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Dizziness History and Physical Examination

Dizziness History and Physical Examination

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Published by rapannika
Narrative review providing a template for the history taking and physical examination of patients with a primary complaint of dizziness
Narrative review providing a template for the history taking and physical examination of patients with a primary complaint of dizziness

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Published by: rapannika on May 07, 2009
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02/01/2013

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22 / The Journal of Manual & Manipulative Therapy, 2005
T
o facilitate differential diagnosis and screening of atients with a complaint of dizziness, we discussedin an earlier article
1
a diagnostic classification systembased on symptomatology and pathophysiology. Thisclassification system included four subtypes of dizziness:ertigo, presyncope, dysequilibrium, and other dizziness.any tests and measures that are needed for a full dif-erential diagnostic work-up of patients presenting withdizziness are obviously outside of the physical therapyPT) scope of practice. Many causes of dizziness discussedin that earlier article require medical-surgical manage-ent rather than or in addition to PT management.However, there is mounting evidence that conservativeeasures may be beneficial for a select subset of patientsith dizziness. Repositioning maneuvers may decrease
Dizziness in Orthopaedic Physical Therapy Practice: History andPhysical Examination
 Address all correspondence and request for reprints to:Peter HuijbregtsConsultant PhysiotherapistShelbourne Physiotherapy Clinic100B-3200 Shelbourne Street Victoria, BC V8P 5G8 Canadashelbournephysio@telus.net
 Abstract:
Physical therapy (PT) differential diagnosis of patients complaining of dizzinesscenters on distinguishing those patients who might benefit from sole management by thehysical therapist from those patients who require referral for medical-surgical differentialdiagnosis and (co) management. There is emerging evidence that PT management may sufficeor patients with benign paroxysmal positional vertigo, cervicogenic dizziness, and muscu-loskeletal impairments leading to dysequilibrium. This article provides information on theistory taking and physical examination relevant to patients with a main complaint of diz-iness. The intention of the article is to enable the therapist to distinguish between patientscomplaining of dizziness due to these three conditions amenable to sole PT managementnd those patients who likely require referral. Where available, we have provided data onreliability and validity of the history items and physical tests described to help the clinicianestablish a level of research-based confidence with which to interpret history and physicalexamination findings. The decision to refer the patient for a medical-surgical evaluation isbased on our findings, the interpretation of such findings in light of data on reliability and validity of history items and physical tests, an analysis of the risk of harm to the patient,nd the response to seemingly appropriate intervention.
 ey Words:
Dizziness, History, Physical Examination, Physical Therapy
 Paul Vidal, PT, MHSc, DPT, OCS, MTC Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT 
symptoms in patients with benign paroxysmal positionalertigo (BPPV) involving the posterior, horizontal, andnterior semicircular canals
2-6
. Manual therapy inter-entions may positively affect cervicogenic dizziness.usculoskeletal impairments, such as decreased musclestrength and endurance, joint stability and mobility,nd posture, which are implicated in patients with thedysequilibrium subtype of dizziness, are dysfunctionsraditionally addressed by PT
1
. Habituation exerciseshave proven beneficial for patients with acute unilateralestibular loss, and adaptation and balance exercises haveroduced positive outcomes in patients with chronicbilateral vestibular deficits
4
. For the latter two patientroups, PT management, of course, is preceded by aedical differential diagnostic work-up. An isolatedotolith dysfunction may theoretically also be amenableo conservative management, but as no clinical testsexist to identify this dysfunction, we cannot make anyevidence-based recommendations at this time.his article provides the orthopaedic physical thera-ist with current knowledge on the history items andhysical tests within the PT scope of practice that arerequired for identifying previously undiagnosed patients
The Journal of Manual & Manipulative Therapy Vol. 13 No. 4 (2005), 222 - 251
 
Dizziness in Orthopaedic Physical Therapy Practice:istory and Physical Examination / 223
complaining of dizziness and who:
ay respond to conservative interventions withinhe PT scope of practice, specifically patients withPPV, cervicogenic dizziness, and musculoskeletalimpairments leading to dysequilibrium.
equire referral for medical differential diagnosisnd medical-surgical (co)management.In keeping with the evidence-based practice paradigm,e have attempted to provide, where available, data onreliability and validity of history items and physical testsby way of a Medline search over the period 1995- March2005 of English-language articles with a title contain-ing search terms relevant to these tests and items. Thecomplete list of search terms is available upon requestrom the authors. In addition, we performed a handsearch of articles in our personal libraries.
History
Our literature search located no studies that discussedhe reliability or validity of history items. History tak-ing with patients complaining of dizziness is complex.able 1 provides a suggested patient self-report intakequestionnaire and Table 2 contains a template for astructured interview.
Symptoms
Symptom Description
 A description of dizziness symptoms may be helpfulor initial classification into one of the four dizzinesssubtypes of vertigo, presyncope, dysequilibrium, andother dizziness
1
. Vertigo is often described as a spin-ing or rotating sensation, a sensation of self-movementor of the environment moving, whereas patients withresyncopal dizziness complain of lightheadedness, asense of impending faint, or tiredness. Patients withdysequilibrium may complain of unsteadiness andeakness. Patients who fall into the subtype of otherdizziness may report anxiety, depression, or fatigue.However, patients commonly have difficulty describingheir symptoms. The above classification system is alsochallenged when an individual complains of symptomsitting more than one subtype, as may be the case inolder adults with multi-system impairment
8
. However,symptom description indicating presyncopal and otherdizziness may indicate the need for referral.
Vertigo
 An illusion of rotary movement implicates the semi-circular canals (SCC)
9
. Rotary vertigo is a symptom inost peripheral vestibulopathies. An illusion of linearovement, arguably not true vertigo, indicates a lesioninvolving the otolith organs but can also occur in pa-ients with a perilymphatic fistula. Vertigo as a result oeripheral lesions is often severe, intermittent in nature,nd of a shorter duration than vertigo due to a centrallesion. A central lesion often produces constant but lesssevere vertigo
10
. Vertigo is a symptom in patients withPPV, Meniere’s disease, acute peripheral vestibulopathy,otosclerosis, toxic vestibulopathies, and autoimmunedisease of the inner ear
10,11
. It is less common in patientsith cerebellopontine angle tumors or acoustic neuropa-hy
10
. Vertigo may only be episodic in patients with aerilymphatic fistula in case of a low-volume leak but canbe severe in patients with a large fistula
12
. Vertigo alsooccurs in the diseases causing brainstem hypoperfusion,e.g., vertebrobasilar insufficiency (VBI), vertebrobasilarinfarction, vertebrobasilar migraine, and subclavian stealsyndrome
10,11,13,14
. Any complaint of vertigo other thanintermittent, severe, rotary, short-lasting vertigo likelyindicates a need for referral.
taxia
 Ataxia is a dyscoordination or clumsiness of move-ent not associated with muscular weakness
10
. It is asymptom in patients with cerebellar tumors and subclaviansteal syndrome
10
. Ataxia may affect gait in patients withhypothyroidism, paraneoplastic cerebellar degeneration,taxia-telangiectasia, Arnold-Chiari malformation, VBI,nd myelopathy
10,13,15-17
. Gait ataxia is the presentingsymptom in all patients with hereditary spinocerebellardegenerations
10
. It is also the most common finding inatients with alcoholic cerebellar degeneration and theresenting complaint in 10-15% of patients with multiplesclerosis
10
. Trunk ataxia is a symptom in patients withtaxia-telangiectasia and Creutzfeldt-Jakob disease
10
;hese two diseases also produce limb ataxia as doesaraneoplastic cerebellar degeneration
10
. In addition,0% of patients with Wernicke’s encephalopathy presentith ataxia of the arms while 20% present with ataxiaffecting the legs
10
. A patient report of ataxia confirmedby physical tests indicates a need for referral.
 Hearing Loss
 A sudden onset of unilateral deafness may be dueo labyrinthine artery infarction, possibly indicating aninfarction in the vertebrobasilar system
18
. A rapid lossof perilymphatic fluid due to a perilymphatic fistulaill produce hearing loss, but hearing may be normalin case of a low-volume leak
12
. Meniere’s disease pro-duces a fluctuating low-frequency hearing loss, whichis progressive over multiple episodes
10,19
. Autoimmunedisease of the inner ear also produces a fluctuatinghearing loss
11
. Progressive unilateral hearing loss islso a typical presentation of patients with acousticeuromas
20
. Hearing loss is also a symptom in patientsith acute labyrinthitis, quinine or quinidine toxicity,salicylate overdosage, Friedreich’s ataxia, otosclerosis,estibulocochlear nerve compression due to bacterial,syphilitic, or tuberculous infection or due to sarcoidosis,

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