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- Past medical history
- Past surgical history -
- Setting
Impact of other factors
Illusion of movement, false sense of rotation or linear movement
Vertigo
- Abnormal smooth pursuit or saccades
- Pure upbeat or torsional nystagmus
- 5Ds
Interpretation: findings
Moving objects in the environment, subjective
Oscillopsia
- Menieres disease
- Acoustic neuroma
- Superior canal dehiscence
Unilateral hypofunction (unstable)
- Fixation REDUCES nystagmus
- Direction is FIXED; MIXED HORIZONTAL OR TORSIONAL
- Nystagmus INCREASES with gaze directed towards FAST phase
- Unidirectional
- Tinnitus or deafness may occur
Peripheral nystagmus ***
- Any of the 5 D's
- Pure upbeat or pure torsional nystagmus
- True impairment in smooth pursuit or saccades without known CNS dysfunction
Red flags -- Refer, do not treat ***
Unsteadiness, observable
Imbalance
- Hypofunction
- Concussion
- Stroke, MS (CNS disorder)
Vestibular rehab (referrals)
Diaphoresis, emesis
Autonomic signs
- Observation
- Smooth pursuits
- Saccades
- Gaze holding
Action: screening
Sensation of being off balance, not observable
Disequilibrium
- CNS or PNS
- Unknown CNS
Decision: Treat or Refer
Fainting feeling
Lightheadedness/presyncope
Which virus usually causes/sparks neuritis?
Herpes simplex II
- Dizziness in an established CNS or PNS dysfunction
- Dizziness of unknown origin: screen CNS/PNS
- Positional dizziness: think peripheral vertigo
- Cervicogenic dizziness/MSK sign
- Disuse deconditioning
Dizziness and giddiness (referrals)
- Fixation ENHANCES nystagmus (or unchanged)
- Direction is PURE VERTICAL OR TORSIONAL
- Nystagmus may change direction with gaze
- Unidirectional or multidirectional
Central nystagmus
- Vestibular neuritis
- Anterior vestibular artery ischemia
- Labyrinthitis
Unilateral hypofunction (stable)
- Event lasts DAYS then compensation occurs
- Unilateral hypofunction: stable: weak VOR. This is what we treat!
- Vestibular neuritis
- Anterior vestibular artery ischemia
- Labyrinthitis
- Unilateral hypofunction: unstable
- Menieres disease
- Acoustic neuroma
- Superior canal dehiscence (SCD)
- Research shows PT is not effective in unstable, fluctuating conditions
Peripheral vestibular disorders
- Ototoxicity, meningitis, sequential vestibular neuritis, progressive disorders, autoimmune disorders, CIDP, congenital loss, and neurofibromatosis
- Most commonly idiopathic (underlying cause not known)
- Treatment: challenging, compensation for lost vestibular function
Bilateral hypofunction -- peripheral vestibular disorders
- Nystagmus lasts, oscillopsia and imbalance
- TIA/stroke, cerebellar degeneration, Arnold Chiari, MS, TBI, concussion
Central vestibular disorders
- No definitive test, eval upper quarter if no apparent neurological or otologic causes for the symptoms
- Address impaired cervical kinesthesia along with MSK impairments
- The cervical spine plays a role in gaze stability and postural control, focus on pain reduction and restoration of cervical mobility (not largely on VRT), most dont complain of vertigo but of imbalance/lightheadedness/disequalibrium
- Cervical ROM, pain
- Limit positional testing
- Impact VOR movement "head thrust"
- Fear avoidance behaviors
- Clear VBI
Cervicogenic dizziness
- Dilated (swollen) labyrinth
- Progressive hearing loss
- Tinnitus
- Imbalance
- Fullness
- Auditory symptoms (hearing loss)
- Spontaneous not positional vertigo (but can have secondary BPPV)
- Difficult to diagnosis; drop attacks in late stages
Meniere's disease
- Deconditioning with fear of falling
- Functional effects of aging nervous system = skeletal mm atrophy, less precise control of movement, decreased sensitivity of somatosensory system, processing speeds slow
- Can be age-related
Disuse disequilibrium
Symptoms are vague and vestibular tests normal, can be frustrating as a clinician
- Vestibular migraine
- Cervicogenic dizziness
- Disuse disequalibrium (deconditioning)
- Cardiac
- Psychological
- Chronic subjective dizziness
- Medication induced dizziness
- Persistent postural perceptual dizziness
- Visual vertigo
Non-otogenic dizziness