Differential Diagnosis of Dizziness in SCI Jordan Cabrera, PT, DPT, NCS Jorge Neira, PT, DPT, NCS 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. 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 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 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 Sources of Dizziness in SCI • Orthostatic Hypotension – Feeling faint – Pre-Syncope/Lightheadedness – Can include • Nausea • Fatigue • Pallor • Perioral and facial numbness 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 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. 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 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 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 Sources of Dizziness in SCI • Medications that can cause dizziness as a side effect – Blood pressure medications: ACE Inhibitors, beta- blockers, diuretics, calcium-channel blockers – Muscle Relaxants – Antidepressants – Anticonvulsants – Pain Relievers – Sleeping Pills – Nitroglycerin for Angina (chest pain) 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 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? 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 48-72 hours continuous you back away from peripheral 4. What makes it worse/ What makes it better? 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) 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: https://www.youtube.com/watch?v=rtS2muvjFbM 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 Differential Diagnosis of Dizziness in SCI 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: https://www.youtube.com/watch?v=9SLm76jQg3g – 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. 2012 Nov-Dec; 33(6):723-30. Modifications for POC Gaze stability exercises for vestibular ocular reflex (VOR) a. Used generally for peripheral involvement b. https://www.youtube.com/watch?v=yL7TBP8fBtg Habituation exercises a. Used generally for motion sensitivity, central disorders b. https://www.youtube.com/watch?v=oKc_Mr_BOWQ Neck proprioception exercises a. Used for cervicogenic involvement b. https://www.youtube.com/watch?v=9siMQ14H9F8 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 References 1. Alsalaheen B, Mucha A, Morris L, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010 Jun;43(2):87-93. 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): S77-84. 3. 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. 2014 Feb;22(2):235-46 4. Fife TD, Giza C. Posttraumatic vertigo and dizziness. Semin Neurol. 2013 Jul;33(3):238-43. 5. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: An evidence-based clinical practice guideline. J Neurol Phys Ther. 2016 April;40(2):124-55.