Dizzy Cases. Outline 10/22/15. Michael Tan Neurologist Rehabilitation Physician

Transcription

1 Dizzy Cases Michael Tan Neurologist Rehabilitation Physician Outline Outcomes from registry studies Unilateral dysfunction Central dysfunction 1

2 Outcomes from Registry Studies Dizziness and Vertigo Registry Tertiary neuro-otology clinic Essen Dizziness and Vertigo Centre March 2010 to February 2012 Follow-up at 2 years consecutive patients with vertigo and dizziness over 2 years. Over 1/3 completed DHI Ob e rma nn et al, J Neurol. 2015;262(9) : Vertigo Syndromes Brandt, T., Dieterich, M., Strupp, M.,

3 Case Ascertainment Clinical Assessment Neuro-otological Neurological and physical examination Complete medical history Diagnostic criteria Meniere s disease Vestibular migraine Phobic postural vertigo Investigations Caloric testing VEMPs Auditory evoked potentials Doppler of brain vessels EEG NCS EMG CT or MRI Ob e rma nn et al, J Neurol. 2015;262(9) : Chronic sample Ob e rma nn et al, J Neurol. 2015;262(9) :

4 Dizziness Handicap Inventory Physical 1 Looking up 4 Walking down aisle 8 Ambitious activities 11 Quick movements of head 13 Turning over in bed 17 Walking down a sidewalk 25 Bending over Emotional 2 Feel frustrated 9 Leave home alone 10 Embarrassed in front of others 15 Afraid people think you intoxicated 18 Concentrate 20 Afraid to stay home alone 21 Feel handicapped 22 Stress on relationships 23 Depressed Functional 3 Restrict travel 5 Getting into/out of bed 6 Social activities 7 Reading 12 Avoid heights 14 Strenuous house/yard work 16 Walk by yourself 19 Walk around in the dark 24 Job/household responsibilities Strong correlation Computerized dynamic posturography Functional reach Electronystagmography Dynamic gait index Head impulse test Table 1 Relationship between vestibular/balance tests and DHI Moderate/weak correlation Single leg stance Timed up and go Rotation chair Sensory organization subtests of the platform posturography Romberg test Four square step test Sit to stand test Firm surface conditions on modified clinical test for the sensory interaction on balance test Smart balance master Score 0-4 points for each item not or mildly affected moderately affected severely affected No correlation Foam surface conditions on modified clinical test for the sensory interaction on balance test Caloric responses cvemp TamberA-L, WilhelmsenKT, Strand L. M e as ure me nt pro pe rtie s o f the Dizzine ss Handic ap Inve nto ry by c ro s s -sectional and longitudinal designs. Health Qua l Life Outcomes. 2009;7(1): Mutlu B, Serbetcioglu B. Disc us s io n o f the dizzine s s handic ap inve nto ry. J Vestib Re s. 2013;23(6): Change in DHI DHI decreased in 72.1% regardless of diagnosis. Magnitude of decrease was points (95%CI to -12.6) Patients <65 had better DHI outcome (-15.6 (95%CI to -13.9)) c/f >65yrs (-11.5 (95%CI to - 9.3)) Ob e rma nn et al, J Neurol. 2015;262(9) :

5 DHI Outcomes by Severity Severely disabled - >50% decreased to moderate or mild. Almost 50% moderately disabled -> mild Ob e rma nn et al, J Neurol. 2015;262(9) : Case 1 65yo female home alone Helps out in family business. Hypertension, depression, episodic migraine with aura Referred for cause of vertigo MRI brain normal. Sudden onset dizziness whilst making sandwich. Staggered back to couch. Called son. Son called ambulance. ED Neurology review - peripheral cause for dizziness. Home with serc and stemetil. 5

6 What does dizziness mean? Light headed? Rocking sensation? Spinning sensation? What does dizziness mean? Did it last all day? Stopping and starting Continuous non-stop Any provoking features? Positional? 6

7 Examination At the bedside Traditional Frenzels Examination At the bedside Video Frenzels Spont. R beat horiz nystagmus 7

8 Examination Video Frenzels NB: example is L beat horiz nystagmus (fast phase) R beat horiz nystagmus Examination R gaze (no Frenzels) L gaze (no Frenzels) 8

9 Examination Head impulse test positive L Remaining neurological examination normal. VHIT 9

10 Treatment Vestibular neuritis Prednisolone Stemetil and serc stopped Vestibular rehabilitation Better outcomes with earlier initiation of vestibular rehabilitation (Herdman et al 2012). Central compensation can render these patients free from symptoms Manage impairment Avoid disability Follow-up at 2mo Ongoing dizziness Swaying side-side imbalance Pressure sensations in head with associated photo and phonophobia Headache Aura Sensory hyperexcitability Vestibular symptoms Prodrome phase Headache phase Resolution phase Postdrome phase Stolte B, Ce phalalgia. 2015;35(3):

11 Vestibular migraine Acute treatment Dosage Trial (Reference) Ob e rma nn M, Strupp M., Front Neurol. 2014;5:257. Response to amitriptyline 12.5mg Continued vestibular physiotherapy in local area. Zolmitriptan 2.5 mg oral Randomized controlled trial (RCT) ( 29) Rizatriptan 10 mg oral RCT, motion sickness ( 30) PROPHYLACTIC TREATMENT Metoprolol 150 mg oral Retrospective cohort analysis ( 31) mg oral Retrospective cohort analysis ( 33) Propranolol 160 mg oral Retrospective cohort analysis ( 31) mg oral Retrospective cohort analysis ( 32, 33) Valproic acid 600 mg oral Retrospective cohort analysis ( 31) 600 mg oral Cohort study, vestibulo-ocluar reflex ( 34) Topiramate 50 mg oral Retrospective cohort analysis ( 31) mg oral Open-label, chart review ( 44) Butterbur extract 50 mg oral Retrospective cohort analysis ( 31) Lamotrigine 75 mg oral Retrospective cohort analysis ( 31) 100 mg oral Retrospective, open-label ( 41) Amitriptyline 100 mg oral Retrospective cohort analysis ( 31) 10 mg oral Retrospective cohort analysis ( 33) Nortriptyline mg oral Open-label, chart review ( 44) Flunarizine 5 mg oral Retrospective cohort analysis ( 31) 5 10 mg oral Retrospective, open-label ( 33) 5 10 mg Open-label, post-marketing ( 36, 37) Magnesium 400 mg oral Retrospective cohort analysis ( 31) Clonazepam 0,25 1 mg oral Retrospective cohort analysis ( 33) Cinnarizine mg oral Retrospective, open-label ( 35) NON-MEDICAL TREATMENT Vestibular rehabilitation exercises 5 therapy sessions over 9 weeks Uncontrolled, observational trial ( 43) Caffeine cessation 4 6 weeks Retrospective, observational trial ( 44) Case 2 34yo female Referred by ENT surgeon for consideration of a central cause. 11

12 Case 2 Lifelong history of incoordination difficulties with coordination and sports since childhood. Presents with 5yr history of progressively worsening balance. R acoustic neuroma resection January Case 2 Ongoing dizziness Spinning sensation provoked by movement Treated for BPPV Significant falls Deteriorating work performance 12

13 Case Examination Spontaneous L beating horizontal nystagmus Head thrust test positive to R. 13

14 Examination Spontaneous nystagmus Head thrust test positive to R. Wide-based gait. Examination Spontaneous nystagmus Head thrust test positive to R. Wide-based gait. Unable to tandem gait Impaired VOR suppression Bilaterally increased lower extremity tone Brisk reflexes bilaterally in upper and lower extremities. Impaired vibration sensation. VOR Suppression 14

15 Examination Spontaneous nystagmus Head thrust test positive to R. Wide-based gait. Unable to tandem gait Impaired VOR suppression Bilaterally increased lower extremity tone Brisk reflexes bilaterally in upper and lower extremities. Impaired vibration sensation. Investigations NCS: symmetrical length dependent sensorimotor large fibre neuropathy with both demyelinating and axonal features. CSPs: no small fibre neuropathy MRI superior vermal atrophy 15

16 Central Dysfunction Observation that the improvements after vestibular and balance rehabilitation are not as strong when compared to peripheral disorders (Badke et al, 2004) Trend for poorer outcomes in those with cerebellar dysfunction (Brown et al, 2006). Central Dysfunction Improved motor performance with intensive coordinative training in progressive cerebellar ataxia (Ilg et al, 2009) At 8 wks after training (Ilg et al, 2009) At 1yr after training despite progression of disease (Ilg et al, 2010) Importance of home based exercise program Long term outcome of neurodegenerative ataxias is influenced by training intensity at home. (Ilg et al 2010) 16

17 Management Cerebellar ataxia Falls Uncompensated R vestibulopathy (e/o R acoustic neuroma) Large fibre axonal neuropathy Cognitive deficits Letters from employer regarding poor work performance. Physiotherapy Vestibular adaptation Gait and balance retraining Static balance Dynamic balance Neuropsychology Characterize deficits Exclude superimposed depression/anxiety Management Neuropsychology Ax Mildly decreased processing speed, especially in tasks requiring visual scanning or graphomotor demands. Mildly decreased attention span and working memory Intact learning and memory with structured information. Executive dysfunction: Moderately decreased verbal fluency improved to average with structure. Mild difficulties with self monitoring, attention to detail, and abstract reasoning. No impulsivity 17

18 Management OT Complement neuropsychology assessment Psychoeducation Compensatory strategies for maintaining employment Fatigue management Return to work Conclusion Balance disorders can be straightforward but sometimes complex. Characterization of the aetiology Unilateral vestibular dysfunction Central dysfunction sometimes it s mixed central and peripheral. Role for multidisciplinary teams in balance disorder management. Proven in unilateral and to some extent bilateral vestibulopathies. Useful in refractory vestibular migraine where there is significant functional limitations. Even in degenerative cerebellar ataxias. 18