Physical Examination and Evaluation of Dizziness

Herausforderung Schwindel Ostschweitzer Physiotherapie Symposium 2013 October 26 th Physical Examination and Evaluation of Dizziness Luc Vereeck, PT, PhD Faculty of Medicine and Health Sciences Division of Rehabilitation Sciences and Physical Therapy University of Antwerp, Belgium Antwerp University Research center for Equilibrium and Aerospace

Vestibular system dysfunction often results in: Nystagmus / Gaze instability / Oscillopsia (Vestibulo-Ocular Reflex) Impaired postural control / Instability (Vestibulo-Spinal Reflex) Vertigo Nausea

Assessment Vestibulo-Ocular Reflex Vestibulo-Spinal Reflex Vertigo (perceived handicap) Correlation between: Balance measures and ENG Balance measures and perceived handicap (DHI)

Assessment of the Vestibulo-Ocular Reflex

Function of the Vestibulo-Ocular Reflex The VOR normally acts to maintain stable vision during head motion. The VOR is responsible for counterrotating the eyes in response to head movements. This allows gaze to stay fixed on a specific point.

VOR-assessment Some considerations Peripheral component (5 sensors) Quid central component? Laboratory tests versus clinical bedside tests

Laboratory tests VOR-assessment Electronystagmography (ENG) (Horizontal SemiCircularCanal) Video-oculoscopy or video-oculography (Anterior & Posterior SemiCircular Canal): observation versus quantification Unilateral centrifugation test (Utriculus): by changing the axis of rotation Vestibular Evoked Myogenic Potentials (VEMP) i.e. Collic-VEMP (Sacculus) & Ocular-VEMP (Utriculus) Subjective Visual vertical test (Utriculus)...

VOR-assessment Clinical bedside tests Halmagyi Head Thrust Test (HHTT) or Head Impulse Test (HIT) Head shaking test (Barany) Dynamic Visual Acuity test (DVA test) (BPPV: Dix-Hallpike test, Side lying test, Roll test (Pagnini-McClure s test)) VOR cancellation test

Halmagyi Head Thrust Test Halmagyi & Curthoys (1988) Observe eyes of patient FAST, PASSIVE head thrust, small arc Eyes of patient should fixate on target (e.g. nose of therapist (variation: distant target)) If positive a corrective saccade is observed (if VOR function is insufficient, a refixation saccade is necessary to refoveate the target)

Schubert 2004

Sensitivity and specificity of the Head Thrust test for identifying subjects with vestibular system disorders* Type or cause of UVL Sensitivity (%) Specificity (%) N Study Complete UVL** 100 100 20 Halmagyi & Curthoys (1988) Complete UVL** 100 100 12 Foster et al (1994) Various 39 97 112 Harvey & Wood (1996) Various 35 95 105 Harvey et al (1997) Various 34 100 150 Beynon et al (1998) Unilateral vestibular loss 75 82 79 Schubert et al (2004) Bilateral vestibular loss 84 82 32 Schubert et al (2004) UVL and BVL 62 /78 72 /64 15 Jorns-Häderli et al (2007) Various 70 81 77 Grine et al (2000) Various 45 91 265 Perez & Rama Lopez (2003) *,Caloric test used as the standard; **, due to nerve section; UVL, unilateral vestibular loss; BVL, bilateral vestibular loss; N, Number of patients;, experts;, non-experts

Head Thrust Test as a function of canal paresis (Beynon et al (1998)) Canal paresis No. Of patients Negative test result Positive test result Normal (0-25) 76 76 (100%) 0(0%) Mild paresis 23 23 (100%) 0 (0%) (25-50) Moderate 21 19 (90%) 2 (10%) paresis (50-75) Severe paresis (75-100) 30 7 (23%) 23 (77%)

Head Shaking Test Therapist oscillates the head (eyes closed and head pitched down 30 ) of the patient 30 times (15 at 2 Hz) horizontally After the head oscillation the patient opens the eyes, which the therapist observes for nystagmus The presence of nystagmus (away from (most) affected side) immediately after this procedure indicates a vestibular imbalance

Head-shaking nystagmus test compared with caloric test Sensitivity % Specificity % N Study 40 60 108 Wei et al (1989) 95 62 85 Takahashi et al (1990) 27 85 116 Jacobson et al (1990) 44 65 105 Burgio et al (1991) 42 85 197 Goebel & Garcia (1992) 35 92 105 Harvey et al (1997) 38 79 290 Asawavichianginda et al (1997) Average Average 46 75

Head-shaking nystagmus test (HSN) as a function of canal paresis (Asawavichianginda et al (1997)) Canal paresis Positive HSN result Normal (0-20) 22% Mild paresis (21-25) 24% Moderate paresis (25-50) 28% Severe paresis (>50) 62%

Dynamic Visual Acuity Test The clinical DVA test compares visual acuity with the head still to visual acuity with the head moving It is a method to measure gaze stabilisation in a controlled condition and seems to be a good indicator of a disturbed VOR (Herdman 1998) Valid test to document the functional effect of vestibular rehabilitation (Tusa 2000)

DVA protocol Enormous diversity: Optotypes Type (chart) Presentation Scoring Head movement Static versus dynamic visual acuity Active versus passive Horizontal versus vertical Frequency / amplitudo

DVA protocol Optotype: An optotype is a sign or object designed to measure psycho-physical aspects of visual acuity. The subject distinguishes this sign or object based on the dimensions of one or more details or he determines its orientation based on the same dimensions. (BIN 1990)

Landolt C Snellen Chart Bailey & Lovie (1976)

Study (normative) age Freq speed H/V optotypes A/P loss Longridge 1987-1 - H 10 P 0-1 Blackley 1989-1.5-2 - H Snellen P 0 2 Burgio 1992-2 - 7 - H Snellen P 0.82 Bhansali 1993-1 (60 arc) H Snellen A Demer 1994 19 40 1 40 V 5 P < 0.5 Lee 1997 19 43 < 1 80 (20 arc) H 5 A < 1 Lee 1997 19 43 2 4 160 320 H 5 A 2 5 Herdman 1998 19 79-120 180 H 5 A <65j <0.5 >65j 1 1.5 Vanchaze 2001 21 59 2.5 60 H 3 P 0 1 Van Meel 2001 22-53 2 - H Snellen P 1.8 H: horizontal; V: vertical; A: active; P: passive

DVA interpretation If the patient can read only lines more than 3 lines above the initial static visual acuity line, he or she likely has a vestibular deficit (Herdman 2007) Sensitivity clinical DVA test for vestibular deficits is 85% and its specificity is 55% (Venuto 1998)

DVA protocol ENT-UHAntwerp EDTRS charts V-DVA treadmill 3,4,5,6,9 km/h H-DVA Active 2Hz: not reliable Passive 2Hz: 2nd therapist needed

VOR cancellation test Disturbed VOR cancellation test (the subject cannot fixate his eyes on a target that s moving in phase with the head) indicates desinhibition of the VOR (central component, e.g. brainstem or cerebellar lesion)

Assessment of the Vestibulo-Spinal Reflex 30

VSR-assessment Some items to consider when assessing postural control: Qualitative versus quantitative Static versus dynamic (functional) Clinical versus machine based

VSR assessment Vestibulopathic gait Widened base of support Lateropulsion (navigation) Difficulties with handling head movements while walking Standing balance Sensory organisation testing (Romberg and derivates)

Functional (walking) Tandem walking Babinski-Weil test or Marche en étoile 30 5 passes forward and then backward Fukuda stepping or Unterberger stepping Singleton test (walk 180 turn and stop) Walk rotate walk test (HSCC-BPPV (Rahko)) Timed Up and Go test Dynamic Gait Index (Functional Gait Assessment)

Fukuda stepping or Unterberger stepping Turning more then 45 or 2 m forward in the course of 50 steps is pathological (other sources allow 30 rotation, 50 cm forward stepping & NO backward stepping (Fukuda 1959)) Unterberger is not sensitive for chronic vestibular problems but possibly for acute unilateral problems (Hickey 1990)

Timed Up & Go test Is a very easy test to perform Patient stands, walks 10 feet, turns, and sits back down in the chair Requires a stop watch and a chair with arms Patient can use an assistive device for the testing

Timed Up & Go test Usually you do at least one practice walk and then time the patient They must be seated in the back of the chair to start the testing It is a very reliable test Be careful with your verbal cueing Pace!!

Dynamic Gait Index It is a tool that was developed to test gait in older adults (A. Shumway-Cook & M. Woollacott) Because the tasks involve a lot of head movements, the DGI includes many items that are valuable for therapists to assess patient s with vestibular deficits

Dynamic Gait Index There are 8 items and it takes 7-10 minutes to perform Recent adaptation by D. Wrisley in 2004 (conversion into 10 items (Functional Gait Assessment)) It is based on a four point scale of normal (3), mild (2), moderate (1), or severely (0) impaired This results in a maximum score of 24 for the DGI and 30 for the FGA

Dynamic Gait Index Walking Walking acceleration / deceleration on command Walking with horizontal head turns Walking with vertical head turns Walking with 180 turn and stop Walking over an object Tandem walking with eyes open Tandem walking with eyes closed Walking backwards (Walking around 2 cones (figure 8)) Doing stairs

Dynamic Gait Index Variable Gait Instability (DGI 19 or less) Number 148 99 Mean age 66 57 Number of fallers 67 24 Gait stable (DGI greater than 19) For the entire group, subjects with gait instability (19 or less on the DGI) were 2.58 times more likely to have at least 1 self-reported fall in the past 6 months (this ratio increases to 3.55 if only subjects older than 65 were included in the analysis). Whitney 2000

Standing balance Romberg and derivates Double tasks motor task (with or without Barré- or Jendrassikmanoeuvre) cognitive task Base of support (BOS) unstable BOS (e.g. standing on foam) magnitude (Sharpened Romberg, (semi) tandem stance, single leg stance) Vision (eyes open / eyes closed) Headmovements (with / without) (e.g. metronome)

CTSIB Clinical Test for Sensory Interaction in Balance Shumway-Cook A. & Horak F. 1986

Quasi-static balance tests Protocol ENT Dept. Antwerp Univ. Hospital Feet together with Jendrassik manœuvre on stable BOS Feet parallel with Jendrassik manœuvre on medium density foam (photo) Tandem stance on stable BOS Single leg stance on stable BOS All tests are performed with eyes open and closed for 30 seconds (best of 3 trials)

Quasi-static balance tests Gender and age effects (Int J Audiol 2008; 47: 67-75) Gender: < TR-EC (30 sec) (p = 0.002) (decade 6) Age (normative data): Age related decline in performance is different for each test

All tests were performed with eyes closed ROMJ Int J Audiol 2008; 47: 67-75

Standing on foam - eyes closed

Tandem Romberg eyes closed

One leg standing eyes closed

Evaluation of Desorientation Dizziness Vertigo Vertigo: sensation of movement of self or environment (rotation, translation, tilt)

Evaluation of dizziness The Vestibular Symptom Index (VSI) UCLA Dizziness Questionnaire Dizziness Handicap Inventory (DHI) (Motion Sensitivity Quotient (MSQ) or VHT test protocol)

The Vestibular Symptom Index (VSI) Use the following scale to grade the severity of your symptoms since the last visit: Balance Vertigo Dizziness Nausea Visual sensitivity Headache 0 = normal or absent 1 = very, very mild 2 = very mild 3 = mild 4 = low moderate 5 = moderate 6 = high moderate 7 = strong 8 = very strong 9 = extremely strong 10 = disabling; as severe as it can be Vertigo, a sensation that you or the world is spinning or moving; Visual sensitivity, symptoms of imbalance, vertigo, dizziness, motion sickness, etc., that are caused by movement in the visual periphery, flashing lights, or other types of visual stimulation. Original reference: Black FO, Angel CR, Pesznecker SC, Gianna C. Outcome analysis of individualized vestibular rehabilitation protocols. Am J Otol 2000;21:543-551.

UCLA Dizziness Questionnaire Please complete all five of the following statements. Circle the response that best describes your dizziness. Please give only one answer for each statement. 1. I am dizzy (frequency): 2. When I am dizzy, my symptoms are most often (severity): 3. When I experience dizziness, it has the following effect on my daily activities, such as working, driving, taking care of a family, and taking care of myself: 4. What impact does my condition have on the overall quality of my life? Examples: participating in social activities, sharing intimate relationships, making plans for the future, obtaining or maintaining work, and participating in leisure activities: 5. Regarding my fear of becoming dizzy: Original reference: Honrubia V, Bell TS, harris MR, Baloh RW, Fisher LM. Qualitative evaluation of dizziness characteristics and impact on quality of life. Am J otol 1996;17:595-602.

Dizziness Handicap Inventory (Jacobson & Newman 1990) 25 questions (does looking up increase your problem?) Problem = dizziness & instability Yes (4 points) sometimes (2 points) no (0 points) Score 100 = maximal perceived handicap Physical subscale (does bending over increase your problem) Functional subscale (restricted travelling for business or recreation) Emotional subschale ( are you afraid to stay home alone?)

Dizziness Handicap Inventory Reliability & Measurement error ICC (total score and subscores): 0.94-0.99 Measurement error: 9 (95%); 12 (99%) Weighted kappa (individual items): 0.74 0.97 %-agreement (individual tems): > 80 %, except item 8 (ambitious activities such as dancing, sports and householding activities): 74% B-ENT 2006; 2: 75-80

Dizziness Handicap Inventory Use total score Factoranalysis Original subcategories (Jacobson & Newman 1990) Emotional (emotional aspects - participation) Functional (global ADL - participation) Physical ( motion sensitivity BPPV (Whitney et al 2005)) Fourth cluster: impaired VOR function (aisle supermarket/reading/concentration/stressed relationships family & friends) Acta Oto-Laryngol 2007; 127: 788-795

Dizziness Handicap Inventory Relation with clinical balance measures Relation DHI-T & static balance tests Standing balance sum: r Pearson : -0.54 (p < 0.01) Seperate tests: r Spearman : -0.25-0.51 Relation DHI-T score & functional balance tests Timed Up and Go test: r Spearman : 0.57 (p < 0.01) Stappen op één lijn: r Spearman : -0.47 (p < 0.01) Dynamic Gait Index: r Spearman : -0.69 (p < 0.01) Otol Neurotol 2006; 28; 87-93

Dizziness Handicap Inventory Stepwise regression analysis (DHI) Dynamic Gait Index explaining 42 % of variance Standing on foam with eyes closed adding 1% Otol Neurotol 2006; 28; 87-93

Relation between ENG (VOR-function) results and clinical balance test results (VSR-function)

Relation between ENG (VOR-function) results and clinical balance test results Retrospective chart review of subjects with vertigo and/or instability (n = 87) Correlation study between clinical static (SOF, TR and SLS (eo & ec), Stabalsum), dynamic (TUG, DGI tandem walking) balance tests and ENG findings (caloric asymmetry, VOR-gain, VOR-phase and VOR-asymmetry)

Relation between ENG (VOR-function) results and clinical balance test results Correlation study (n = 87) (Vereeck 2009) VOR-phase with SOFec: - 0.42 VOR-phase with TReo: - 0.46 VOR-phase with Stabalsum: - 0.45

Relation between ENG (VOR-function) results and clinical balance test results Retrospective chart review of subjects with vertigo and/or instability (n = 67) Group 1: patients with normal caloric and rotational findings (n = 9) Group 2: patients with asymmetry on caloric test results and normal rotational findings (n = 20) Group 3: patients with abnormal caloric and rotational findings (n = 38)

Relation between ENG (VOR-function) results and clinical balance test results Significant differences (Kruskal Wallis test) between the 3 groups were found on (Vereeck 2009): Standing on foam eyes closed (SOFec): p<0.01 Standing balance sum (Stabalsum): p=0.03 Post hoc analysis (Mann Whitney U test) Group 3 < group 1 (SOFec): p=0.02 Group 3 < group 1 (Stabalsum): p=0.08 Group 3 < group 2 (SOFec): p<0.01 Group 3 < group 2 (Stabalsum): p=0.02

Relation between ENG (VOR-function) results and clinical balance test results This study demonstrates that patients with symmetrical central vestibular compensation findings, irrespective of peripheral vestibular system status, perform better on static clinical balance tests when compared with patients with asymmetry on rotational testing (disagreement with Gouveris et al 2007)

You need to test both VOR & VSR!!