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got dizziness?





My patient came in complaining of dizziness. They felt anxious and scared.


Wouldn’t you?



That patient was:


a) a 60 year old with hypertension

b) a 50 year old with insignificant health history

c) a 16 year old post-concussion

d) a 45 year old with a history of migraines

e) a 35 year old post-op ACL repair



They were all my patients at some time over the last two years. All with a chief complaint of dizziness.

Like pain that persists, ongoing dizziness can feel quite unsettling and….



No, not everyone has BPPV and needs an Epley’s


Only one of the patients above did.



Dizziness is a nonspecific term but I’m using it because it’s the term most patients will use to describe their symptoms.


But the term itself doesn't tell us much.





Here is a short list: (** most common)

  • Vestibular dysfunction (most common: BPPV, Meniere’s Disease)**

  • Side effect of many prescription medications (esp those that cause vasodilation- such as diuretics, hypertension, opiates)**

  • Stress and anxiety**

  • Labyrinthitis**

  • Orthostatic Hypotension**

  • Migraines**

  • Vestibular neuritis

  • Acoustic neuroma

  • Side effect of supplements

  • Breathing pattern disorder

  • Reaction to environmental toxins

  • High blood pressure

  • Altitude sickness

  • Allergies

  • Persistent postural-perceptual dizziness (PPPD)

  • Metabolic disorders (eg, Paget's disease, otosclerosis)

  • Dysautonomia

  • Visually induced dizziness/vertigo

  • Perilymph fistula

  • Superior Semicircular Canal Dehiscence

  • POTS (Postural Orthostatic Tachycardia Syndrome)

  • Panic disorder

  • Heat exhaustion/heat stroke

  • Post-concussion disorder

  • Peripheral neuropathy

  • Vascular disease (eg, vertebrobasilar insufficiency)

  • Chronic neurological disorders (Parkinson’s disease, Multiple Sclerosis)

  • PTSD

  • Cerebrovascular accident (CVA) or TIA (stroke)

  • Brain tumor

  • Peripheral Vascular disorders

  • Mal de debarquement syndrome

  • Cerebellar disorders

  • Cervicogenic dizziness

  • TMJ dysfunction

  • CSF leak

  • Anemia

  • b12 deficiency

  • Hypoglyciemia

  • Hormonal changes

  • A sequelae of pregnancy

  • Cardiac disease

  • Ear infection

  • Hyper or Hypothyroidism

  • Electrolyte balance (dehydration or hyponatremia)

  • Hypoxia



Phew! That is a LONG short list



While BPPV is the most common cause of vertigo symptoms don't assume that's always the case. Patients with a complaint of dizziness need a thorough assessment.


You need is to figure out if you are the best person to help them and if not, who is?


Remember.....



How do you figure that out?





Here are the questions you should ask:



Can you give me a DETAILED description of your dizziness?


  • Does it feel like the room is spinning around? (vertigo)

  • Do you feel unsteady? (disequilibrium)

  • Have you fainted? (syncope)

  • Do you you feel lightheaded? (presyncope)



from TiTrATE article referenced below


What is the timeline of your symptoms?


  • Acute or gradual onset?

  • Duration: How long does your dizzy spell last?

  • How frequently do they occur?

  • What aggravates your symptom onset? (Postional changes, stress, walking etc)


Are there Associated Symptoms?


  • Do you have hearing loss or changes to your hearing? Including, tinnitus and feeling of fullness or pressure? (Ask date of last hearing exam)


  • Do you have any recent changes to vision? (Ask date of last vision exam)


  • Have you had nausea or vomiting?



Questions to differentiate peripheral vs. central (brain)


  • Question about “the 5D’s”: dizziness, dysphagia, dysarthria, diploplia and drop attacks And 3 N's: ataxic gait, nausea, nystagmus and numbness (refer to ER when dizziness is combined with 1 or more of these symptoms to rule out stroke)

  • Ask about (and test for) weakness/numbness

  • How quickly do you get dizzy with positional changes? (quick is common with peripheral causes)

  • Does lying down lessen the intensity of your dizziness (more common with peripheral causes)


Also, this table from the book Primary Care for the Physical Therapist is helpful:


#madlove for Bill Boissonnault


Questions with sensitivity for certain diagnoses


  • Does rolling over in bed make you dizzy? (BPPV)

  • Do you feel sensitive to light when flared up? (Vertigo related to migraines)

  • Do you have a fullness feeling in your ear? (Meniere’s Disease)

  • Do your symptoms occur mostly when going sit to stand (Orthostatic Hypotension)

  • Did you feel nauseous or vomit with symptom onset? (Labrynthitis or Vestibular Neuritis)



Want an outcome tool?


The Dizziness Handicap Inventory is an outcome tool that can be beneficial as well.






After asking those initial questions, your evaluation should include (most of) the following:


1. Review past/present medical history

2. Review past and present stressors

3. Review medication https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853661/

4. Review Diet

5. Review Sleep

6. Check vitals ( HR ,blood pressure, temp)

7. Check Cervical motion

8. Check VOR & other Gaze tests

9. Check Cranial nerves

10. Check SLS (or Romberg)

11. Check CTSIB (part of SFMA SLS breakout)

12. Check Dix-Hallpike maneuver

13. Coordination (eg, counting on digits) & Gait

14. Vagal/ANS function tests (6) (eg, Uvular lift test, breath hold test, pupillary release test)



The exam components above are what I consider the basics for an evaluation of someone complaining of dizziness. Note: I'm not a specialist in vestibular therapy. They will likely do even more specific testing.





Maybe you can help that patient with dizziness. If not, I hope learning how to ask the right questions helps you direct them to the appropriate specialist.


There are many different types of medical practitioners that are able to help individuals with dizziness, including:


Physical therapists, Occupational Therapists, Chiropractors, Athletic Trainers, Osteopaths, Medical doctors (including, but not limited to, the specialties of Internal medicine, Emergency medicine, Cardiology, ENTs, Ophthalmology and Neurology), Psychologists and Dentists.



Let's make sure we get these folks the care they need.




REFERENCES




1. William Boissonnault, Primary Care for the Physical Therapist: Examination and Triage


2. Catherine Goodman and Kenda Fuller, Pathology: Implications for the Physical Therapist.


3. Vidal P, Huijbregts P, Dizziness in Orthopedic Physical Therapy Practice: History and Physical Exam, J of Man and Manip Ther. 2005;13(4):222-251


4. Goebel, JA, The Ten-Minute Examination of the Dizzy Patient, Seminars in Neurology, 2001;21:391-8.


5. Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015;33(3):577–viii. doi:10.1016/j.ncl.2015.04.011


6. Course Manual from Seth Oberst: Stress, Movement & Pain: A Systematic Approach



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