

• ‘Other’?– Metabolic

• Relationship with food/fluid intake; dietary excesses• Excessive exercise, wt loss, poorly controlled diabetes

– Psychogenic• Spontaneous or situational• Accompanied by somatic complaints: palpitations, fear,

sweating, paraesthesias• May have dizziness with eye movement but not head • May or may not have a pre-existing psychological condition

– Peripheral neuropathy• Whenever on feet / symptom-free in sitting or lying

As a general guide:

Peripheral Vestibular Non-Vestibular:Central / Other

Rotational vertigoIllusion of things moving

Vague descriptionLightheadedness

BriefIncreased with certain head movements/positions

ConstantUnaffected by head position/movement.

No other central s/s (other than possible auditory involvement)

Other central s/s or accompanied by palpitations, H/A, etc.

Your 1st Responsibility

• Does this person need further investigation?– Thorough history taking:

• Hearing change? Unrelenting Headache? New or progressing central symptoms

– Screen for “flags”:• Cranial nerve / cerebellar scan• Blood pressure: high, low, orthostatic hypotension• Ligamentous stability of upper c-spine, esp. if RA or

injury• Findings in Hautard’s or cervical extension/rotation

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Vestibular vs. Neck vs. VBI

• Cervical extension + rotation of questionable value for VBI but ‘due diligence’ before further testing– BUT, do from a trunk forward-flexed position so that BPPV

doesn’t give you a false +ve ! :

• If dizzy from mechanoreceptor errors, symptoms decrease or stabilize once position is reached

• If dizzy from VBI, symptoms continue to build +/-accompanied by other ischemic s/s

Vestibular vs. Neck• Compare ‘head on body’ to ‘body on head’ to ‘en

bloc’:

• Sometimes more repetition required– 5 turns via c-spine vs. 5 turns ‘en bloc’, comparing

intensity and duration of resulting symptoms

x5x5

Head Thrust Test for VOR

• With any head movement, the labyrinths are stimulated VOR relays instructions to the extraocular mm to generate appropriate eye movement in order to keep images fixed on the retina = dynamic “gaze stability”.

Head Thrust Test

– Ensure oculomotor function looks intact– Explain / demonstrate test first!– Hold client’s head firmly in 30º flexion.– Ask the client to maintain focus on your nose.

(Stay back to convergence)– Turn their head slowly ~30º, looking for ability to

maintain fixation on your nose– Then, suddenly move client’s head rapidly in one

direction (small amplitude - 5-10 degrees) and stop.

Head Thrust Test

• Positive test = presence of a corrective eye movement (saccade) to re-fixate on your nose

• Indicates a low gain of the vestibular system on the side toward which you thrust

• With 30° flexion, unpredictability and an experienced tester:– Sensitivity 71% for UVL, 84% for BVL

• 88% and 100% respectively if complete loss– Specificity >82+%

Head Thrust Test

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Sensory Integration Tests for VSR

• Look for a degradation of stance or gait when adding a proprioceptive +/or visual challenge (mCTSIB)– Romberg eyes open/closed

• Most children over 9 and all adults 20-79 should be able to maintain for 30 sec.s, eyes open & closed. (Bohannon et al, 1984)

– Romberg on compliant surface, eyes open/closed

• Shortfall– Romberg not a reliable test for vestibular dysfunction but

gives some insight and a guide to rehab.

Screening Tests

• Positioning Tests for BPPV(R) Dix-Hallpike:

• Ensure client has sufficient neck ROM (without s/s VBI!)

• Turn head 45° and lay client back into supine at moderate speed with head declined 20-30°.

• Can lay back with pillow under torso if head of bed fixed.

• Can tilt bed if insufficient cervical ROM or VBI concerns, or do side lying alternate.

Dix-Hallpike Test

• This is a test for Posterior canal BPPV (and Anterior – rare)– may miss horizontal canal problems – Roll Test

• What to look for:– Reproduction of the patient’s vertigo– Brief (<~30 sec) up-beating (or down-beating if Anterior

canal) nystagmus with a torsional component toward the dependent ear

– Should decrease with repeated testing– Should reverse with return to sitting position

Dix-Hallpike Test Roll Test

• The Hallpike-Dix can miss eliciting nystagmus from horizontal canal BPPV.

• Roll Test:– Client is supine with head propped up at 30 degrees from

horizontal– Briskly rotate the head ~45 degrees to one side; pause 30-

60 seconds while looking for horizontal nystagmus and symptom reproduction.

– Return to neutral and wait 1’. Repeat other rot’n., looking for the direction of the horizontal nystagmus to reverse.

– (If neck concerns, just log-roll onto the sides.)

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BPPV – roll test Positioning Tests – Flags

• Associated symptoms of tinnitus, hearing loss, aural fullness or other neurologic s/s

• Atypical or sustained pattern of nystagmus in positional tests:– This could still be BPPV but requires assessment by a well-

trained vestibular physiotherapist– over 12 patterns of nystagmus that you might see depending

upon which ear, canal, and variant of BPPV is present, plus central positional nystagmus. Each requires a different tx.

• Failure to respond to repositioning maneuvers– 74.8% / 93.8% / 98.4% efficacy in 1-3 treatments

Nystagmus Tips (non-BPPV)

• Nystagmus from a peripheral loss should be able to be suppressed by fixation in 1-2 weeks.

• Central nystagmus vs. Peripheral nystagmus:

Peripheral Vestibular Central

Direction of nystagmus

Primarily horizontal +/- slight torsion(excluding BPPV)

Usually vertical (pure up or down-beating) or pure

torsion

Effect of gaze(avoid end range)

Nystagmus with gaze toward quick phase

(Alexander’s law)

No change, or reverses direction

Central Nystagmus

• Nystagmus in a pure vertical plane, or pure torsion, indicates a central pathology:

Nystagmus with Gaze

• Look for nystagmus with gaze 30 degrees from midline in each direction– Gaze beyond 30 degrees may evoke normal end-

range nystagmus

Alexander’s Law

• In the case of UVH, Alexander’s law states that with gaze toward the fast phase, nystagmus increases, and with away from the fast phase, nystagmus decreases.

• It doesn’t reverse directions – ‘direction-fixed’

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• Gaze-evoked nystagmus not following Alexander’s law:

• right-beating nystagmus with right gaze; left-beating nystagmus with left gaze – direction changing.

Refer On or Treat?

• Alert Doctor if findings/symptoms suggest:– Central disorder– Peripheral neuropathy– Medication issue– Cardiovascular or cerebrovascular issue– C-spine instability– Psychological– Dietary issues (or refer to dietician)

• Decide with Doctor whether to continue treating

Refer On or Treat?

• If suspect c-spine or other musculoskeletal contribution and within your scope – treat.– i.e. manual therapy, cervico-cephalic kinesthetic

awareness, deep neck flexor strength, etc.

• If suspect vestibular involvement, if not in your scope refer to Vestibular Physiotherapist, ideally:– one where vestibular rehabilitation is a primary focus– one who is using infrared goggles– one who has or is trained by someone with certificate

from Emory U competency course ideally.

Summary

• Determine nature and duration of dizziness.• Determine whether or not influenced by head

movement.– If not, screen for other causes: neurologic, cardiovascular,

med changes, etc., and inform Doctor.– If so, distinguish head movement (vestibular) from neck

movement.• if ? Vestibular, check balance, head-thrust, nystagmus related to

positioning tests and gaze• If ? Neck, c-sp exam and cx-cephalic kinesthetic awareness testing

• If within your scope/skill-set, treat; if not, refer on

Resources

• The Vestibular Disorders Association (VEDA) www.vestibular.org

• My team: www.lifemarkvestibular.ca• Peripheral Vestibular Hypofunction CPGs:

http://neuropt.org/special-interest-groups/vestibular-rehabilitation

• BPPV CPGs: http://www.entnet.org/?q=node/335

Contact

Sheelah Woodhouse PT, BScPTCertificate in Vestibular Rehabilitation, 2000Director of Vestibular Rehabilitation, LifemarkC: 403-390-3258sheelah.woodhouse@lifemark.ca

Thanks for your interest in assisting patients with dizziness!