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THE DIZZY PATIENT Erica Uzzell, SPT Slide 2 CAUSES OF DIZZINESS Arrhythmia Defective heart valve Dehydration Hyperventilation Medications Orthostatic Hypotension Stress, Tension, Fatigue Vasovagal syndrome Vestibular Dysfunction Disruption of blood flow Other symptoms Palpitations Weakness Fatigue SOB Low BP Fainting Slide 3 CAUSES OF DIZZINESS Arrhythmia Defective heart valve Dehydration Hyperventilation Medications Orthostatic Hypotension Stress, Tension, Fatigue Vasovagal syndrome Vestibular Dysfunction Loss of body fluids= decreased BP Slide 4 CAUSES OF DIZZINESS Arrhythmia Defective heart valve Dehydration Hyperventilation Medications Orthostatic Hypotension Stress, Tension, Fatigue Vasovagal syndrome Vestibular Dysfunction Common side effect Drug interactions Slide 5 CAUSES OF DIZZINESS Arrhythmia Defective heart valve Dehydration Hyperventilation Medications Orthostatic Hypotension Stress, Tension, Fatigue Vasovagal syndrome Vestibular Dysfunction Positive dx when there is a 20 mmHg drop in systolic BP and 10 mmHG drop in diastlic BP within 3 minutes of standing up Slide 6 CAUSES OF DIZZINESS Arrhythmia Defective heart valve Dehydration Hyperventilation Medications Orthostatic Hypotension Stress, Tension, Fatigue Vasovagal syndrome Vestibular Dysfunction Overstimulation of vagus nerve Blood vessels dilate HR decreases Decreased blood flow to brain Slide 7 CAUSES OF DIZZINESS Arrhythmia Defective heart valve Dehydration Hyperventilation Medications Orthostatic Hypotension Stress, Tension, Fatigue Vasovagal syndrome Vestibular Dysfunction Slide 8 OVERVIEW OF VESTIBULAR FUNCTION Maintenance of stance and body posture Coordination of body, head and eye movements Visual fixation Slide 9 ANATOMY Semicircular canals (anterior, posterior, & lateral) Aligned at right angles with each other Maximally sensitive to motion in the plane of that particular SCC Respond to angular acceleration of the head Act in functional pairs with the contralateral canal in the same plane Rotation in one place will be excitatory to one canal and inhibitory to the contralateral canal Filled with endolymph, which moves freely within each canal in response to head rotation Each enlarged at one end to form the ampulla, which contains the sensory hair cells Otolith organs (utricle & saccule) Respond to linear acceleration of the head Utricle excitation occurs during horizontal linear acceleration or static head tilt Saccule excitation occurs during vertical linear acceleration Contain calcium carbonate crystals (otoconia) Slide 10 Slide 11 COMMON COMPLAINT DIZZINESS! Important to distinguish between dizziness, vertigo, lightheadedness & dysequilibrium Dizziness- sensation of whirling or feeling a tendency to fall Vertigo- illusion of movement Lightheadedness -feeling that fainting is about to occur Dysequilibrium- sensation of being off balance Slide 12 SymptomPossible Cause Vertigo BPPV UVH unilateral central lesion affecting the vestibular nuclei Lightheadedness Orthostatic Hypotension Hypoglycemia Anxiety Panic disorder Dysequilibrium BVH Chronic unilateral vestibular hypofunction LE somatosensory loss Upper brainstem/vestibular cortex lesion cerebellar and motor pathway lesions Slide 13 OTHER SYMPTOMS Balance & spatial orientation Imbalance, stumbling, difficulty walking straight Clumsiness or difficulty with coordination Difficulty maintaining straight posture; tend to look downward to confirm the location of the ground Head may be tilted in a direction Tendency to touch or hold onto something while standing Sensitive to changes in walking surface or footwear Vision Trouble focusing or tracking objects with the eyes Sensitivity to light, glare or moving lights Poor depth perception Hearing Hearing loss Tinnitus Sensitivity to loud noises or environments Slide 14 OTHER SYMPTOMS Cognitive Difficulty concentrating and paying attention Confusion, disorientation, difficulty comprehending directions or instructions Mental and/or physical fatigues out of proportion to activity Psychological Loss of self-reliance, self-confidence, self-esteem Anxiety, panic, social isolation Depression Other Nausea or vomiting Hangover or seasick feeling in the head Motion sickness Sensation of fullness in the ears Headaches Slurred speech Sensitivity to pressure or temperature changes Slide 15 DURATION & CIRCUMSTANCES OF SYMPTOMS Important to distinguish between vestibular disorders Vertigo Seconds to minutes-Benign Paroxysmal Positional Vertigo Minutes to hours- Menieres disease Days- Vestibular neuronitis or migraine associated dizziness What circumstances causes the patient to experience symptoms? Particular movements, positions? Slide 16 TEST & MEASURES Motion Sensitivity Quotient Provides subjective score of an individuals dizziness Involves placing patients into positions incorporating head of entire body motion to determine if movement reproduces dizziness Most often used to determine the positions that causes symptoms Slide 17 TEST & MEASURES Eye Movements Observation of nystagmus Used to identify more peripheral and central vestibular lesions Examination of VOR at high acceleration Head thrust test Examines SCC function Patient fixates on nearby target and while keeping the eyes focused on target, the head is moved in unpredictable direction using small amplitude, high acceleration angular thrust Head shaking induced nystagmus Used to detect unilateral peripheral vestibular defect Patients vision is occluded and the head is flexed to 30 degrees and oscillated for 20 cycles at a frequency of 2 repetitions per second; patient then opens eyes and is checked for nystagmus Slide 18 TEST & MEASURES Eye Movements Positional testing Used to identify whether otoconia have been displaced into the SCC, causing BPPV Hallpike-Dix test Patient is moved from sitting with the head rotated 45 degrees to one side to a supine position with the head extended 30 degrees beyond horizontal with the head still rotated Direction of nystagmus correlates to involved SCC http://www.youtube.com/watch?v=eOuzUi5ckrk Slide 19 HOW DO WE TREAT? Epley Maneuver Patients head moved in different positions in a sequence that will move the debris out of the involved SCC Slide 20 HOW DO WE TREAT? Liberatory (Semont) maneuver Involves rapidly moving the patient through positions to dislodge the debris More difficult for patient to tolerate Slide 21 HOW DO WE TREAT? Brandt-Daroff exercises Habituation of provoking positions Should be performed multiple times daily until no vertigo persists for 2 days Can be given as a HEP component after repositioning maneuvers Slide 22 AFTER TREATMENT RECOMMENDATIONS Stay in upright position for 48 hours Avoid excessive head motion Avoid prolonged cervical flexion or extension Slide 23 RESOURCES http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular _diseases/arrhythmias_85,P00195/ http://www.tg.org.au/etg_demo/phone/etg34-brandt-daroff.pdf Waxman SG. The Vestibular System. In: Clinical Neuroanatomy. McGraw- Hill;2010:221-224. Schubert MC. Vestibular Disorders. In: OSullivan S, Schmitz T. eds. Physical Rehabilitation. Philadelphia, PA: FA Davis; 2007: 999-1025. Vestibular Disorders Association. Available at http://vestibular.org/node/2