Vertigo: the illusion of movement without stimulation
Equilibrium
is performed by three systems:
·
eyes
·
proprioception
·
cervical
spine—MVA , too much C-spine manipulations
·
vestibular
apparatus
Eyes:
·
1/3rd
of the balance system
·
the
other 1/3rd is the ears
Proprioceptive
input—upper cervical area
Examination:
·
gait
and vertigo tests
·
hautant’s
test
·
meniere’s
disease—patient may look like they are drunk
·
c
spine
·
perform
slowly due to spinning sensation lying down
·
cranial
nerves
·
complete
neurological—CN’s
·
eyes—SOL,
atherosclerosis
·
ears
–acoustic neuroma—broad based gait
·
nose--infections
·
throat--infections
·
vitals
& history
Postural
hypotension—patient stands up and feels woosy due to impaired vasoconstrictor
response
·
seen
worse in age
·
has
a high incidence of stroke
C
spine examination: trigger points, hypertonicity, arthritis, joint irritiation
Nose
and throat examination: URI, sinusitis
can cause vertigo
Otoscopic
exam: eustachian tube dysfunction or
any ear disease
Romberg’s: The eyes are closed depriving the patient of
this input. It is positive for loss of
proprioception or peripheral vestibular disturbance.
Blood
pressure: may reveal postural
hypotension
Vertigo
tests [see later notes]
History:
·
Setting:
·
changing
position,
·
worse
when riding in car,
·
turning
over,
·
veering
when walking
·
Sympathetic
symptoms:
·
nausea,
·
vomiting
·
perspiration
·
sense
of fear
·
Other
S&S: fever, paresis, slurred
speech, change in vision, sensory impariment, hearing loss, tinnitus
Sensation: imbalance, spinning
Rotary vertigo peripheral
vestibular disease
[acoustic
neuroma, Meniere’s, etc.]
Fainting lightheadedness postural
hypotension
woozy antihypertensives
and other Rx
psychiatric
– including anxiety
alcohol
Unsteady gait unsteadiness ageing-
cervical spondylosis
(proprioception and constriction of vertebral
artery)
poor
sight, TIAs
migraine,
head injury,
middle
ear diseases
Blacking out LOC neurologic
or cardiac arrhythmias
epilepsy and other
seizures
Length
of episode: can be one of the most important clues
Seconds benign
paroxysmal vertigo
Postural
hypotension
Cervical
spondylosis, cervical joint irritation
Myofascitis,
cervical strain/sprain
Minutes Meniere’s Disease
to hours Labyrinthitis
Hours ototoxicity
to days central vestibular disease [brain stem]
labyrinthe
failure
1.
Benign
paroxysmal vertigo- postural or positional vertigo
Seconds in duration
Induced
by certain head positions
Due
to granulation masses in posterior semicircular cupula
See
testing section
2.
Postural
hypotension
Seconds
Occurs
after extended periods of sitting or lying, dehydration, low blood pressure
Patient
experiences brief lightheadedness upon standing or walking short distance then
stopping
Perform
standing, seated and recumbent blood pressure
Patients
with low Blood pressure are more at risk as a geriatric
Patients
crave salt.
3.
Cervical
spondylosis, cervical strain/sprain, cervical joint irritation
Seconds
Due
to aberration in proprioception
Changes
in joints interrupts proprioception and the changes in motion alters the
muscular length which complicates and may worsen the symptoms.
Treat
with adjustments, full body exercises, cervical range of motion, wobble board
Treat
cervical injuries appropriately.
Note: the patient may be able to walk and perform
well on the wobble board but if the head is rotated to irritate the offending
structures, the patient may veer or have trouble maintaining balance.
4.
Myofascitis
Seconds
Sensation
of disagreeable motion on turning the head or other cervical motions
Associated
with trigger points
q
Typically
the clavicular division of the SCM
The
patient may fall when bending forward or stooping.
Nausea
is common.
Also:
Carsickness, frontal headaches,
May
be activated by: turning over in bed, holding the phone with the shoulder,
painting, sleepign on two pillows, sports, scoliosis, emphysema, neckties.
Dramamine
relieves the nausea but not the dizziness.
q
Meniere’s Disease Minutes to hours
Labyrinthitis Minutes to
hours
ototoxicity
Hours to days
central vestibular
disease [brain stem] Hours to days
·
Acoustic
neuroma—benign expansile tumor of the eigth cranial nerve anywhwere in the
inner ear
·
Can
have tinnitus that is faint and gets louder
·
Vertigo
may n=begin that may be more ataxia
than vertigo due to a slow growing lesion
·
Proprioceptive
vertigo—commonly seen in whiplash injuries, discogenic spondylitic injuries and
myofascitis
·
Myofascial
proprioceptive vertigo—typically the clavicular division of the SCM.
·
The
patient will have the illusion of diagreeable motion that occur with a sudden
to other motions.
·
Patient
may fall when bending forward stooping or be ataxic
·
The
patient may simply feel like falling backwards when looking up and visa versa.
·
Attacks
can last just a few seconds
·
Nausea
is common
·
Other
symptoms include: carsickness, frontal headaches, dizziness, turning in bed,
the shoulder
·
Activated
by painting, sleeping on two pillows, sports, scoliosis, emphysema, neck ache.
·
The
key is DRAMAMINE, RELIEVES NAUSEA BUT NOT DIZZINESS
·
Eagle
syndrome—styloid process is elogated by calcification of the ligament. There
are trigger points in the posterior muscle belly of the digastric and medial
pterygoid.
·
Concurrent
tp’s in the SCM
·
S&S
dizziness, visual blurrign w/ ¯ vision on the same side,
pian dizziness on extreme rotation of the head.
·
May
give + George’s test but no nystagmus
·
Hypoglycemia—mostly
the complaints are of lightheadedness nature. The complaints will typically be
in the morning or 3-4 hours post-prandial.
·
A
serum glucose test should be performed while th patient is symptomatic.
·
If
the results are positive, then order a glucose tolerance test.
·
Vestibular
neuronitis
·
Viral
infection of the vestibular nature
·
Complaints
are typically in the morning or 3-4
post-prandial
·
There
is a sudden onset of dizziness and sometimes nausea
·
The
patient may complain of feeling the earth move
·
The
episodes may be short and mild or long and severe
·
The
viral infection typically clears in 3 weeks to 3months
·
Demyelinating
diseases
·
Nystagmus
·
Sensorineural
hearing loss
·
Dizziness,
etc.
·
What
is seen here is a global pattern that involves several systems
·
Middle
ear disease
·
Unsteadiness
on the feet, true vertigo
·
Benign
paroxysmal positional vertigo—An episodic veritgo usually draws in turning the
head periodically in bed. It can follow an URI
but there are no preceeding illnesses. The veritgo lasts several seconds
and repeats on positional testing. Typically can resolve spontaneously.
·
Ageing—loss
of balance due to falling eyesight and hearing. Cervical spine ischemia and
atherosclerosis or the cerebral arteries. There may also be arrythmias. A
medication may be at fault—antihypertensives
·
Migraine—only
unsteadiness and imbalance not a true vertigo
·
Transient
ischemic attacks—A sense of imbalance associated with other hours.
Training
heart rate = (220-age – resting pulse) X x + RP = TR
·
X
= .6 for weight loss