Examiniation of Vestibular System Disorders

• The overarching purpose of the physical therapy examination of persons presenting with vestibular system dysfunction is to determine movement diagnoses and identify peripheral and/or central vestibular involvement to guide intervention
• Eighty five percent of persons presenting with vertigo are caused by peripheral vestibular system disorders with 15% resulting from a central vestibular disorder
• An accurate diagnosis is critical in determining the most appropriate plan of care including patients who are not candidates for vestibular rehabilitation and require further referral
• During testing of the vestibular system, the physical therapist will often intentionally provoke symptoms which is a critical component of the diagnostic process
• Vestibular suppressants


  Medications for dizziness and/or nausea that will likely interfere with the reliability of test results
• It is essential to identify what tests exacerbate the symptoms, and the physical therapist should measure or grade the severity of the patient's symptoms
• It is equally important to observe for the latency, timing, and duration of any symptoms that occur
• Communication with the patient is key including explaining what movements are going to be performed, expectations from the patient, and what the patient may experience during testing
• The physical therapist must reassure the patient of the value of these tests to make an accurate diagnosis and select effective interventions since some of the tests will most likely reproduce the very sensation or experience the patient is trying to avoid
• Performance of a thorough medical and subjective history and systems review should be done to sort out potential causes of complaints of dizziness and imbalance
• Therapists should also ask the patient or obtain from the medical record any diagnostic test reports, such as ENG/VNG, caloric, rotational chair, or VEMP tests
• Vertigo


  An illusion of movement. Patients may describe that they sense their environment is moving or that they see the environment moving or spinning
• Light-headedness


  A feeling that fainting is about to occur and can be caused by nonvestibular factors such as hypotension, hypoglycemia, or anxiety
• Disequilibrium


  The sensation of being off balance
• Oscillopsia


  The subjective experience of motion of objects in the visual environment that are known to be stationary
• Acute onset is a time of seconds to hours to maximal symptoms. Chronic onset is gradual, worsening over weeks to years and symptoms may plateau
• In continuous dizziness, symptoms are always present, even at rest. In episodic dizziness the person is completely asymptomatic between episodes
• Triggered dizziness must be absent when the head is stationary, always occurs immediately following a specific movement, and occurs only following that movement
• Characteristics of BPPV


  • Short spells of vertigo that are brief in nature (could last up to several minutes)
  • Symptoms exacerbated by movement in one particular direction, including turning head to right or to the left, lying down, rolling over, looking up, and/or bending over
• Characteristics of Meniere's Disease

  • Low frequency hearing loss
  • Fluctuating hearing loss
  • Fluctuating fullness/pressure in the ears
  • Fluctuating tinnitus (noises/ringing in the ear)
  • Spells of vertigo that are usually minutes to hours and accompanied with nausea and residual imbalance/dizziness
  • Spells typically spontaneously recover (although may have residual symptoms between spells)
  • Frequency may vary from years, months, days
• Characteristics of Vestibular Neuritis

  • Sudden onset that often follows another illness and/or stressful event
  • Duration of vertigo is hours to days
  • Nausea
  • No hearing loss
  • Occurs as a single event in more than 95% of individuals
  • May have residual imbalance and dizziness with head movements
• Characteristics of Vestibular Labyrinthitis

  • Same as Vestibular Neuritis, but with hearing loss
• Characteristics of Acoustic Neuroma

  • Asymmetrical hearing loss
  • Tinnitus
  • Vertigo does not occur until more advanced stages
• Characteristics of BVH


  • Unsteadiness with wide-based gait pattern
  • Vertigo is usually absent
  • May include hearing loss
  • Oscillopsia
  • Common cause: ototoxicity results in bilateral peripheral vestibular system pathology due to damage of the vestibular hair cells usually after receiving antibiotic treatment, aminoglycosides
• Characteristics of Perilymphatic Fistula

  • Dizziness/vertigo
  • Hearing loss
  • Oscillopsia
  • Exacerbated by coughing, sneezing, lifting
  • May follow head trauma, barometric pressure trauma
  • Superior canal dehiscence: symptoms of dizziness and imbalance with loud noises and/or changes in intracranial pressure (coughing); Tullio phenomenon
• Characteristics of Anxiety


  • Shortness of breath
  • Tingling sensations around the mouth and occasionally in extremities
  • Lightheadedness
• Characteristics of Mal de Debarquement Syndrome

  • Primarily associated with residual "rocking" sensations after being on a boat, train, or plane
  • Most common in women (30–40 years of age)
  • Previous testing (including vestibular) is often normal
  • Symptoms are typically worse when patient is not moving and improved (if not alleviated) with movement
• Characteristics of Neurological Conditions

  • Diplopia
  • Symptoms are constant with difficulty describing exacerbating and alleviating factors
  • Could have a PMH of dementia, seizures, CVA, TBI, neurodegenerative diseases, demyelinating diseases, hereditary diseases, Parkinson disease, medications, toxicity
• Characteristics of Vascular Impairment

  • Arrhythmias
  • Symptoms with supine-to-sit-to-stand
  • Cervicogenic symptoms: occur with cervical extension (and rotation)
  • Drop attacks
  • Headache (Migraine-Associated Vertigo) and difficulty with speech
  • Medication
• Characteristics of Cervicogenic Dizziness

  • Symptoms of dizziness (including vertigo, disequilibrium, and light-headedness) arising from the cervical spine
  • Due to altered proprioceptive signals from the upper cervical spine, caused by disorders in vertebral segments C1–C3 and vertebrobasilar insufficiency
  • Altered oculomotor function and VOR, altered balance function, and perceptions of dizziness
  • Inaccurate afferent inputs from inflamed or irritated cervical roots, proprioceptors of the facet joints, or the cervical musculature conflict with vestibular and visual inputs converging on brainstem nuclei
  • Whiplash, cervical spondylosis
• Dizziness Handicap Inventory


  • Measure patient's self-perceived handicap as a result of vestibular disorders
  • Functional, emotional, physical components
  • Quantifies the patient's perception of disequilibrium and its impact on daily activities
  • Establishes subjective improvement (MDC = 17.18; MCID = 18 points)
  • 100 points: the higher the score, the greater the perceived handicap due to dizziness
  • Cut-off Scores: Mild: 0-30, Moderate: 31-60, Severe: 61-100
  • Persons who perceive greater handicap on DHI demonstrate greater functional impairment

  
• Motion Sensitivity Quotient


  • Provides a subjective score of a patient's sensitivity to motion
  • Place patients into positions incorporating head or entire body motion to determine if the movement reproduces dizziness
  • Rate symptom intensity and duration = score
  • MSQ is calculated by multiplying the number of positions that provoke symptoms by the average symptom intensity and duration

  
• Dizziness Handicap Inventory


  • Measure patient's self-perceived handicap as a result of vestibular disorders
  • Functional, emotional, physical components
  • Quantifies the patient's perception of disequilibrium and its impact on daily activities
  • Establishes subjective improvement (MDC = 17.18; MCID = 18 points)
  • 100 points: the higher the score, the greater the perceived handicap due to dizziness
• Dizziness Handicap Inventory Cut-off Scores

  • Mild: 0-30
  • Moderate: 31-60
  • Severe: 61-100
• Persons who perceive greater handicap on DHI demonstrate greater functional impairment
• Motion Sensitivity Quotient


  • Provides a subjective score of a patient's sensitivity to motion
  • Place patients into positions incorporating head or entire body motion to determine if the movement reproduces dizziness
  • Rate symptom intensity and duration = score
  • MSQ is calculated by multiplying the number of positions that provoke symptoms by the score divided by 2,048
  • 0 = no symptoms; 100 = severe dizziness in all positions
  • Improvement is indicated by decreased number of provoking positions, increased number of reps before symptoms, shorter duration of symptoms, decreased intensity of symptoms
• Motion Sensitivity Quotient Cut-Off Scores

  • 0-10% = mild motion sensitivity
  • 11-30% = moderate
  • 31-100% = severe
• Visual Analogue Scale


  • Subjective intensity ratings of vertigo, light-headedness, dysequilibrium, and oscillopsia
  • How intense are your symptoms?
  • Mark on a 10-cm line (on a continuum from "none" to "worst possible intensity") where the symptoms exist at the moment
  • Measure the line for a quantified value
• ABC Scale


  • Determining the patient's perceptions of his ability to balance
  • Measures balance confidence in performing various activities without losing balance or experiencing a sense of unsteadiness
  • Score of 0 = no confidence; Score of 100 = complete confidence
• ABC Scale Cut-off Scores

  • <67% indicates a risk for falling