Differential Diagnosis of Dizziness in SCI. Jordan Cabrera, PT, DPT, NCS Jorge Neira, PT, DPT, NCS

Transcription

1 Differential Diagnosis of Dizziness in SCI Jordan Cabrera, PT, DPT, NCS Jorge Neira, PT, DPT, NCS

2 Learning Objectives Participant will be able to identify the need to perform a basic oculomotor and vestibular screen to assist in the differential diagnosis of dizziness. Participant will be able to identify ways to adapt their plan of care to address vestibular impairment with the SCI population.

3 Introduction When an SCI patient complains of dizziness, what do you assess first? Dizziness can have various meanings based on Symptoms Culture/language of patient Several causes Important to address the cause of dizziness to optimize outcomes and participation

4 What is Dizziness? Types of Dizziness Vertigo: False sense of movement, complaints of a sensation that the environment is spinning Lightheadedness: feeling faint or pre-syncope symptoms Disequilibrium: feeling off-balance or inability to walk Many cultures may confuse dizziness with headache Some patients may also complain of floating sensations, rocking, or swaying

5 Sources of Dizziness in SCI Autonomic Dysreflexia Hypertension Common Symptoms Pounding headache Profuse sweating and flushing above level of injury Blurry vision Nausea Nasal Stuffiness Goosebumps or clammy skin below level of injury

6 Sources of Dizziness in SCI Orthostatic Hypotension Feeling faint Pre-Syncope/Lightheadedness Can include Nausea Fatigue Pallor Perioral and facial numbness

7 Consider other reasons for dizziness Why? Individuals may have other sources of dizziness due to conditions pre-injury, during the injury, or post-injury Incidence of a dual diagnosis of traumatic brain injury (TBI) and spinal cord injury (SCI) is 60-74% (Kushner, 2015) Mild Traumatic Brain Injury occurs in 64-73% of dual diagnosis cases (Kushner 2015, Macciocci et al., 2008) Missed TBI diagnosis in SCI patients higher in non-mva (75%) compared to traumatic MVA (42.9%) (Sharma et al., 2014) Reasons for Missed TBI Diagnosis in SCI (Kushner, 2015) Attention to acute care management of SCI Need for sedation or intubation CT or MRI not sensitive or specific to mild TBI Failure to collect Glasgow Coma Scale Scores Duration of Post-Traumatic Amnesia or loss of consciousness Overlap in symptoms of mild TBI with medications, lack of rest, or emotional response to SCI: Attentional disturbance, impaired concentration/cognition, anxiety, emotional lability Lessened expectation of TBI in non-mva patients

8 Sources of Dizziness in SCI Dizziness from Central Origin Examples: TBI/concussion, CVA, Brain Tumor, MS Slower onset, usually less intense, generally constant Not typically based on position Cerebellar and/or brain signs may be present Central signs from Oculomotor exam Balance impairment and Motion Sensitivity Common Motion Sensitivity: Disorientation, dizziness or postural instability in situations with visual and vestibular conflict.

9 Sources of Dizziness in SCI Peripheral Vestibular Dysfunction Examples: BPPV, Unilateral/Bilateral Hypofunction Common conditions: Labyrinthitis, Vestibular Neuritis, Meniere s disease Vertigo (spinning) with changes in head position Sudden onset, usually more intense, intermittent Position dependent May involve hearing loss BPPV, VOR impairment (Gaze Instability), and Balance impairment common

10 Sources of Dizziness in SCI Cervicogenic Dizziness Common with whiplash injuries Abnormal sensory input to CNS due to cervical injury leads to mismatched cervical somatosensory information with vestibular and visual systems Dizziness related to cervical movement/posture Neck pain Impaired neck kinesthesia/proprioception

11 Sources of Dizziness Migraine Moderate to severe, pulsating recurrent headaches Often unilateral and accompanied by nausea, photosensitivity, and/or phonosensitivity May or may not include aura Symptoms can involve visual distortions, swaying or spinning sensations, fatigue, motion intolerance, and head or ear pressure. Aggravated by: stress, sleep dysregulation, anxiety, emotional changes, dietary triggers Chronic migraine can be precipitated by head trauma Personal and family history of migraine can increase risk

12 Sources of Dizziness in SCI Medications that can cause dizziness as a side effect Blood pressure medications: ACE Inhibitors, betablockers, diuretics, calcium-channel blockers Muscle Relaxants Antidepressants Anticonvulsants Pain Relievers Sleeping Pills Nitroglycerin for Angina (chest pain)

13 Sources of Dizziness in SCI Anxiety Vestibular disorders may lead to: Development of anxiety disorder Exacerbations of pre-existing anxiety disorders Overlap in neural circuitry Autonomic nervous system pathways and vestibular pathways converge Results: Vestibular system afferents stimulate autonomic responses Symptoms of vestibular dysfunction overlap with symptoms of anxiety

14 Considerations for Chart Review 1. History of dizziness? 2. What medications are they taking for any co-morbidities? Dizziness a side-effect? 3. What are the co-morbidities? 4. Mechanism of SCI - do you suspect or is there a recorded TBI? 5. Past ear surgeries?

15 Subjective/History Exam 1. Explain your symptoms without using the word "dizzy." Off-balance : unilateral vestibular hypofunction, impaired foot sensation (veering), cervicogenic, motion sensitivity, central disorder Spinning sensations: vertigo caused likely by BPPV (positional) Blacking out/fainting/light-headedness: cardiovascular, diabetes, c spine ligament laxity or fracture from trauma Floating/Rocking /Swaying (not related to movement): anxiety-related, psychogenic, motion sensitivity Headache: may be described as dizziness by some cultures, may have association with TBI/concussion, motion sensitivity, migraine 2. When did it start? 3. How long does it last? - Greater than hours continuous you back away from peripheral 4. What makes it worse/ What makes it better?

16 Subjective/History Exam 5. Does it start or get worse when you change body position? If experiencing vertigo (true spinning) think BPPV 6. Do you have ringing in the ear or have you lost hearing in an ear? If so think peripheral vestibular issue if this is a new symptom 7. Do you have neck pain? If so, does patient get dizzy with neck AROM? Think cervicogenic Evaluate c spine if you believe patient may have a brain injury as well 8. Ask your 5 D's: diplopia, dysphagia, dizziness, drop-attacks, dysarthria (Red flags)

17 Subjective/History Exam Specific BPPV questions: Does it start when you roll in bed, sit up from bed (OH vs. nystagmus reversal), or lay in bed? Does it start when you tilt your head down or look up? ex: working on leaning fwd edge of mat for balance or transfer training, bowel program, etc Nystagmus in Dix-Hallpike maneuver for BPPV assessment:

18 Oculomotor Exam Assesses central vs peripheral vestibular dysfunction Spontaneous Nystagmus Smooth Pursuit Gaze Holding Nystagmus Saccades VOR Cancellation Dynamic Visual Acuity Head Impulse Test (Head Trust) Optokinetic Nystagmus Dix-Hallpike: posterior and anterior canal BPPV Roll Test: horizontal canal BPPV

19 Differential Diagnosis of Dizziness in SCI

20 Modifications for Plan of Care (POC) Repositioning maneuvers for BPPV can be modified with wedges or with bed in Trendelenburg position (head below horizontal ~30 deg) Traditional canalith repositioning (Epley) maneuver for anterior and posterior canal BPPV: Modifications: Lee WK, Koh SW, Wee SK. Benign paroxysmal positional vertigo in people with traumatic spinal cord injury: incidence, treatment efficacy, and implications. Am J Otolaryngol Nov-Dec; 33(6):

21 Modifications for POC Gaze stability exercises for vestibular ocular reflex (VOR) a. Used generally for peripheral involvement b. Habituation exercises a. Used generally for motion sensitivity, central disorders b. Neck proprioception exercises a. Used for cervicogenic involvement b.

22 Keep in Mind Essentially, the point of this presentation is to 1. Help you narrow the possible etiology 1. Know when to refer to or seek guidance from a vestibular therapist on staff 1. No trained vestibular therapist? Opportunity to seek out research, guidance from published articles (especially in rehab setting) Opportunity to take continuing competency courses 4. Know when to refer to an MD for further work-up if insidious etiology is suspected

23 References 1. Alsalaheen B, Mucha A, Morris L, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther Jun;43(2): Bradbury CL, Wodchis WP, Mikulis DJ. Traumatic brain injury in patients with traumatic spinal cord injury: Clinical and economic consequences. Arch Phys Med Rehabil. 2008;89(12 Suppl 2): S Collins MW, Kontos AP, Reynolds E, et al. A comprehensive targeted approach to the clinical care of athletes following sport related concussion. Knee Surg Sports Traumatol Arthrosc Feb;22(2): Fife TD, Giza C. Posttraumatic vertigo and dizziness. Semin Neurol Jul;33(3): Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: An evidence-based clinical practice guideline. J Neurol Phys Ther April;40(2): Kim HA, Yi HA, Lee H. Recent advances in orthostatic hypotension presenting orthostatic dizziness or vertigo. Neurol Sci Nov;36(11): Kushner DS. Strategies to avoid a missed diagnosis of co-occurring concussion in post-acute patients having a spinal cord injury. Neural Regen Res Jun; 10(6):

24 References 8. Lee WK, Koh SW, Wee SK. Benign paroxysmal positional vertigo in people with traumatic spinal cord injury: incidence, treatment efficacy, and implications. Am J Otolaryngol Nov-Dec; 33(6): Liu H. Presentation and outcome of post-traumatic benign paroxysmal positional vertigo Aug;132(8): Jeon EJ, Park YS, Park SN, et al. Clinical significance of orthostatic dizziness in the diagnosis of benign paroxysmal positional vertigo and orthostatic intolerance. Am J Otolaryngol Sep-Oct;34(5): Krassioukov A, Warburton DE, Teasell R, et al. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil April;90(4): Macciocchi S, See RT, Thompson N, et al. Spinal cord injury and co-occurring traumatic brain injury: Assessment and incidence. Arch Phys Med Rehabil July; 89: Macciocchi, S, Bowman B, Coker J. Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries. Am J Phys Med Rehabil. 2004; 83:

25 References 14. Paiva WS, Oliveira A, Andrade AF. Spinal cord injury and its association with blunt head trauma. International J General Med. 2011;4: Ricci F, De Caterina R, Fedorowski A. Orthostatic Hypotension: Epidemiology, Prognosis, and Treatment. J Am Coll Cardiol Aug 18;66(7): Szczupak M, Hoffer ME, Murphy S, et al. Posttraumatic dizziness and vertigo. Handb Clin Neurol. 2016;137: Tolonen A, Turkka J, Salonen O, et al. Traumatic brain injury is underdiagnosed in patients with Spinal Cord Injury. J Rehabil Med. 2007;39: Whitney, SL. Anxiety and psychiatric co-morbidities that affect therapeutic outcomes. Expanding Neurological Expertise: Advanced Practice in Vestibular Physical Therapy

26 Appendix: Oculomotor Exam Can be completed in the laboratory (ENG) or in the clinic/at bedside When having a pt view an object, have the object inches away from the patient s nose Instruct the pt of what movement to expect prior to moving head Use clinical judgment in cases of cervical pain or limited ROM Certain tests can be done in room light or with fixation blocked (using Frenzel lenses)

27 Spontaneous Nystagmus Instruct pt to look straight ahead Observe eyes for nystagmus. If nystagmus is present, this is abnormal and is a central sign. Note direction of nystagmus.

28 Gaze-holding Nystagmus Ask patient to look at your finger (30 degrees and inches away) to one side and hold gaze. Repeat to other side. Make sure the patient s head remains in the center and does not turn. Make sure that the patient does not look at the end of the visual field (End range gaze nystagmus is normal) Observe the patient s eyes for nystagmus at the L and R holding points. Nystagmus is abnormal. Note the direction of the nystagmus. Purely horizontal nystagmus beating to one direction is a peripheral sign. Direction changing, purely vertical, and purely rotational is a central sign.

29 Smooth Pursuit and Eye Range of Motion Have patient follow your finger or pen (18-24 inches away) with their eyes as you move it slowly (~20 degrees/second) up/down and left/right. Make sure the patient s head does not move. Note the quality of eye movement. Is it smooth when moving and when changing directions? It is abnormal if the movement is saccadic (jerky), dysconjugate, and not smooth in nature. This is a central sign. Smooth pursuit gets more saccadic with age (this is normal) and vertical eye smooth pursuit is often interrupted by a saccade even in younger individuals.

30 Saccadic Eye Movement Instruct patient to look back and forth between your nose and tip of index finger or pen (30 degrees of eye movement). Test horizontally and vertically. Observe for speed, accuracy, and how long it takes to initiate. Are there any dysconjugate movements? Overshooting or undershooting? More than 1 corrective saccade is abnormal. Difficulty with saccadic eye movement is a central sign.

31 VOR to Slow Head Movements Instruct patient to keep focus on your nose. Hold patients head between your hands and flex the head forward 30 degrees. Slowly move the patients head back and forth 30 degrees L and R from midline The patient should be able to maintain visual fixation. It is abnormal to see the presence of corrective saccades. This is typically a peripheral sign.

32 VOR to fast head movements (Head Thrust) Hold patients head between your hands and flex head down 30 degrees. Have patient keep focus on your nose and quickly move the patient s head to one side then to the other side. Warn the patient of the speed of the head movement and screen for any cervical ROM limitations. Do not let the patient know which side you are turning towards. The test is abnormal if the patient performs a corrective saccade to refixate to nose. This is peripheral sign. Note the direction of head movement that caused the saccade. This is the side of unilateral hypofunction.

33 VOR Cancellation Hold the patients head between your hands, flex the patient s head 30 degrees. Have patient look at your nose and move the patients head to L and R 30 degrees while you move in the same direction as the patient. Pt should be able to maintain gaze on your nose. If there are corrective saccades present, this is abnormal and a central sign.

34 Optokinetic Nystagmus Place a optokinetic drum or a striped piece of fabric in front of the patient. Have the patient count the stripes a they go by. Normal response is nystagmus with slow phase in the direction of the drum rotation or of the fabric. Note if the patient does not produce slow phase movements or if they are saccadic in nature. This is a central sign.

35 Static and Dynamic Visual Acuity Have patient sit in front of an eye chart (typically 2-4 meters away). Have pt read lowest line possible. This is the static acuity. Then stand behind pt and use your hands to flex head 30 degrees and rotate head to L and R 2 cycles/seconds. Have patient read the lowest line possible. This is the dynamic visual acuity. A change in more than 3 lines is considered abnormal and indicates oscillopsia.

36 Dix-Hallpike Test Dix-Hallpike is used to test for BPPV (Benign Paroxysmal Positional Vertigo) for posterior and anterior canal. BPPV is a peripheral dysfunction. Do not perform with patients who have vertebral artery insufficiency with these head movements. In long sitting, turn patient s head 45 degrees to the side. Instruct the patient to keep the eyes open. Quickly move the patient to the supine position and extend neck 30 degrees. Hold patient in this position for 30 seconds. Repeat to other side.

37 Dix-Hallpike Test The nystagmus will allow you to diagnose the type of BPPV: Side of torsion determines L or R side Up/down beating determines anterior (down beating) or posterior canal (up beating) Duration of symptoms determines cupulolithiasis (more than 60 sec) or canalithiasis (less than 60 sec)

38 Roll Test Roll test will allow you to diagnose horizontal canal BPPV. Bring the patient to the supine position then flex neck 30 degrees. Instruct pt to keep eyes open. Roll the patient s head quickly to one side (~90 degrees). Look for nystagmus and note vertigo. Bring patient s head back to neutral and repeat to other side. Hold each position for 1 min. Ageotropic nystagmus (away from the ground) signifies cupulolithiasis and geotropic (toward the ground) nystagmus signifies canalithiasis