1. The Dizzy Patient
Erica Uzzell, SPT

2. Causes of Dizziness Arrhythmia Defective heart valve Dehydration
Hyperventilation
Medications
Orthostatic Hypotension
Stress, Tension, Fatigue
Vasovagal syndrome
Vestibular Dysfunction
Disruption of blood flow
Other symptoms
Palpitations
Weakness
Fatigue
SOB
Low BP
Fainting
Causes Of Dizziness. Vestibular Disorders Association. Available at

3. Causes of Dizziness Arrhythmia Defective heart valve Dehydration
Hyperventilation
Medications
Orthostatic Hypotension
Stress, Tension, Fatigue
Vasovagal syndrome
Vestibular Dysfunction
Loss of body fluids= decreased BP
Causes Of Dizziness. Vestibular Disorders Association. Available at

4. Causes of Dizziness Arrhythmia Defective heart valve Dehydration
Hyperventilation
Medications
Orthostatic Hypotension
Stress, Tension, Fatigue
Vasovagal syndrome
Vestibular Dysfunction
Common side effect
Drug interactions
Causes Of Dizziness. Vestibular Disorders Association. Available at

5. Causes of Dizziness Arrhythmia Defective heart valve Dehydration
Hyperventilation
Medications
Orthostatic Hypotension
Stress, Tension, Fatigue
Vasovagal syndrome
Vestibular Dysfunction
Positive dx when there is a 20 mmHg drop in systolic BP and 10 mmHG drop in diastlic BP within 3 minutes of standing up
Causes Of Dizziness. Vestibular Disorders Association. Available at

6. Causes of Dizziness Arrhythmia Defective heart valve Dehydration
Hyperventilation
Medications
Orthostatic Hypotension
Stress, Tension, Fatigue
Vasovagal syndrome
Vestibular Dysfunction
Overstimulation of vagus nerve
Blood vessels dilate
HR decreases
Decreased blood flow to brain
Causes Of Dizziness. Vestibular Disorders Association. Available at

7. Causes of Dizziness Arrhythmia Defective heart valve Dehydration
Hyperventilation
Medications
Orthostatic Hypotension
Stress, Tension, Fatigue
Vasovagal syndrome
Vestibular Dysfunction
Causes Of Dizziness. Vestibular Disorders Association. Available at

8. Overview of Vestibular Function
Maintenance of stance and body posture
Coordination of body, head and eye movements
Visual fixation
Waxman SG. The Vestibular System. In: Clinical Neuroanatomy. McGraw-Hill;2010:

9. Anatomy Semicircular canals (anterior, posterior, & lateral)
Aligned at right angles with each other
Maximally sensitive to motion in the plane of that particular SCC
Respond to angular acceleration of the head
Act in functional pairs with the contralateral canal in the same plane
Rotation in one place will be excitatory to one canal and inhibitory to the contralateral canal
Filled with endolymph, which moves freely within each canal in response to head rotation
Each enlarged at one end to form the ampulla, which contains the sensory hair cells
Otolith organs (utricle & saccule)
Respond to linear acceleration of the head
Utricle excitation occurs during horizontal linear acceleration or static head tilt
Saccule excitation occurs during vertical linear acceleration
Contain calcium carbonate crystals (otoconia)
-Horizontal SCC’s form coplanar pair while posterior SCC is paired with CL anterior SCC

10. Earsite.com

11. Common complaint DIZZINESS!
Important to distinguish between dizziness, vertigo, lightheadedness & dysequilibrium
Dizziness- sensation of whirling or feeling a tendency to fall
Vertigo- illusion of movement
Lightheadedness-feeling that fainting is about to occur
Dysequilibrium-sensation of being off balance

12. Symptom
Possible Cause
Vertigo
BPPV
UVH
unilateral central lesion affecting the vestibular nuclei
Lightheadedness
Orthostatic Hypotension
Hypoglycemia
Anxiety
Panic disorder
Dysequilibrium
BVH
Chronic unilateral vestibular hypofunction
LE somatosensory loss
Upper brainstem/vestibular cortex lesion cerebellar and motor pathway lesions

13. Other symptoms Balance & spatial orientation Vision Hearing
Imbalance, stumbling, difficulty walking straight
Clumsiness or difficulty with coordination
Difficulty maintaining straight posture; tend to look downward to confirm the location of the ground
Head may be tilted in a direction
Tendency to touch or hold onto something while standing
Sensitive to changes in walking surface or footwear
Vision
Trouble focusing or tracking objects with the eyes
Sensitivity to light, glare or moving lights
Poor depth perception
Hearing
Hearing loss
Tinnitus
Sensitivity to loud noises or environments

14. Other symptoms Cognitive Psychological Other
Difficulty concentrating and paying attention
Confusion, disorientation, difficulty comprehending directions or instructions
Mental and/or physical fatigues out of proportion to activity
Psychological
Loss of self-reliance, self-confidence, self-esteem
Anxiety, panic, social isolation
Depression
Other
Nausea or vomiting
“Hangover” or “seasick” feeling in the head
Motion sickness
Sensation of fullness in the ears
Headaches
Slurred speech
Sensitivity to pressure or temperature changes
Vestibular Disorders Association. Available at

15. Duration & Circumstances of symptoms
Important to distinguish between vestibular disorders
Vertigo
Seconds to minutes-Benign Paroxysmal Positional Vertigo
Minutes to hours- Meniere’s disease
Days- Vestibular neuronitis or migraine associated dizziness
What circumstances causes the patient to experience symptoms?
Particular movements, positions?

16. Test & Measures Motion Sensitivity Quotient
Provides subjective score of an individual’s dizziness
Involves placing patients into positions incorporating head of entire body motion to determine if movement reproduces dizziness
Most often used to determine the positions that causes symptoms
Pass out copies

17. Test & Measures Eye Movements Observation of nystagmus
Used to identify more peripheral and central vestibular lesions
Examination of VOR at high acceleration
Head thrust test
Examines SCC function
Patient fixates on nearby target and while keeping the eyes focused on target, the head is moved in unpredictable direction using small amplitude, high acceleration angular thrust
Head shaking induced nystagmus
Used to detect unilateral peripheral vestibular defect
Patient’s vision is occluded and the head is flexed to 30 degrees and oscillated for 20 cycles at a frequency of 2 repetitions per second; patient then opens eyes and is checked for nystagmus
HEAD THRUST TEST
When VOR is functioning properly, the eyes move in the direction opposite to the head movement and the gaze will remain on the target
In a patient with vestibular dysfunction, the VOR will not move the eyes as quickly and the eyes will move off target
HEAD SHAKING INDUCED NYSTAGMUS
In subjects with normal vestibular function, nystagmus will not be present

18. Test & measures Eye Movements Positional testing Hallpike-Dix test
Used to identify whether otoconia have been displaced into the SCC, causing BPPV
Hallpike-Dix test
Patient is moved from sitting with the head rotated 45 degrees to one side to a supine position with the head extended 30 degrees beyond horizontal with the head still rotated
Direction of nystagmus correlates to involved SCC
HALLPIKE-DIX TEST
Turn head towards SCC being tested
Ear towards ground is the one being tested

19. How do we treat? Epley Maneuver
Patient’s head moved in different positions in a sequence that will move the debris out of the involved SCC

20. How do we treat? Liberatory (Semont) maneuver
Involves rapidly moving the patient through positions to dislodge the debris
More difficult for patient to tolerate

21. How do we treat? Brandt-Daroff exercises
Habituation of provoking positions
Should be performed multiple times
daily until no vertigo persists for 2 days
Can be given as a HEP component after
repositioning maneuvers

22. After treatment recommendations
Stay in upright position for 48 hours
Avoid excessive head motion
Avoid prolonged cervical flexion or extension

23. Resources
_diseases/arrhythmias_85,P00195/
Waxman SG. The Vestibular System. In: Clinical Neuroanatomy. McGraw- Hill;2010:
Schubert MC. Vestibular Disorders. In: O’Sullivan S, Schmitz T. eds. Physical Rehabilitation. Philadelphia, PA: FA Davis; 2007:
Vestibular Disorders Association. Available at