Differential diagnosis and management of a patient with peripheral vestibular and central nervous system disorders: a case study

Background

Clinical examination and management of patients with meningiomas is primarily dependent upon appropriate diagnosis of tumor type and surgical intervention. Physical therapists should be able to identify patients presenting with signs and symptoms suggestive of potential central nervous system (CNS) disorders and refer the patient appropriately.

Patient characteristics

In this case report, a 52-year-old female was referred to physical therapy after 18 months of unresolved dizziness.

Examination

Oculomotor examination revealed evidence of peripheral vestibular and potential CNS disorders. The physical therapist referred the patient to a physician who ordered magnetic resonance imaging (MRI).

Intervention

The patient received five physical therapy sessions while waiting for the MRI which revealed a meningioma. The meningioma was surgically removed and the patient was subsequently relieved of all symptoms.

Outcomes

Despite the presence of the meningioma, the patient reported improved stability during work-related activities and decreased dizziness as a result of physical therapy intervention pre-operatively.

Discussion

This case report emphasizes the importance of a physical therapists ability to perform and interpret an oculomotor examination in a patient presenting with signs consistent with peripheral vestibular and CNS disorders. It also demonstrates the role of physical therapy in collaboration with physicians in order to provide appropriate patient care management.     

Dizziness in Orthopaedic Physical Therapy Practice: Classification and Pathophysiology

Abstract

Dizziness is a frequent complaint in patients presenting to orthopaedic physical therapists. Differential diagnosis of dizziness is complex but essential and requires knowledge of musculoskeletal, vestibular, cardiovascular, neurological, metabolic, and psychiatric conditions, thus transcending the musculoskeletal boundaries of orthopaedic physical therapy clinical practice. Physical therapy intervention is not indicated for many causes of dizziness. Some types of dizziness present contra-indications to certain orthopaedic physical therapy interventions. This article presents a diagnostic classification system and relevant pathophysiology that may facilitate orthopaedic physical therapy diagnosis, screening, and subsequent appropriate physical therapy management or medical referral.     

Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Acute Poisoning with the Neonicotinoid Insecticide Imidacloprid in N-Methyl Pyrrolidone

Background: Imidacloprid [1-(6-chloro-3-pyridylmethyl)-N-nitroimidazolidin-2-ylideneamine, CAS 138261-41-3] belongs to a relatively new class of insecticidal chemistry, the chloronicotinyl neonicotinoid compounds. Animal studies indicate relatively low toxicity to mammals because they have resistant nicotinic receptor subtypes compared to insects, as well as protection of the central nervous system by the blood brain barrier. Despite wide usage, human exposure experience resulting in toxicity is quite limited. Case Report: Here, we report a case of acute ingestion of an insecticide formulation containing 9.7% imidacloprid, <2 % surfactant, and the balance as solvent, N-methyl pyrrolidone. Clinical manifestation included drowsiness, disorientation, dizziness, oral and gastroesophageal erosions, hemorrhagic gastritis, productive cough, fever, leukocytosis, and hyperglycemia. The patient recovered without complication with supportive treatment and was discharged 4 days after ingestion. Follow-up barium upper gastrointestinal examination 1 month later was normal. Because moderate to high dose imidacloprid in animals causes central nervous system activation similar to nicotine, including tremors, impaired pupillary function, and hypothermia, it is unclear whether imidacloprid had a causal role in the patient's initial drowsiness and dizziness. It is more likely that the formulation ingredients, particularly N-methyl pyrrolidone, caused most of the clinical symptoms including minor central nervous system depression, gastrointestinal irritation, and hyperglycemia.     

Retrospective Review: Effectiveness of Cervical Proprioception Retraining for Dizziness After Mild Traumatic Brain Injury in a Military Population With Abnormal Cervical Proprioception

ObjectiveThis study aimed to assess the outcomes of 2 treatments for patients with dizziness after mild traumatic brain injury (mTBI) who demonstrate abnormal cervical spine proprioception (CSP).MethodsA retrospective records review was conducted on the medical charts of patients treated for dizziness after mTBI who received either standard care (vestibular rehabilitation therapy [VRT]) or cervical spine proprioceptive retraining (CSPR) from 2009 to 2013. All patients included in the analysis were active-duty military with recurring dizziness after mTBI who had at least 1 abnormal CSP test. Patients were excluded for dizziness with a clear peripheral vestibular or central symptom origin, incomplete data, or no CSP assessment, or if both treatments were administered. Forty-eight total patients were included in the final dataset (22 VRT; 26 CSPR). Traditional VRT was compared with CSPR when abnormal CSP tests were present, regardless of the presence or absence of neck pain. A clinician review of records was used to determine improvement of dizziness based on patient reports of symptoms at discharge evaluation (ie, no symptoms for at least 2 weeks).ResultsPatients who received CSPR were 30 times more likely to report improvement in dizziness symptoms compared with those who received VRT (adjusted odds ratio: 30.12; 95% confidence interval 4.44-204.26, P < .001) when abnormal CSP tests were present. Patients with dizziness over 1 year were significantly less likely to improve.ConclusionThese results suggest that patients with dizziness after mTBI and who had abnormal CSP assessments responded better to CSPR compared with those who received VRT.     

The effectiveness of vestibular rehabilitation therapy vs conservative treatment on dizziness: a systematic review and meta-analysis

Abstract

Background: Dizziness is a common condition which may lead to loss of function and disability. Vestibular Rehabilitation Therapy (VRT) may be utilized to affect the vestibular system and reduce dizziness. However, controversy exists regarding the most effective interventions to treat dizziness.

Objectives: To examine the effectiveness of VRT compared to other conservative treatments in reducing dizziness and disability.

Methods: A literature search was performed using different combinations of the terms: dizziness, physical therapy, vertigo, vestibular, cervicogenic dizziness to identify randomized clinical trials comparing VRT to conservative treatments. The Cochrane Risk of Bias Tool was used to assess the quality of each included study. Additionally, a meta-analysis and qualitative analysis of the evidence was performed.

Results: Ten studies were included in the systematic review. Only four studies were included in the meta-analysis due to lack of adequate data reported for continuous outcomes. Eight studies scored less than a 69% on the Cochrane risk of bias tool indicating a low to moderate risk of bias. The meta-analysis revealed that VRT was found to be more effective than conservative treatment for short term outcomes (0–3?weeks) but not long-term outcomes (4 or more weeks). The results from the studies excluded from the meta-analysis but included in the systematic review are inconclusive.

Conclusions: VRT was only found to be more effective than other conservative treatments in the short term.     

Rate and Predictors of Serious Neurologic Causes of Dizziness in the Emergency Department

ObjectiveTo describe the rate and predictors of central nervous system (CNS) disease in emergency department (ED) patients with dizziness in the modern era of neuroimaging.Patients and MethodsWe retrospectively reviewed the medical records of all adults presenting between January 1, 2007, and December 31, 2009, to an academic ED for a primary triage complaint of dizziness, vertigo, or imbalance. The final diagnosis for the cause of dizziness was independently assigned by 2 neurologists, with a third neurologist resolving any disagreements. The primary outcome was a composite of ischemic stroke, intracranial hemorrhage, transient ischemic attack, seizure, brain tumor, demyelinating disease, and CNS infection. Univariate and multivariate logistic regression were used to assess the association between clinical variables and serious CNS causes of dizziness.ResultsOf 907 patients experiencing dizziness (mean age, 59 years; 58% women [n=529]), 49 (5%) had a serious neurologic diagnosis, including 37 cerebrovascular events. Dizziness was often caused by benign conditions, such as peripheral vertigo (294 patients [32%]) or orthostatic hypotension (121 patients [13%]). Age 60 years or older (odds ratio [OR], 5.7; 95% confidence interval [CI], 2.5-11.2), a chief complaint of imbalance (OR, 5.9; 95% CI, 2.3-15.2), and any focal examination abnormality (OR, 5.9; 95% CI, 3.1-11.2) were independently associated with serious neurologic diagnoses, whereas isolated dizziness symptoms were inversely associated (OR, 0.2; 95% CI, 0.0-0.7).ConclusionDizziness in the ED is generally benign, although a substantial fraction of patients harbor serious neurologic disease. Clinical suspicion should be heightened for patients with advanced age, imbalance, or focal deficits.     

Transient ventricular arrhythmia as a rare cause of dizziness during exercise: A case report

BACKGROUNDDizziness is a common symptom in adults and usually due to peripheral causes affecting semicircular canal function or central causes affecting the pons, medulla, or cerebellum. Arrhythmia is a recognized cause of dizziness in people with structural or ischemic heart disease. We report a case of exercise-induced transient ventricular tachycardia and dizziness in a man with no evidence of organic heart disease.CASE SUMMARYA 42-year-old man presented with a 6 mo history of transient exercise-induced dizziness and prodromal palpitations. The patient was otherwise asymptomatic. Physical examination, otoscopy, vestibular tests, cerebellar tests, laboratory investigations, and imaging investigations were all unremarkable. Twenty-four hour Holter monitoring revealed four episodes of transient ventricular tachycardia during exercise. The patient was started on metoprolol and subsequently underwent radiofrequency catheter ablation. The patient reported a full recovery and no dizziness during daily activities. These results were maintained at the 6 mo follow-up.CONCLUSIONVentricular tachycardia is an uncommon but potentially serious cause of dizziness. The outcome of this case illustrates the benefits of careful clinical examination and communication with specialized centers. High clinical suspicion of arrhythmia in a patient with dizziness merits consultation with a cardiologist and referral to a specialized center to ensure timely diagnosis and treatment.     

Evaluation and management of the dizzy patient.

Evaluation and management of the dizzy patient remains frustrating to both the patient and physician. Numerous disorders may induce dizziness; these include not only inner ear disoders but also various central nervous system, ocular, and general systemic disturbances. Since dizziness has many variations, the subtle nuances the symptom may manifest must be explored throughly. Similarly, a consistent approach to the patient's physical and larboratory examination must be taken to understand the pathophysiology of the dizziness. This includes comprehensive auditory and vestibular evaluation, complete neurologic and ophthalmologic examination, and laboratory evaluation for latent or manifest systemic disease. The management of dizziness and vertigo is largely symptomatic. Certain exceptions exist where specific medical and surgical approaches may be beneficial, but the limitations of such treatment must be appreciated.     

Physical findings in patients with dizziness undergoing a group exercise programme

Background and Purpose . Although there have been studies on patients with persistent dizziness, physical findings have not been formerly focused. The aim of this study was to investigate localization and extent of physical dysfunctions in patients with long‐lasting dizziness. To investigate physical change, we re‐examined patients who had completed a vestibular rehabilitation (VR) programme. Methods . A longitudinal design was used. Patients with peripheral vestibular dysfunction were examined with the Global Physiotherapy Examination (GPE‐52) and the Vertigo Symptom Scale‐short form (VSS‐SF). The GPE‐52 consists of 52 standardized items within posture, respiration, movement, muscle and skin. Initially, 32 patients were included; 20 completed the VR programme. The programme, based upon traditional VR exercises combined with a body awareness approach, was administered as group sessions taking place once weekly for nine weeks. Results . The majority of patients had a flexed head posture, and their respiration was restricted. Reduced flexibility, reduced ability to relax, measured with passive movements, and restricted range of motion (ROM) were found in about half of the patients in the neck, jaw, shoulder girdle and thorax. On palpation of muscles, 70–94% of the patients had reduced stretch in the abdominals/diaphragm, upper trapezius, sternocleidomastoid and medial gastrocnemius muscles. After the VR programme, significant improvements (p < 0.05) were shown in the following areas: respiration, flexibility and passive movement tests in the shoulder and cervical region, and ROM in the neck and jaw. Significant improvement (p < 0.05) was also reported in the balance subscale of the VSS‐SF. Conclusions . This study documents that postural changes, restricted respiration, lack of flexibility, ability to relax and reduced muscular stretch seem quite common in patients with dizziness. A modified VR comprising body awareness significantly improved respiration and movements in the upper body as well as self‐reported balance. Copyright © 2008 John Wiley & Sons, Ltd.     

Bedside Diagnosis of Vertigo: Value of the History and Neurological Examination

Vertigo is caused by disturbance of the input or central processing of sensory signals from the vestibular apparatus that provide information regarding the position of the body in space. It is caused either by asymmetric disruption of sensory input from the vestibular organs or asymmetric integration of vestibular input into the central nervous system. Vertigo is readily differentiated from other causes of dizziness by a sensation of motion. A crucial aspect of the management of the emergency department patient with vertigo is the differentiation of vertigo associated with acute stroke syndromes from vertigo due to peripheral causes. Routine computerized axial tomography imaging is insensitive for posterior circulation strokes, so for emergency physicians, the history and neurological examination remain the most useful diagnostic tools. This article emphasizes the history and physical examination in the localization of the lesion in patients with vertigo and offers a rational basis for decisions regarding the need for special neurological imaging and consultation. It also emphasizes subtle findings that may prevent the erroneous diagnosis of peripheral vertigo in the presence of an acute stroke syndrome.     

Effectiveness of vestibular rehabilitation on concussion-induced vertigo: a systematic review

Background: Approximately 5% of all Americans have experienced a concussion sometime during their lifetime. The predominant symptoms associated with a concussion are physical issues, cognitive issues, emotional issues, and sleep disturbances; and one of the most common physical issues is vertigo.

Objectives: The purpose of this systematic review was to investigate the effectiveness of vestibular rehabilitation on concussion-induced vertigo.

Methods: Those databases that were utilized for search terms included CINAHL Complete, Proquest Medical Library, and PubMed. Each of these databases was examined from inception through the end of 2017. The search terms were ‘concussion’ OR ‘brain injury’ OR ‘head injury’ AND ‘vestibular rehabilitation’ OR ‘vestibular therapy’ AND ‘vertigo’ OR ‘dizziness’. The Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence system was used to assess the evidence level of each included study, and methodological rigor was assessed utilizing criteria set forth in a systematic review by Medlicott and Harris.

Results: Seven articles met the inclusion criteria and were included in the qualitative synthesis. Six of the seven studies had an evidence level of less than two, and four of the seven studies had weak methodological rigor. Despite these limitations, this systematic review demonstrated that vestibular rehabilitation is generally an effective intervention for individuals with concussion-induced vertigo, even in the presence of visual disorders.

Conclusions: Vestibular rehabilitation should be considered as a component of the plan of care for individuals who experience vertigo following a concussion.     

Challenges in conducting a randomized clinical trial of older people with chronic dizziness: Before,during and after vestibular rehabilitation

PurposeThis study aims to describe the process of conducting a randomized clinical trial of elderly with chronic dizziness subjected to vestibular rehabilitation (VR) and to verify its effectiveness on dizziness intensity.MethodsOlder adults (≥ 65 years) with chronic dizziness from vestibular disorders referred to VR were enrolled to the trial. The control group (n = 40) was submitted to the Cawthorne & Cooksey protocol and the experimental group (n = 42) to the modified Cawthorne & Cooksey protocol which included multiple components. Protocols were performed during individual 50-minute sessions, twice-weekly, for eight weeks. Main measures were: recruitment data (refusal and eligibility), baseline characteristics, dropout rate, session attendance, protocol adherence, adverse effects, exercise adaptation and follow-up events. The Visual Analog Scale (VAS) was used to measure dizziness intensity.Results144 elderly were referred to VR, 26.4% declined to participate and 16.7% were ineligible. There were 51 session non-attendances, with disease being the most frequent reason. Regardless of VR protocol, VAS dizziness intensity diminished along sessions (p < 0.001). 88.6% of the participants reported improvement after treatment, and 22.9% mentioned an increase in dizziness on follow-up. Home exercises were no longer being performed by 21.4% of the subjects after 3 months from discharge. The final dropout rate was 14.6%. There were no differences between VR protocols on recruitment, dropout, session's attendance, adherence to protocol and treatment effects.ConclusionsOur results revealed many challenges in conducting a rehabilitation trial with an elderly sample. The VR protocols showed to be feasible and suitable to reduce dizziness in older adults.     

Comparison of Activity-Based Home Program and Cawthorne-Cooksey Exercises in Patients With Chronic Unilateral Peripheral Vestibular Disorders

ObjectiveThis study aimed to investigate the effects of an activity-based home program and an exercise-based home program on dizziness severity, balance, and independent level of daily life activities in patients with dizziness due to chronic unilateral peripheral vestibular disorders.DesignA single-blind randomized controlled trial.SettingUniversity dizziness management clinics.ParticipantsIndividuals (N=75) between 18 and 65 years of age who had chronic unilateral peripheric vestibular disorders and vestibular rehabilitation indication.InterventionParticipants were randomly divided into 3 groups: an activity-based home program (group 1/activity group), an exercise-based home program (group 2/exercise group), and a control group (group 3). After an initial assessment, all groups participated in the patient education program. In addition, the activity-based home program was administered to the first group, while the Cawthorne-Cooksey home exercise program was administered to the second group.Main Outcome MeasuresVisual analog scale (VAS), Vestibular Disorders Activities of Daily Living Scale (VADL), and computerized dynamic posturography before and immediately after the treatment program.ResultsA statistically significant improvement was found in the activity and exercise groups in terms of VAS, VADL, Sensory Organization Test (SOT) 5, SOT 6, and SOT (composite) scores compared with the control group (P<.05). A statistically significant improvement was found in the activity group in terms of the instrumental subscale of VADL, SOT 5, SOT 6, and SOT (composite) scores compared with the exercise group.ConclusionsThe activity-based home program was more effective in improving the home management task, the occupational task, and balance than the exercise-based home treatment program in patients with chronic peripheral vestibular disorders.