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Assessment of Dizziness

In my clinical experience it would appear that patients presenting with dizziness is not uncommon.

Is there a protocol for assessment of dizziness?

I am certainly not an expert on dizziness, but I think the following information is a key minimum to know when assessing a dizzy patient.

From a physiotherapy perspective I think the more common types we tend to encounter are:

  • Vestibular dysfunction e.g. Benign Paroxysmal Positional Vertigo (BPPV)
  • Orthostatic intolerance/blood pressure issues.
  • Cerviogenic Dizziness

It is also is important for us to be aware of Vertebrobasilar Insufficiency (VBI). Personally I don’t see this as a common presentation. I believe I have seen 1 occurrence of VBI  in 11 years of clinical practice.

How do we differentiate between types of dizziness?

  • When does the dizziness occur?
    • VBI
      • When the patient moves their head and sustains it in the provocative position (usually extension and/or rotation). The symptoms in this position will also not fatigue (see below for more information)
    • Vestibular and cervicogenic dizziness
      • Tend to occur with changes in head position.
    • Vestibular symptoms can also occur with change of head position relative to gravity.
    • Dizziness on moving from a low to high position may also indicate orthostatic intolerance.
  • Latency of symptoms
    • Cervicogenic symptoms tend to occur immediately with the provocative movement.
    • Vestibular tend to be delayed by a small amount (e.g. 1 to 5 seconds).
    • VBI symptoms can have significant latency (up to 55 seconds).
  • Fatiguability of symptoms
    • Cervicogenic, Vestibular and Orthostatic issues will demonstrate fatiguing of symptoms i.e. if the provocative position/movement is maintained the symptoms will fatigue/reduce.
    • VBI symptoms will not fatigue/reduce in the provocative position.
  • Nystagmus direction
    • Cervicogenic and Vestibular
      • Torsional and/or horizontal
    • VBI
      • Vertical

Additional Information Regarding VBI

  • The Australian Physiotherapy Association’s (APA) Guidelines suggest that in the presence of dizziness that the following subjective symptoms, that are suggestive of VBI, are screened for:
      • Double vision
      • Drop Attacks/Black outs
      • Difficulty talking
      • Difficulty swallowing
      • Numbness/tingling in face/mouth
      • Nausea/Vomiting
      • Nystagmus
      • Ataxia
      • In addition to this VBI symptoms are rarely constant in nature.

Examining the Dizzy Patient (see references for further information relating to these tests)

    • Hallpike-Dix Test
      • Can distinguish between cervicogenic and BPPV.
      • If the test is positive for rotational/torsional nystagmus then a BPPV diagnosis is likely.
    • Neck Torsion Test
      • Head is maintained still and the patient rotates the body.
        • If positive (dizziness reproduced) the symptoms are likely to  be cervicogenic rather than vestibular in origin.
    • Sustained Neck Rotation
      • If positive it is suggestive of VBI particularly if symptoms don’t fatigue (as discussed above).
      • It should be noted that efficacy for testing of VBI is poor. Having said that, here in Australia it is the Australian Physiotherapy Association’s (APA) recommendation that VBI is assessed prior to any end of range cervical treatment or manipulation (high velocity thrust).
      • The APA’s minimum recommendations for assessment of VBI are:
        • Sustaining the provoked position and end of range cervical rotation for a minimum of 10 seconds.
        • On return to neutral the neutral position should be sustained for 10 seconds.
        • In all of the above positions the patient is observed and questioned regarding symptoms.
        • Provocative testing of VBI should be immediately ceased upon commencement of symptoms suggestive of VBI.
    • Cervical Assessment
      • As per normal physiotherapy/manual therapy examination to attempt to see if symptoms can be reproduced and/or changed with cervical treatment.
      • Unfortunately there is no gold standard test of cervicogenic dizziness so it is almost a diagnosis of exclusion.
      • Sensorimotor Assessment
        • This is another area to be assessed as part of a patient presenting with dizziness, but is worthy of its own post.

As an addition to this post I just read a recent article by Hutting et al (2012) that looked at a systematic review of premanipulative VBI tests. The conclusion being:

  • Based on this systematic review of only 4 studies it was not possible to draw firm conclusions about the diagnostic accuracy of premanipulative tests. However, data on diagnostic accuracy indicate that the premanipulative tests do not seem valid in the premanipulative screening procedure. A surplus value for premanipulative tests seems unlikely.

Sp why do we do them here in Australia…..I think mostly because our professional associations guidelines (APA) guide us to do so. Perhaps we need some change in these guidelines…..

References:

APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders (2006)

Gargano F, Hing W and Cross C (2012): Vestibular influence on cranio-cervical pain: a case report. New Zealand Journal of Physiotherapy 40(2) 51-58.

Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: A systematic review. Man Ther. 2012 Nov 3. pii: S1356-689X(12)00201-9.

Vidal P and Huijbregts P (2005) Dizziness in Orthopaedic Physical Therapy Practice: History and Physical Examination. The Journal of Manual & Manipulative Therapy Vol. 13No. 4(2005), 221 -250.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

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