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.
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.
A description of dizziness symptoms may be helpfulor initial classification into one of the four dizzinesssubtypes of vertigo, presyncope, dysequilibrium, andother dizziness
. 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
. However,symptom description indicating presyncopal and otherdizziness may indicate the need for referral.
An illusion of rotary movement implicates the semi-circular canals (SCC)
. 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 of eripheral 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
. Vertigo is a symptom in patients withPPV, Meniere’s disease, acute peripheral vestibulopathy,otosclerosis, toxic vestibulopathies, and autoimmunedisease of the inner ear
. It is less common in patientsith cerebellopontine angle tumors or acoustic neuropa-hy
. 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
. Vertigo alsooccurs in the diseases causing brainstem hypoperfusion,e.g., vertebrobasilar insufficiency (VBI), vertebrobasilarinfarction, vertebrobasilar migraine, and subclavian stealsyndrome
. Any complaint of vertigo other thanintermittent, severe, rotary, short-lasting vertigo likelyindicates a need for referral.
Ataxia is a dyscoordination or clumsiness of move-ent not associated with muscular weakness
. It is asymptom in patients with cerebellar tumors and subclaviansteal syndrome
. Ataxia may affect gait in patients withhypothyroidism, paraneoplastic cerebellar degeneration,taxia-telangiectasia, Arnold-Chiari malformation, VBI,nd myelopathy
. Gait ataxia is the presentingsymptom in all patients with hereditary spinocerebellardegenerations
. It is also the most common finding inatients with alcoholic cerebellar degeneration and theresenting complaint in 10-15% of patients with multiplesclerosis
. Trunk ataxia is a symptom in patients withtaxia-telangiectasia and Creutzfeldt-Jakob disease
;hese two diseases also produce limb ataxia as doesaraneoplastic cerebellar degeneration
. In addition,0% of patients with Wernicke’s encephalopathy presentith ataxia of the arms while 20% present with ataxiaffecting the legs
. A patient report of ataxia confirmedby physical tests indicates a need for referral.
A sudden onset of unilateral deafness may be dueo labyrinthine artery infarction, possibly indicating aninfarction in the vertebrobasilar system
. A rapid lossof perilymphatic fluid due to a perilymphatic fistulaill produce hearing loss, but hearing may be normalin case of a low-volume leak
. Meniere’s disease pro-duces a fluctuating low-frequency hearing loss, whichis progressive over multiple episodes
. Autoimmunedisease of the inner ear also produces a fluctuatinghearing loss
. Progressive unilateral hearing loss islso a typical presentation of patients with acousticeuromas
. 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,