Dizziness assessment and management

What is the definition of dizziness?

non-specific term implying false sense of motion of the body or disorientation

What is the definition of veritgo?

abnormal sensation of movement or spinning - rotatory

How many percent are peripheral and central respectively?

75% peripheral and 25% central

What are some characteristics of peripheral dizziness?

rapid onset, server symptoms, nausea, vomiting, auditory, nystagmus

why and when do we need to ask about dizziness?

• screen for potential red flags (VBI)

• expore whether sx from Cspine

• every headache and neck pain patient

What is the prevalence of dizziness?

• common in primary care (40-80% unexplained)

• 15-35% of adults at some point in their lives in large population-based studies

• dizziness mod severity 1yr incidence 4%, prevalence 28.9%

• vestibular vertigo 1 yr incidence 1.9%, prevalence 7%

• more prevalent in elderly, and more impact on ADLs

what are the differential diagnosis of dizziness?

central (red flags)

• concussion

• vascular

• stroke

• TIA

• neuro

• MS

• tumour

peripheral (Vestibular)

• vestibular migraine

• unilateral vestibular loss

  • labrynthitis

  • vestibular neuritis

• BPPV

• meniere’s disease

cervicogenic dizziness

What is cervical artherial dissection (CAD), and its history?

CAD is a tear in the artery wall, most commonly vertebral artery, or internal carotid. Leading to stroke; tearing in the lining ± embolism

History

• under 55

• actue onset head and neck pain

• moderate to severe (progressing)

• recent trauma or neck strain

• recent infections

• 5Ds, 3Ns

• subtle neurological symptoms, balance, gait, Horner’s syndrome, speech

• pt looking unwell, agitated, severe pain

What is vertebral artery insufficiency and its history?

VBI is temporary symptoms due to decreaed blood flow in the posterior circulation of the brain; occulusion or embolism

history

• over 65 (can be younger)

• long term neck pain stiffness

• CVS risk factors (smoke, BP, choleserol

• movement of neck dizziness

• dizziness or unsteadiness - related to head movement or position

• subtle neurological signs

• 5Ds, 3Ns on testing VBI

What are the 5Ds and 3Ns adn their meanings?

• dizziness and/or unsteadiness

• diplopia (double vision, visual field loss)

• dysarthria/dysphasia (difficulty with speech or finding words)

• dysphagia (difficulty swallowing or unexplained hoarse voice)

• drop attacks (sudden collapse without loss of consciousness)

VBI testing what it is and what it is not

• test the ability of vertebrobasilar system to maintain hindbrain perfusion and adequacy of collateral supply

• to rule out a possible vascular contribution

• occlusion of the posterior cerebral circulation related to head position

• not a test for presence of arterial dissection

• a negative test does not confirm safety with manual therapy or high velocity manipulation

• eliciting dizziness alone does not confirm VBI could be cervicogenic

What should we do if there is positive cervical arterial dissection or VBI?

CAD

• immediate referral to nearest ED/ambulance

• send written reports of history

• signs/symptoms of concern

VBI

• immediate referral for medical evaluation ± treatment

What is MR angiography?

• highest sensitivity and specificity for detectign VA stenosis compared to CT and US

What is positive doppler?

• reduced flow when turns head, then increaed flow when comes back

what are some vestibular function tests?

• hallpike test for BPPV with frenzel goggles

• hearing tests

• eletrocochleography

What are some examinations for red flags?

• cranial nerve testing (particularly bottom 4)

• blood pressure

• central signs: gait assessment (ataxic gait), coordination - heel to shin or finger to nose

• ausultate or palpate carotid artery

What is the vestibular system?

the inner ear and brain that helps control balance, spatial orientation, and coordination. It allows you to stay upright, maintain posutre, and move smoothly by detecting head movements and position changes. Controls vestibular ocular reflex - adjust eyes at the speed the head moves

What are the three semicircular canals, what do they detect, and what is the fluid in it called?

Horizontal (detects rotation); posterior (detects side flexion); anterior (detects nodding)

endolymph

what are some conditions that would affect the vestibular system?

• BPPV (Benign Paraxysmal Positional Vertigo)

• Unilateral vestibular loss/hypofunctions

• menieres

• vestibular migraine

What is BPPV, and its presentations?

cacium crystals in the utricle of inner ear become dislodge and move into semicircular canals, causing altered signalling

Presentation

• sudden, brief episodes of spinning vertigo triggered by head movements

• rolling over in bed, looking up

• under 1 minute

• nausea

• nystagmus

• no hearing loss or tinnitus

What are some special tests of BPPV?

Posterior/anterior canals

• Diz hallpike Maneuver (sens 79% spec 75%)

Horizontal canals

• log roll/supine roll test

• sens/spec not available for horizontal canals

What are the treatments for BPPV?

Posterior/anterior canals

• epley’s manoeuvre

• long sitting

• turn head to effected side

• lay back quicly wiht head in extension and right rotation

• hold until dizziness clears

• turn to left

• log roll onto side

• sit up via log roll

Horizontal canals

• BBQ roll

  • lay on right side 30 secs

  • roll onto back 30 secs

  • lay on left side 30 secs

  • stomach 30 seconds

  • roll onto right 30 seconds

  • return to sitting

What is unilateral vestibular loss (UVL)/hypofunction and its special test and treatments?

• each balance organ in cochlea of each ear sends electrical information to the brain when moving

• following an ear infection or neuritis or labrinythitis one side may stop working - sensation of movement

• onset: sudden, initial vertigo, nausea 3-4 dyas then on head movements, feels off balance

• symptoms: imbalance, nausea, rotational vertigo, unsteadiness with eyes closed, difficulty focusing when moving quicly

• bilateral: no dizziness, but severs balance deficit

• test: head impulse test

• treatment: improve gaze stability, will cause dizziness

What are some additional vestibular assessments?

• colaric tests - record neck and eye movement while irrigating ears with warm and cool water

• Ax for nystagmus

  • eye movement ROM

  • smooth pursuit -gaze ability

  • saccadic eye movement (rapid movements to move gaze

• vergence - eye movements (rapid movements to move gaze)

• COR cancellation

• Skew deviation