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One Page Cheat Sheet: Exam for the Patient with Dizziness

History Questions*1) Type of Dizziness/Quality: be specific – spinning, unsteady, lightheaded2) Onset3) Frequency3) Duration: Fleeting (only during movement), seconds – minutes, weeks4) Spontaneous or Motion Induced: recurrent vertigo or recurrent motion induced5) Auditory complaints: fullness, ringing in ears6) Aggravating or Alleviating Factors: what do you do to simulate the symptoms7) Falls: any falls caused due to dizziness

Test Normal Response Abnormal ResponseSpontaneous Nystagmus

Gaze Nystagmus

Smooth Pursuit

Saccades

Slow VOR

Head Thrust

Gait Observation

CTSIB

Hallpike Positioning*Alternative side lying test

Roll Test

Examination for the Patient with Dizziness

Created by: Susan Miller, SPT; Regis University 2013

GAZE STABILITY ASSESSMENT: Spontaneous Nystagmus:Procedure: Ask patient to gaze at tip your finger without head

movement with best-corrected vision (glasses or contact lenses in place)

Normal Response: Patient will display no nystagmus.

Abnormal Response: Spontaneous nystagmus; observe direction.

Interpretation: If an abnormal response is present, observe amplitudeand direction. A central lesion presents with vertical

(down beating) or torsional nystagmus. A peripheral lesion presents as a mixed nystagmus of horizontal and torsional.

Gaze Nystagmus:Procedure: Ask patient to gaze at your finger

outstretched to the right side of your head (approximately 20° - 30° from central position) without moving their head for 20 seconds. Repeat on left side.

Normal Response: Patient will display no nystagmus.

Abnormal Response: Gaze-evoked nystagmus; Eyes change in direction, form or intensity; Spontaneous Nystagmus

Interpretation: A peripheral dysfunction is present if the gaze provokes nystagmus in a uni-lateral direction, magnitude mayincrease. Changing direction of the gaze should not change thedirection of the nystagmus. A central dysfunction is present if the nystagmus spontaneously changes.

Smooth Pursuit:Procedure: Ask patient to follow your finger in an “H” formation

without moving their head.

Normal Response: Patient will track finger with asmooth movement, no nystagmus and eyes move in aconjugate manner.

Abnormal Response: Patient cannot track finger in the horizontalor vertical planes.

Interpretation: If abnormal response is present, a dysfunction with central nervous system (CNS) or loss of oculomotor range of motion. Smooth pursuit will not detect a peripheral lesion. If impairment occurs with the vertical portion of the “H”, weakness of the eye musclesmay be present. If the impairment occurs with the horizontalportion of the “H”, this is a marker CNS dysfunction.

Created by: Susan Miller, SPT; Regis University 2013

Saccades: Procedure: Ask patient to look back and forth between

your finger (outstretched to the right of your head) and to your nose without moving their head. Repeat on the left.

Normal Response: Patient will track finger in quick, accurate and conjugate manner.

Abnormal Response: Latency of movement, abnormal speed, accuracy, or disconjugate movement.

Interpretation: Abnormal response indicates a dysfunction of central involvement.

Slow VOR TEST:Procedure: Ask patient to sit & focus their eyes on your finger

as they move their head side to side.

Normal Response: Patient maintains gaze (eyes) on your finger.

Abnormal Response: Eyes do not stay fixed on your finger and they willneed to correct to move back to the focal point. Observe directionof eye movement. Some patients may be resistant to move their headin a smooth manner.

Interpretation: A vestibular loss is indicated if a patient cannot fixate theireyes on the target and is an indication of a vestibular peripherallesion.

Head Thrust: Procedure: Ask patient to sit with eyes open & focus

on your nose. Grasp patient’s head between your hands high on the skull. Place patient’s head in a chin tuck position, quickly apply a small amplituderotation of the head to the left or right. Create unpredictable head movements

Normal Response: Patient maintains gaze (eyes) on your nose.

Abnormal Response: Eyes do not stay fixed on your nose and a correcting saccade takes placeback to the focal point Observe if the reflex is hyper/hypo-active.

Interpretation: A vestibular loss is present is the patient has a reflex that is hyper/hypoactive. It is an indication of a peripheral loss for hypoactive and central loss for

Created by: Susan Miller, SPT; Regis University 2013

hyperactive.

BALANCE/POSTURAL CONTROL TESTING: Gait Observation: Procedure: Ask patient to walk 30 – 50 feet: 1) Normal gait2) Pitch – move head up & down3) Yaw – move head left & right

Normal Response: No imbalances

Abnormal Response: Slow movements, stride length, speed, veering (direction), wobbling, imbalances, muscle weakness, and position of arms.

Interpretation: Most patients with a peripheral vestibular loss will veer or wobble towards the dysfunction side and typicallydo not fall from this disorder. However, this test alone cannot determine inner ear dysfunction.

CTSIB (Clinical Test for Sensory Interaction for Balance): Procedure: 1) Ask patient to stand with feet as close

together as possible – 1st with eyes open; 2nd with eyes closed for 30 sec. each2) Ask patient to stand on a piece of foam, repeat procedure above. NOTE: PT to stand close to patient for safety.

Normal Response: Maintain consistent position throughouteach test with no sway.

Abnormal Response: minimal, moderate or severe sway.

Interpretation: The test is to determine which system (visual, vestibular or somatosensory) the patient is using for

balance. The last condition indicates difficulty with the vestibular system. However, this does not tell us specifically which vestibular disorder.

HEAD POSITIONING TEST: Dix-Hallpike Positioning: Procedure: Have patient long sit on the table. Turn

patient’s head 30°-45° to the rightand lay them down in a steady movement with their head extended off the table. Once you elicit nystagmus and the symptoms calm down, sit the

Created by: Susan Miller, SPT; Regis University 2013

patient up. Guard the patient in the seated positionbefore repeating on the left side.

Normal Response: No symptoms

Abnormal Response: Nystagmus (horizontal, torsional); symptoms of dizziness, room spinning.

Interpretation: The direction of the nystagmus directs which canal is causing the dizziness:

Posterior Canal: Torsional & rotates toward involved earHorizontal Canal: Beats horizontal towards involved earAnterior Canal: Rotates away from involved ear

Alternative Test: Side lying Test (Specific for Posterior Canal)*Use the alternative test is a patient has neck or back pain (NOTE: cannot not treat symptoms in this position). Procedure: Have patient sit with legs off in the center of the plinth and a place a pillow to one side of them. If test left posterior canal, turn patients head right (right posterior canal, turn left). Place hands on patient’s head and lay them down on their side with a steady motion maintaining the head position. Have patient keep their eyes open to watch for nystagmus. Bring patient back to starting position with a slight forward flexed position. Guard patient for any instability.

Roll Test: Procedure: Ask patient to long sit. Place patient’s head in 30° flexion and turn to left as far as you can. Lay the patient on their back. Observe if any nystagmus occurs. Proceed to roll the patient’s head to the right.

Normal Response: No Nystagmus

Abnormal Response: observe for horizontal nystagmus

Interpretation: Only perform test if nystagmus occurred in a horizontal direction with the Dix-Hallpike test OR if the history & symptoms lead to Benign Paroxysmal Positionalvertigo (BPPV) but cannot elicit symptoms with Dix- Hallpike test

Created by: Susan Miller, SPT; Regis University 2013

Created by: Susan Miller, SPT; Regis University 2013

*History Algorithm to helpdirect the exam

References:

1) Fuller, K., Esses, B., Hedenberg, R. My World Is Spinning! What Can I Do? Vestibular Rehabilitation Part 2: Intermediate Module. Evergreen, CO: IRB Solutions: 2004.

2) Walter, J. Bedside and Office Examination of the Vestibular System. Medbridge Education website. Available at: www.medbridgeeducation.com. Accessed: September 2013.

3) Goebel, J. The Ten-Minute Examination of the Dizzy Patient. Seminars in Neurology. 2001; 21: 4; 391-398.

Created by: Susan Miller, SPT; Regis University 2013