What Is Cervicogenic Dizziness?

Transcription

Diane M. Wrisley, PT, PhD, NCS
Mira Mariano, PT, PhD, OCS
Dizziness, Imbalance, and the
Cervical Spine, 2007
Dr. DM Wrisley
What Is Cervicogenic Dizziness?
“A non-specific sensation of altered orientation
in space, and dysequilibrium originating from
abnormal afferent activity from the neck.”
(Furman and Cass, 2003)
Dizziness, Imbalance, and the Cervical Spine
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History of Cervicogenic Dizziness
 A syndrome of postural instability arising from a
disturbance of cervical joint receptors proposed for
over 100 years
 Term “Cervical Vertigo” given to the syndrome by Ryan
and Cope in 1955.
 Does not result from vestibular dysfunction and rarely
results in true vertigo – more appropriate name
“Cervicogenic Dizziness”
Cervical Spine, 2007
Dr. DM Wrisley
When did theories of cervical influences on
posture originate?
 The influence of the head and neck position on
postural responses has been demonstrated in animals
since the 1850’s
 Majendie and others in mid-1800s demonstrated that
lesions of cervical muscles and receptors created a
profound influence on postural control (Brown J 1992,
Wilson 1988)
 Magnus originated the theory of neck reflexes and their
influence on the limbs in relation to the head-body
angle (Magnus 1926)
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Theories of Pathophysiology
 Irritation of cervical sympathetic nerves
(Barre, 1926; Lieou, 1926; Norré, 1983;Hinoki, 1975,1985)
 Abnormalities of vascular structures (Vertebral
Basilar Insufficiency)
(Sandstrom, 1962; Sheehan, 1960)
 Aberrant information from cervical muscle or
joint receptors
(Ryan and Cope, 1955; Gray, 1956; Travell and Weeks, 1955; deJong, 1977,
Norré, 1976)
 Combination of mechanisms
Incidence
 20-58 % of individuals who have sustained a closed head
injury or whiplash will experience dizziness, vertigo or
dysequilibrium (Oostendorp et al, 1999, Rubin, 1973, Toglia
1976)
 The number of people with true cervicogenic dizziness is
undetermined
 Probably < 1% of all people with dizziness (Hain 1996)
Cervicogenic Dizziness: Diagnostic
Criteria
 Complaints of ataxia, unsteadiness of gait, postural
imbalance, and illusory sensation of movement
 Close temporal relationship between neck pain or
headache and symptoms of dizziness
 Previous neck pain or pathology
 Elimination of other causes of dizziness
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Cervicogenic Dizziness
 Associated with cervical flexion/extension
(whiplash) injuries
 Reported with cervical arthritis, herniated
cervical discs, cervical spondylosis, cervical
muscle spasms and head trauma (Ryan & Cope,
1955; Sandler, 1967; Rubin et al, 1995)
Symptoms of Cervicogenic
Dizziness
 Occur in episodes that last minutes to hours
 Symptoms may increase with neck movement or neck
pain
 Symptoms of dizziness are often relieved with a
decrease in neck pain
Symptoms of Cervicogenic
Dizziness
 Ataxia
 Unsteadiness of gait
 Postural instability
 Visual Disturbances
 Illusionary sense of motion
 Space and motion sensitivity
 Associated with neck pain, limited neck ROM or
headache
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Definition of Dizziness
 lightheaded
 a “swimmy” sensation in their head
 spinning
 being tired; especially at the end of the day
 imbalance
 blurred vision
 tinnitus (ringing in the ear(s))
 giddiness
 instability of gait
 loss of consciousness
Definition of Vertigo
 “an illusory sensation of motion of either self or
surroundings”
 this sensation can be a rotational sensation,
translational (a sense of rising), or a tilting of the visual
environment
Furman and Cass, 1996
Association of Dizziness and
Neck Pain
 Neck pain may be cause of dizziness
 Neck pain may be result of vestibular dysfunction
 Neck pain and dizziness may have separate pathology
and be unrelated
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Differential Diagnosis of Cervicogenic Dizziness
 Benign Paroxysmal Positional Vertigo
 Migraine-related Vertigo
 Post-traumatic Meniere’s Disease
 Labyrinthine concussion
 Peripheral vestibulopathy
 Central Vestibulopathy
 Central nervous system abnormality
 Vertebral Basilar Insufficiency
 Anxiety related dizziness
 TMJ associated dizziness
(Furman and Cass 2003)
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Questions to Think About
1.
2.
3.
Why do people spin when they are drunk?
Why are some people able to ride carousels and
others able to ride roller coasters without getting
ill?
What are the connections/interactions between the
cervical region and the vestibular system?
Peripheral Vestibular System
Hain TC, Hillman MA. Anatomy and physiology of the normal vestibular system. In Herdman SJ. (ed.) Vestibular
Rehabilitation. FA Davis Co. Philadelphia. 1994:4
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Membranous Labyrinth
Kelly JP. The sense of balance. In Kandel ER, Scwartz JH, Jessell TM. (eds) Principles of Neural Science:
Third Edition. Appleton and Lange. Norwalk, CN. 1991:502
Location within the Skull
Orientation of Semicircular Canals
Baloh RW, Honrubia V. Clinical Neurophysiology of the Vestibular System. FA Davis Co. Philadelphia.
1990:27.
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Anatomy of Semicircular Canal
Furman JM and Cass SP. Vestibular Disorders: A Case
Study Approach. Oxford University Press, Oxford 2003:5
Semicircular Canal Physiology
Hain TC, Hillman MA. Anatomy and Physiology of the Normal Vestibular System. In: Herdman SJ
(ed): Vestibular Rehabilitation. F.A. Davis. Philadelphia. 1994 :6.
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Push – Pull Mechanism
Furman JM and
Cass SP.
Vestibular
Disorders: A Case
Study Approach.
Oxford University
Press, Oxford
2003:11
Summary of important concepts
 Semicircular Canals
 Respond to angular acceleration
 Have a spontaneous firing rate
 The canals are excited by movement in their plane
 Are arranged in a push-pull system
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Otoliths
Anatomy of Otoliths
Furman JM and Cass SP. Vestibular Disorders: A Case Study Approach. Oxford University Press, Oxford 2003:7
Otoconia
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Otoliths: Haircells and Otoconia
Otoliths
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Summary of Important Concepts
 Otoliths
 Respond to linear acceleration and gravity
 Have a spontaneous firing rate
 The otoliths are excited by movement within the plane
of macula
 Push pull relationship within each otolith organ
Vascular Supply
 Peripheral vestibular system supplied by labyrinthine
artery (usually branch of anterior inferior cerebellar
artery)
 Labyrinth has no collateral anastomatic network
 At risk for ischemic and embolic events
Central and Peripheral Vestibular Pathways
Cerebral Cortex
Ocular Motor Nuclei (VOR)
Thalamus
Peripheral Vestibular
Organs
Cervical Proprioceptors
Vestibular Nuclei
ANS (parasympathetic)
Nausea/Vomiting
Cerebellum
MVST and LVST (Vestibulospinal
Reflexes)
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Vestibular Ocular Reflex
Vestibular Ocular Reflex
Young PA, Young PH. Basic Clinical Neuroanatomy. Williams and
Wilkins, Baltimore, MD. 1997:121.
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Eye movements evoked by stimulation
of individual semicircular canals
VOR Gain Adaptation
VOR gain is modified by repeated stimulus in the light.
Lisberger, SG. Trends Neurosci 11:147, 1988
VOR Gain Adaptation
Cohen et al. Exp Brain Res 90:526, 1992
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Vestibular Spinal Reflex
Young PA, Young
PH. Basic Clinical
Neuroanatomy.
Williams and
Wilkins, Baltimore,
MD. 1997:74.
Vestibular
Nuclei
Otolithic
Input
To
Cerebellum
Medulla
Lateral
Vestibulospinal
tract
To Cerebellum
Medial
Vestibulospinal
tract
Ia afferent
Cervical Spinal
Cord
Central
Cervical
Nucleus
To
Lumbar
Spinal
Cord
To
C2C8
Tonic Neck
Reflexes
through
Propriospinal
pathway
Cervical
Musculature
Cervical-Vestibular Interactions
Human Experimentally Induced Lesions
 Lesions of cervical dorsal roots
 Anesthetic injected around the upper cervical
dorsal roots caused dysequilibrium, a strong
sensation of imbalance and being pulled towards
the side of the injection
 Nystagmus was only seen with injections at the
occipital condyle in monkeys
 No nystagmus was seen in humans as injections
were only performed at C2 and C3 (deJong et al,
1977)
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Human Experimentally Induced
Lesions
 Lesions of cervical musculature
 Warner et al (1951) demonstrated that people had a
sensation of tilting or falling during vibration of the
cervical muscles
 Vibration of neck muscles in the dark evokes smooth
eye movements that can be suppressed be fixation of a
visual target (Popov et al 1999, Yagi and Ohyama 1996,
Strupp et al 1998)
Postural Instability Associated With
Cervical Pathology
 Dizziness and postural instability have been
demonstrated in humans following cervical spine
disease and whiplash injury
 Symptoms of postural stability resolved with
treatment of the impairments of the cervical spine
(Ryan & Cope, 1955; Alund et al, 1991, 1993; Rubin et al, 1995;
Karlberg et al, 1991, 1995, 1996; Travell & Weeks, 1955; Norré,
1986, 1987, 1989)
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Visual Disturbances Associated
With Cervical Pathology
 Abnormal smooth pursuit (Hildingsson et al 1989,
Carlsson et al 1990, Gimse et al 1996, Heikkila and
Wenngren 1998)
 Abnormal saccades (Hildingsson et al 1989, Carlsson
et al 1988, Heikkila and Wenngren 1998, Mosimann et
al 2000)
 Impaired eye movements during reading (Gimse et al
1996)
 Abnormal VOR (de Jong et al 1996)
Sensory and motor influences on balance
Peripheral Sensory Apparatus
Central Processing
System
Motor Outputs
Visual
Common Central
Processor
Vestibular
Proprioception
Individual
Motor
Eye
Movements
Neurons
Sensory
Postural
Movements
Auditory
Processors
Cerebellum
What are the systems underlying balance?
-Sensory system function
-Strength, tone
-Degrees of Freedom
(ROM)
-Limits of stability
Musculoskeletal
Sensory
strategies
Postural
Control
-Perceived vertical (visual,
Orientation
postural)
-Internal representation
-Adaptability to changing
environments
Space
-Sensory Integration
-Sensory re-weighting
Movement
strategies
-Anticipatory (proactive)
in
-Adaptive (reactive)
Cognitive
control
-Attention
-Learning
1 Adapted
from: Shumway-Cook A, Woollacott MH. Motor Control - Theory and Practical Applications: Lippincott
Williams and Wilkins; 2001. p 165 and Horak, FB (2003) Advanced Competency in the Evaluation & Treatment of
Complex Balance Disorders, p 4; Courtesy of NeuroCom International
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Sensory weighting is task-dependent in
normal individuals
WEIGHTING
Stable Surface
 70% SOM
 20% VEST
 10% VIS
RE-WEIGHTING
Unstable Surface
 60% VEST
 30% VIS
 10% SOM
Q: What is ‘normal’ – Who is ‘normal’?
Q: What occurs when an individual has a lesion within
a given sensory system?
Horak 2003 based on Peterka RJ 2002
Sensory Reweighting after Unilateral
Vestibular Loss
Vestibular Weight (%)
1
0.8
Control
0.6
UVL
0.4
0.2
0
0
2
4
6
8
10
Stimulus Amplitude (deg)
Statler KD, Wrisley DM Peterka RJ, Horak FB 2004
Questions?
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CERVICAL SPINE ANATOMY AND PHYSIOLOGY
What is the purpose of osseous anatomy?
 Provides rigid framework to support body
 Protects viscera
 Forms joints
 Attachment site for muscles, ligaments,
viscera
 Shock absorption
What is the osseous anatomy of cervical spine?
7 vertebrae
 2 atypical vertebrae

Atlas (C1)

Axis (C2)
 5 typical vertebrae

C3-C7
What are the characteristic features of a typical
cervical vertebrae?
 Vertebral body
 Uncinate process
 Transverse process with nerve root gutter
Cervical Vertebrae (From Rothstein et al. The Rehabilitation
Specialist’s Handbook. FA Davis.Philadelphia. 1991, p18)
 Bifed spinous process with exception of C7
 Lamina
 Pedicle
 Superior and inferior articular process
 Transverse foramen
 Intervertebral foramen
 Vertebral canal
 Articular column
What are the characteristic features of C1, the Atlas?
 Ring-shaped
 No spinous process
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Seventh Cervical Vertebrae (From Rothstein et al. The
Rehabilitation Specialist’s Handbook. FA Davis.Philadelphia.
1991, p19)
 Longer transverse process
 Articular process (superior/inferior/anterior)
 Anterior/posterior tubercles
 Vertebral body absent
What are the characteristic features of C2, the Axis?
 Strongest cervical vertebrae
 Odontoid process (DENS)
 Anterior process
 Otherwise like typical vertebrae
What types of joints are in the Cervical Spine?
 Synovial

Two bones covered with hyaline cartilage

Joint cavity covered by fibrous joint capsule

Synovial membrane, ligaments, muscles, meniscus

Highly mobile
 Cartilaginous: Fibrocartilage connecting two bones
What are the joints of the Cervical Spine?
 Zygapophyseal joints (facet joints)

Formed by adjacent articular processes

DENS and C1

synovial
 Intervertebral disc and vertebral body: cartilaginous
 Uncovertebral joints (Von Luschka joints)

Formed by adjacent uncinate processes

Especially in adults

Synovial or cartilaginous?
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Cervical vertebral column: intervertebral disc and
joints of von Luschka (From Richardson and Iglarsh.
Clinical Orthopedic Physical Therapy. WB
Saunders, Philadelphia,PA 1994, p12)
What is the anatomy and purpose of the intervertebral disc?
 Intervertebral disc is present at levels below
C2/C3
 No intervertebral disc present at O/A and A/A
 The disc accounts for 25% of cervical spine
height
 Nucleus pulposus: Absorbs axial compression
 Annulus fibrosus: Stabilizes joint and
withstands the tension of disc
 With increasing age and pathology, the height of
the nucleus pulposus decreases, decreasing
Occipital-Atlantal motion (From Richardson and
Iglarsh. Clinical Orthopedic Physical Therapy.
WB Saunders, Philadelphia,PA 1994, p15)
space between uncinate processes
What are the joints of the upper cervical spine?
 Occipital-Atlantal joint
 Atlantal-Axial joint
What are the motions of the Cervical Joints?
 Nodding at the occipital-atlantal joint

Roll and glide in opposite directions
(Convex-concave rule)
Atlantal-axial motion (From Richardson and
 Rotation: the atlantal-axial joint accounts for 50% of motion
 Flexion: pure motion
 Extension: pure motion
 Sidebending: non-functional vs.
functional
 Coupled motion

Rotation and Sidebending occur
in same direction (C3-C7)

Rotation and Sidebending occur
in opposite directions (upper
cervical spine)
What is the purpose of ligaments?
 Maintain relationship of articular surfaces
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Vertebral body rotation (From Richardson and
 Restrict excessive motion
 Provide passive support
 Provide proprioceptive information
 Guide motion
Ligaments of cervical region (From Richardson and Iglarsh. Clinical Orthopedic Physical Therapy. WB Saunders,
Philadelphia,PA 1994, p12)
What are the ligaments of the cervical spine?
 Posterior longitudinal ligament

Tectorial membrane (C1 to occiput)
 Anterior longitudinal ligament
 Ligamentum nuchae

Supraspinous/interspinous ligaments
 Ligamentum flava
 Intertransverse ligaments
What are the ligaments of the upper cervical spine?
 Alar ligament: from DENS to occiput
 Transverse or cruciform ligament: from atlas to axis
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 Upper cervical ligaments are important clinically due to mechanism of injury in
acceleration-deceleration
(whiplash) injury
What is the purpose of Muscles?
 Generate forces for movement
 Shock absorption
 Protection
What are the cervical superficial muscles?
 Trapezius
 Levator Scapula
 Sternocleidomastoid
 Easily palpable
What are the sub-occipital muscles?
 Deep location
 Oblique capitis inferior
 Oblique capitis superior
 Rectus capitis posterior major
 Rectus capitis posterior minor
What are the deep cervical flexors?
 Longus colli
Cervical musculature (From Richardson and Iglarsh. Clinical Orthopedic
Physical Therapy. WB Saunders, Philadelphia,PA 1994, p 9)
 Longus capitus
 Important for spinal segmental stability
What is the cervical vascular anatomy?
 Vertebral artery

Travels in the transverse foramen of C6-C1
 Important clinically

Location of vertebral artery in transverse
foramen (From Warfel 1973)
Dissection of artery
with whiplash injuries,
high thrust
manipulation
 When should vertebral artery
testing be done?
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Distribution of the vertebral artery in the caudal and rostral
medulla (From Young and Young. Basic Clinical
Neuroanatomy, 1997)
What is the cervical neuroanatomy?
 Joint mechanoreceptors

Type I and Type II

Stimulated by joint movement, muscle
contraction, altered joint pressure
 Muscle spindle and Golgi Tendon Organs

High density of muscle spindles in cervical
musculature

Muscle spindles are arranged in series or
tandem and often in combination with golgi
tendon organs.

Respond to stretch and contraction of muscle
 Cervical nerve roots
Cervical Nerve Roots (From Richardson and Iglarsh.
Clinical Orthopedic Physical Therapy. WB
Saunders, Philadelphia,PA 1994, p13)

Eight nerve roots; seven vertebrae

Nerve root named for the vertebra below it

Innervate upper extremity and trunk

Carry cervical, upper extremity afferents to cerebellum and brainstem

C1-C3 dorsal roots project to vestibular nucleus
 Cranial nerves

Trigeminal nerve (CN V) has input to Trigeminocervical
nucleus located in lamina 2 of cervical spinal cord
interacts with dorsal root fibers of C1-C3

This interaction may explain headaches , facial
pain, jaw pain with cervical spine injury.
 Autonomic nervous system: related to vascular anatomy of face
and neck
Location of the Trigeminal
Nuclues. (Bogduk, N. In:Grieve:
Modern Manual Therapy of the
Vertebral Column, 1986)
Considerations for Cervical Spine
 Provides mobile base for sensory systems
 Houses components of somatosensory system
 Orthopedic physical therapy intervention to cervical spine may facilitate recovery from
dizziness and postural control
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History
 Symptom description
 Precipitating factors
 Prodromal/Associated symptoms
 Symptom latency
 Symptom duration
 Symptom frequency
 Time and Mode of onset
 Past medical history
 Diagnostic tests/imaging
Symptom Description
 Have patient describe their symptoms
 Commonly used words/phrases (Wrisley et al., 2000)
 Dizziness
 Spinning
 Headache
 Lightheaded
 Swimming
 “My neck hurts”
 “I am having trouble reading”
 “I am having trouble concentrating”
Dizziness, Imbalance and the Cervical Spine
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Precipitating Factors
 What provokes the patient’s symptoms?
 Cervicogenic dizziness
 Neck movements
 Neck pain
 Positional change
 Consider other diagnoses
 VBI, BPPV, etc...
Prodromal/Associated Symptoms
 Does anything precede the onset of dizziness?
 Visual aura
 Pallor
 Sweating
 Does anything occur with the dizziness?
 Neck pain
 Transient neurological signs
 Nausea/vomiting
 Tinnitus/hearing loss
 May assist in differential diagnosis
Symptom Latency
Time lapse between exposure to precipitating stimulus
and the onset of symptoms
Cervicogenic dizziness
 Variable latency period
BPPV
 Short latency (1-5 seconds) (Van der Velde, 1999)
VBI
 Long latency (almost 60 seconds) (Oostendorp, 1988)
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Symptom Duration
 How long do symptoms last?
 Minutes to hours
 BPPV
 < 60 seconds
 VBI
 Persists as long as position maintained
Symptom Frequency
 intermittent
 Peripheral vestibular dysfunction
 intermittent
 Central vestibular dysfunction
 constant
Time and Mode of Onset




How long ago did symptoms occur?
How did the symptoms occur?
Gradual, sudden, associated with injury
Cervicogenic dizziness
 Associated with cervical pathology
 One of three diagnostic criteria
 Gradual
 Delayed
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Condition
Produced with head
movement and
positional change
Nystagmus
Duration
Neurological
signs
CD
YES
questionable
minutes-hours
NO
BPPV
YES
horizontal-rotary
< 60 seconds
NO
VBI
YES
possible vertical
persists
YES
CD: Cervicogenic Dizziness; BPPV: Benign Paroxysmal Positional Vertigo; VBI: Vertebral
Basilar Insufficiency
Past Medical History
 May provide diagnostic or screening clues in patients
complaining of dizziness
 Diseases
 Surgical history
 Trauma history
 Medications
 Family history
Diagnostic Tests/Imaging
 Vestibular function tests
 Caloric Irrigation and Oculomotor testing (ENG)
 Earth vertical axis rotation
 Computerized Dynamic Posturography
 Cervical radiographs/MRI
 Head CT scan/MRI/MRA
 Doppler studies
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Systems Review & Upper Quarter
Screening: Dutton pp. 256-257 (2 ed)
nd
 Systems review
 To systematically review the upper quarter to
include all structures that could contribute to or
be the sole cause of the patient’s chief complaint
 Used when:
 no hx of trauma, radicular signs, trauma with radicular
signs, sensation problems, spinal cord signs, abnormal
patterns, psychogenic pain
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Upper Quarter Screen
 Cervical/Shoulder AROM check
 Overpressure (OP) applied the joints if pain free
 Spurling’s/Quadrant test
 Myotomal testing
 Dermatomal testing
 Vascular tests?
 Reflexes/Babinski/Hoffman (UMN)
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Myotomes
C1-C2 Neck flexion
C3 Neck lateral flexion
C4 Shoulder shrug
C5 Shoulder abduction, ER
C6 Elbow flexion, wrist extension
C7 Elbow extension, wrist flexion
C8 Thumb extension
T1 Finger abduction and adduction
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Dermatomes
Tests/Measures: Cervical spine
 Pain assessment
 Dizziness assessment
 Posture screen
 AROM
 Passive joint mobility
 Strength
 Flexibility
 Palpation
 Clinical special tests
Tests and Measures: Vestibular
Generalized balance and vestibular evaluation including:
 Provoking symptoms
 Gaze stabilization
 Motion sensitivity/ Space and motion discomfort
 Balance and gait function
 Neck Torsion Nystagmus Test or Head-Fixed Body-Turned
Maneuver
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Tests/Measures: Other systems
 Cardiovascular screen
 Neurological screen
 Psychiatric screen
Pain Assessment
 Verbal Analog Scale: 0 to 10 scale
 Worst pain level
 Best pain level
 Present pain level
 Dizziness present with neck pain?
 Pain Diagram: muscle referral patterns
Dizziness Assessment
 Verbal Analog Scale: 0 to 10 scale
 Worst dizziness
 Best dizziness
 Present dizziness
 Dizziness Handicap Inventory (DHI)
 High test-retest reliability (Jacobson and Newman, 1990)
 Activities-specific Balance Confidence Scale (ABC)
 Moderate strong negative correlation with DHI (Whitney et al.,
1999)
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Tests/Measures: Cervical Spine
 Posture screen
 Lateral view


Forward head posture
Rounded shoulders
 Anterior/Posterior view
 Head tilt
 Elevated shoulder
 Gives sense of muscular imbalances and stress on joints
 Hypomobility of upper cervical spine region (Paris, 1990)
 Tightness of upper trapezius & sternocleidomastoid
 Active range of motion
 Nodding
 Flexion, Extension
 Rotation
 Sidebending


Non-functional: head rotates contralaterally
Functional: head follows neck
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Patterns of AROM
Capsular patterns (Paris, 1997)
  flexion w/deviation to hypomobile side;  rotation and
sidebending opposite of hypomobile side: (mid-lower
cervical)
 Rotation and sidebending  but to opposite sides: (upper
cervical spine)
Myofascial patterns (Paris, 1997)
 Limitation in one motion (opposite to line of pull of
muscle)
Passive joint mobility
 Reliable in detecting painful segments (Jull et al., 1988)
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 Upper cervical spine restricted (Galm et al.,1998, McPartland et al., 1997)
 Nodding (occipital-atlantal joint)
 Rotation (atlantal-axial joint)
 Grading of mobility
 0-6 scale (0 = ankylosed; 6 = unstable) (Paris,et al.,1982)
 Poor interrater reliability (Paris et al., 1982)
 Reliability in cervicogenic headache patients (Hanten et al., 2002)

Normal mobility vs. Not normal mobility
VPTA 2012
Strength
Deep cervical flexors
 Longus colli
 Longus capitis
Craniocervical flexion
test (CCF)
(Jull,
1997; Falla et al., 2003)
 Motor control vs.
strength
VPTA 2012
 Flexibility/Palpation
(Wrisley et al., 2000)
 Upper trapezius
 Sternocleidomastoid
 Sub-occipital muscles
 Any tenderness, pain,
fullness, or
reproduction of
symptoms?
X X
X
 Clinical special tests
 Vertebral artery test
 Should we test?
 0% sensitivity (Cote et al., 1996)
 Alar ligament test
 Firm ligamentous end-feel
 Excessive sidebending/rotation
 Transverse ligament test/Sharp-Purser test
 Assess for pain or clunking
 Excessive forward translation of atlas
VPTA 2012
VPTA 2012
C2
 Neck torsion test
 Used to detect cervicogenic dizziness
 Developed by Philipzoon and Bos, 1963
 Head is held still while the body is rotated to each side
 Observe for nystagmus or symptoms of dizziness as an
indication for cervicogenic dizziness
VPTA 2012
Neck Torsion Test
Neck Torsion Nystagmus Test or Head-Fixed BodyTurned Maneuver
Questionable diagnostic accuracy
 50% of subjects w/out cervical pathology tested positive
for nystagmus (Norre, 1987)
 11% of patients with suspected cervicogenic dizziness
and 10.9% of people without pathology had positive
tests using nystagmus (Van de Calseyde et al., 1977)
Neck Torsion Test
 Sensitivity and Specificity
 sensitivity of 90% and a specificity of 91% using the gain
of smooth pursuit during body turned positions (Tjell et
al., 1998)
 47% of patients with cervical trauma demonstrated
subjective symptoms of vertigo or postural instability
during the maneuver, 90% improved following therapy
(Fitz-Ritson, 1991)
 64% of 262 patients with neck pain post-whiplash had
nystagmus with the NTNT (Oosterveld et al., 1991)
Tests/ Measures: Other Systems
Psychiatric screen
 Beck Depression Inventory
(Available at: www.cps.nova.edu/~cpphelp/BDI.html: accessed: 6/24/03)
 Designed
to measure severity of depression
 Hyperventilation test (Fetter, 2000)
 Causes
dizziness in patients with panic disorder
voluntary hyperventilation
 Perform

30 breaths/minute x 3 minutes
VPTA 2012
Tests/Measures: Other Systems
 Cardiovascular system
 Blood pressure

Orthostatic hypotension test
  SBP (30 mmHg);  DBP (10 mmHg) (Simon et al., 1999)
 Heart rate

Tachycardia (>100 bpm)/Bradycardia (< 60 bpm)
(Boissonnault, 1995)
 Neurological system
 Dermatomes, myotomes, DTR’s
 Cranial nerve testing
Cervicogenic Dizziness

A diagnosis of exclusion

Diagnostic criteria (Wrisley et al, 2000)
1.
2.
3.
A close temporal relationship b/w neck pain and
dizziness.
Previous neck injury and pathology
Elimination of other causes of dizziness
VPTA 2012
Cervical treatment laboratory session
Cervical Examination
I. Posture
Observe for:
- forward head
- lateral tilt of head
- rounded shoulders/protracted scapula
Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
II. Cervical active range of motion
Observe for:
- flexion, extension, lateral flexion, rotation
- Functional O-A AROM (full rotation; head nod)
- Functional A-A AROM (full lat flexion; rotate opposite “look over to
the top corner”)
o quantity of motion
o quality of motion
o any deviation with movement
o presence of myofacial pattern
Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
III. Cervical passive joint mobility
Assess:
- occipital-atlantal joint via nodding (fwd/bwd)
o any deviation of chin
- atlantal-axial joint via rotation with lower cervical spine locked
o via full flexion or sidebending
- Sidegliding and translation of the upper and lower cervical spine
- Posterior-anterior glides (Central and Unilateral)
- Transverse pressure
- presence of capsular pattern
o upper vs. lower cervical spine
Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
[2012 VPTA Annual Conference]
1
IV. Soft tissue assessment
Assess for:
- tightness, tenderness, trigger points, reproduction of pain
o upper trapezius, levator scapula, sternocleidomastoid, suboccipital muscles
- flexibility
o upper trapezius, levator scapula, sternocleidomastoid
Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
V. Special tests
Assess:
- ligamentous integrity: Alar ligament test and Transverse ligament test
- Swallow test
- Compression/Distraction/Spurling’s/Quadrant test
- Vertebral artery test
Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Cervical Intervention
I. Soft tissue mobilization
- Deep pressure to trigger points
o upper trapezius, levator scapula, sternocleidomastoid, suboccipital muscles
- Sub-occipital release (occipital-atlantal distraction)
- Massage
o pectoralis major/minor
o subscapularis
Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
II. Joint mobilization/manipulation
- Nodding stretch for occipital-atlantal joint
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2
- Rotation for atlantal-axial joint
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
- Posterior-anterior (PA) glides for all joints (Central and Unilateral)
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
- Transverse glides for all joints
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
- Nonspecific HVLA thrust technique (Thoracic spine)
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
III. Stretching
-
Contract-relax stretching
o Upper trapezius, levator scapula, sub-occipital muscles
-
Stretching
o Sternocleidomastoid, pectoralis major/minor
Notes:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
IV. Stabilization/Strengthening/Postural re-education
- Motor control exercises
o Cranial flexion, quadruped w/arm lift
- Strengthening
o Cranial flexion w/head lift, cervical isometrics, scapular
retraction, shoulder depression
o Address entire upper quarter, especially posterior shoulder,
scapular, and upper back musculature
o Deep neck flexor program (Jull)
[2012 VPTA Annual Conference]
3
Patient Case
 41 year old female presents to clinic
 Chief complaint: difficulty walking, imbalance, 2 falls in
last 4 weeks
 Symptoms started 4 weeks ago with 3 day episode of
dizziness, now only has imbalance, disorientation and
difficulty walking
 Associated symptoms of headache and neck pain
 What is your differential diagnosis?
VPTA 2012
1
The Differential Diagnosis is Critical
 Often patients present to the clinic with “dizziness”
and neck pain. The PT needs to determine the source
of the dizziness and how to treat it.
 Dizziness often occurs in conjunction with
 Cardiovascular dysfunction
 Neurocardiogenic syncope
 hypoxia
 Central Nervous System Pathology
 CVA
 MS
 Migraine
 Peripheral Nervous System Abnormalities
 Vestibular Pathologies
 Somatosensory Deficits
 Neck injuries
Peripheral and Central Vestibular Causes of
Dizziness
 Disorders of the Brain (vestibular nuclei, brainstem, and
cerebellum common)
 Migraine
 MS
 CVA
 Disorders of the Peripheral Vestibular system
 Unilateral Vestibular Loss
 Neuritis
 Labyrinthitis
 Acoustic Neuroma
 Bilateral Vestibular Loss
 Ototoxicity
 Idiopathic
 Mechanical: Benign Paroxysmal Positional Vertigo (BPPV)
 Meniere's Disease
 Disorders of the Neck (and brain)
 Cervicogenic Dizziness
APTA Practice Pattern for Patients with
Vestibular and Balance Disorders
Neuromuscular Pattern 5A Primary Prevention/ Risk
Reduction for Loss of Balance and Falling
VPTA 2012
2
Vestibular Evaluation
 History
 Present Illness







Description of symptoms
Precipitating factors
Associated symptoms
Symptom latency
Symptom duration
Symptom frequency
Time and mode of onset
Symptom Description
 Have the patient describe their symptoms and
remember the words they use
 Commonly used words/phrases










Dizziness
Spinning
Headache
Lightheaded
Swimming
Difficulty reading
Difficulty concentrating
Off balance
Falling
Unable to lie down
Precipitating Factors
 What provokes the patient’s symptoms?
 Common provoking factors
 Position changes
 Change in head position
 Walking in open spaces
 Movement in the environment
 Walking in the dark or on compliant surfaces
 Neck pain
 Headache
VPTA 2012
3
Associated Symptoms
 Does anything precede the onset of dizziness?
 Visual aura
 Pallor
 Sweating
 Headache/ migraine
 Neck pain
 Does anything occur with the dizziness?
 Nausea
 Vomiting
 Hearing loss
 Tinnitus
 Visual disturbances
 Transient neurological signs
 Falls
Temporal Factors
 Symptom Latency
 The time lapsed between exposure to precipitating
stimulus and onset of symptoms
 Symptom Duration
 How long do symptoms last
 Symptom Frequency
 Time and Mode of onset of symptoms
Past Medical History
 Trauma History
 Surgical History
 Other Pathology/Impairments
 Anxiety
 Migraine
 Family History
 Migraine
 BPPV
 Meniere’s Disease
VPTA 2012
4
Medications
 Benzodiazepines, anti-anxiety, sedatives
 Decreased awareness of movement/ position in space
 Slowed central nervous system integration
 Slowed motor output
 Orthostatic hypotension
 Antihypertensives
 Orthostatic hypotension, urinary urgency
 Aminoglycoside antibiotics (i.e. gentamicin);
Diuretics (Loop); Chemotherapeutic agents
 Toxic to vestibular hair cells, may lead to vertigo, impaired
balance, bilateral vestibular dysfunction
Diagnostic Tests and Imaging
 Audiometry (Hearing Assessment)
 Vestibular Function Tests
 Caloric Irrigation and Ocular Motor Testing
(ENG/VNG)
 Earth vertical Axis rotation
 Vestibular Evoked Myogenic Potential (VEMP)
 Computerized Dynamic Posturography
 Head CT scan, MRI, MRA
 Doppler Studies
 Tilt test
 Cervical radiographs and/or MRI
Subjective Assessment of Dizziness
 Why quantify subjective symptoms?
 Dizziness/Vertigo is difficult to quantify as primarily a
subjective symptom
 Self-perception measures can help guide your patient
interview
 Use as outcome measure
 How do you choose a test?
 Psychometric properties of the test

Reliabilty, validity, discriminative properties
 Patient population, functional level
VPTA 2012
5
 Verbal Analog Scale
 0 (no dizziness) to 10 (worst dizziness)
 Worst, best, present levels
 Can use for symptoms of dizziness, space and motion
discomfort, neck pain, etc
 Dizziness Handicap Inventory Jacobson and Newman, 1990
 25 item test that assess the self perceived handicap due to
dizziness




3 subcategories: functional, emotional, and physical
Scored No: 0; Sometimes: 2; Yes: 4
Maximum: 100
Scoring: http://www.clinicalhealthservices.com/DHI.html
 High test-retest reliability Jacobson and Newman, 1990
 Useful in directing patient interview
 Questions 1, 5, 11, 13, and 25 are predictive of BPPV Whitney et al 2005
 Correlates with Physical Function Measures Whitney, Wrisley et al
2004



0-30 minimal impairment
31-60 moderate impairment
61-100 severe impairment
 Activities-specific Balance Confidence Scale
 16 functional items with varying degrees of difficulty
 Items rated on scale of 0 (not confidence) to 100% (Completely
confident) on confidence in performing activity
 Responses are averaged and a percentage score generated
 Developed to quantify fear of falling in older adults
 Lower scores indicate greater fear of falling Myers et al 1998



Scores < 50 indicate home bound older adult
Scores 50-79 indicate older adult with chronic health problems or in
retirement centers
Scores > 80 indicate highly functioning community dwelling older adult
 Correlates with DHI in persons with vestibular disorders
Whitney et al 1999
 High test-retest reliability Myers et al 1998
VPTA 2012
6
 Vestibular Disorders Activities of Daily Living
Scale (VADL) Cohen et al 2000; Cohen and Kimball 2000
 Developed to assess self-perceived disability in patients
with vestibular impairments
 Items include 27 activities of daily living
 Scale rated from 1 (independent) to 10 (ceasing to participate in
the activity)
 Scored as a median so patients can skip an item and the test still
has validity
 Internal consistency high (Cronbach’s α >.90)
 Excellent test-retest reliability (r > .87)
Ocular Motor Function
 Ocular Motor Function
 Purpose: To determine if CNS
problem and to ensure that eye
movements are normal so VOR
can be tested
 Smooth pursuit
 Smooth eye movement
tracking a slowly moving
discrete target


Mediated by brainstem eye
fields, medial longitudinal
fasciculus, and cranial
nerves III, IV, and VI
Abnormalities are seen with
cerebellar or brain stem
lesions
http://library.med.utah.edu/neurologicex
am/movies/cranialnerve_n_11_x2.mov
 Saccades
 A quick eye movement or
refixation
 Mediated by frontal eye fields
(voluntary saccades),
brainstem reticular formation
(voluntary and involuntary
saccades) and cranial nerves
III, IV, and VI
 Abnormalities are seen with
cortical, brainstem and
cerebellar lesions
am/movies/cranialnerve_n_10_x2.mov
Abnormal smooth pursuit and saccades
am/movies/cranialnerve_ab_11_x2.mov
VPTA 2012
7
Saccadic Disorder
 Optokinetic Nystagmus


Involuntary reflexive refixation eye movements
Mediated primarily through motion sensitive neurons in retina
http://library.med.utah.edu/neurologicexam/movies/cranialnerve_
n_12_x2.mov
 Convergence



The ability of the eyes to move symmetrically to look at
objects at varying distance from the eyes
Mediated by medial rectus neurons
Abnormalities are seen with brainstem or basal ganglia
lesions
http://library.med.utah.edu/neurologicexam/movies/cra
nialnerve_n_14_x2.mov
VPTA 2012
8
Convergence Insufficiency
Clinical Measures of Vestibular Function and
Balance
 Ocular Motor Function
 Skew Deviation (Cover/Uncover test)





Test for ocular torsion and strabismus
Ocular torsion is mediated by otolith function
Strabismus is mediated by ocular muscles and central nervous
system
Ocular torsion may be seen with acute vestibular dysfunction
Deviation of the eye may be seen with ocular muscle
imbalance or central nervous system lesions
Clinical Measures of Vestibular Function
 Eye Head Coordination Testing
 Spontaneous Nystagmus
 Look for repetitive fast and slow movements of the eyes in room light
with and without fixation and/or with fixation suppressing goggles
 Direction fixed, horizontal-rotary nystagmus is indicative of an acute
asymmetry in the firing of the labyrinth, VIII cranial nerve or
vestibular nucleus


The nystagmus will intensify with gaze in the direction of the fast phase
Direction changing horizontal, vertical, torsional or pendular
nystagmus is indicative of brain stem, cerebellar or cortical lesions
VPTA 2012
9
 Active and Passive VOR
 Mediated by labyrinth, VIII cranial nerve, and vestibular nucleus
 Active VOR


Passive VOR


While the patient looks at a target have them move their head horizontally
and then vertically at about 2 cycles/second. Look for refixation saccades,
note reports of dizziness or nausea
Hold the patient’s head tipped down approximately 30 degrees, move the
patient’s head horizontally and vertically at about 2 cycles/second while
asking them to focus on your face. Look for refixation saccades, note
reports of dizziness or nausea
Abnormalities are indicative of vestibular dysfunction
 VOR Cancellation (Fixation Suppression)
 Ask the patient to look at their finger or a target that is moving with
them while rotating their head or body from side to side. Note any
visual vestibular nystagmus or symptoms of dizziness or nausea
 Abnormalities in the presence of adequate visual acuity implies
floccular dysfunction
 Dynamic Visual Acuity Longridge and Mallinson 1984
 Performed with a Snellen Eye Chart. The patient reads the lowest line
comfortably with the head still and then with the head moving at 2 Hz
horizontally and vertically. The number of lines of acuity lost are
recorded.
 Patients with bilateral vestibular dysfunction will have a loss of >5-6
lines; patients with acute unilateral vestibular loss will have a loss of
>2-3 lines
 Head Thrust (Head Impulse Test) Schubert et al 2004; Halmagyi and
Curthoys 1988



95% specificity, 35% sensitivity for detecting vestibular lesion
The patient is asked to fixate on a target while the examiner moves the
patients head rapidly to each side
The examiner looks for any movement of the pupil during the head
thrust and a refixation saccade
 Head Shake (Postheadshake nystagmus) Burgio et al 1991, Fetter 2000,
Tseng and Chao 1997


The head is tilted forward 30 degrees and the head is shaken at 2 Hz
for 20 seconds. Observe for any postheadshake nystagmus either in
room light or with fixation suppressing goggles. Can be repeated in
vertical direction
Indicative of acute imbalance in vestibular inputs in the plane of
rotation
VPTA 2012
10
Clinical Vestibular Evaluation
 Positional Testing
 Motion Sensitivity Quotient Norre and deWeerdt 1981, Smith-Wheelock et al
1991, Shepard et al 1993





Provides an objecive score of the patient’s dizziness
The subject moves into positions that involve head and body
movement
The patient reports a dizziness intensity score and the duration of the
symptoms is recorded.
The symptom intensity and the duration values are added to get a
score. The MSQ is calculated by multiplying the number of
provoking positions by the score and dividing by 2048. 0 = no
symptoms; 100 = severe dizziness in all positions
The positions can also be used for treatment
 Dix-Hallpike Maneuver/ Roll Test for BPPV
 Functional and Balance Assessment
 What aspects of balance do we need to quantify?


Motor
 Timing of muscle activity
 Sequence of muscle activity – synergies
 Intensity of muscle activity
Sensory
 Ability to use available sensory information
 Ability to choose appropriate sensory information and ignore
inaccurate information
 How do we chose the appropriate test?
 Single Item tests

Romberg/ Sharpened Romberg Notermans et al 1994, Bohannon et al
1984




Single Limb stance Bohannon et al 1984; Mann 1996
Five Times Sit to Stand Whitney et al 2001
Fukuda step test Fukuda 1959
Singleton step test
VPTA 2012
11
 Multiple item balance tests


Berg Balance Scale Berg et al 1989
Balance Evaluation Systems Test Horak et al 2004


Mini-BESTest
Computerized Dynamic Posturography/ Clinical Test of
Sensory Interaction and Balance Shumway-Cook and Horak 1986
Cervical Spine 2007
Dr. D. M. Wrisley
Cervical Spine 2007
Dr. D. M. Wrisley
VPTA 2012
12
 Gait Assessment




Timed “Up & Go” Podsiadlo and Richardson 1991
Dynamic Gait Index Shumway-Cook and Woolacott 1995
Functional Gait Assessment Wrisley et al 2004, 2010
Timed gait
 Need to walk > 1.22 m/sec to cross street safely
Patient Case
 41 year old female presents to clinic
 Chief complaint: difficulty walking, imbalance, 2 falls in last
4 weeks
 Symptoms started 4 weeks ago with 3 day episode of
dizziness, now only has imbalance, disorientation, history
of falling and difficulty walking
 Associated symptoms of headache and neck pain
 What additional information would you like to know?
 What would you include in her evaluation?
Questions?
VPTA 2012
13
DIZZINESS HANDICAP INVENTORY
Instructions: The purpose of this scale is to identify difficulties that you may be
experiencing because of your dizziness or unsteadiness. Please check the box “yes”,
“no”, or “sometimes” to each question. Answer each question as it pertains to your
dizziness or unsteadiness problem only.
YES SOMETIMES NO
{
{
{
P1. Does looking up increase your problem?
E2. Because of your problem, do you feel frustrated?
{
{
{
F3. Because of your problem, do you restrict your
travel for business or recreation?
{
{
{
P4. Does walking down the aisle of a supermarket
increase your problem?
{
{
{
F5. Because of your problem, do you have difficulty
getting into or out of bed?
{
{
{
F6. Does your problem significantly restrict your
participation in social activities such as going out to
dinner, going to the movies, dancing or to parties?
{
{
{
F7. Because of your problem, do you have difficulty
reading?
{
{
{
P8. Does performing more ambitious activities like
sports, dancing, household chores such as sweeping or
putting away dishes increase your problem?
{
{
{
E9. Because of your problem, are you afraid to leave
your home without having someone accompany you?
{
{
{
E10. Because of your problems, have you been
embarrassed in front of others?
{
{
{
P11. Do quick movements of your head increase you
problem?
{
{
{
F12. Because of your problem, do you avoid heights?
P13. Does turning over in bed increase your problem?
F14. Because of your problem, is it difficult for you to
do strenuous housework or yardwork?
Appendix A.2 Dizziness Handicap Inventory continued
{
{
{
{
{
{
{
{
{
{
{
{
{
{
{
E15. Because of your problem, are you afraid people
may think that you are intoxicated?
{
{
{
E16. Because of your problem, is it difficult for you to
walk by yourself?
{
{
{
P17. Does walking down a sidewalk increase your
problem?
{
{
{
E18. Because of your problem, is it difficult for you to
concentrate?
{
{
{
F19. Because of your problem, is it difficult for you to
walk around the house in the dark?
{
{
{
E20. Because of your problem, are you afraid to stay
home alone?
{
{
{
E21. Because of your problem, do you feel
handicapped?
{
{
{
E22. Has your problem placed stress on your
relationship with members of your family or friends?
{
{
{
E23. Because of your problem, are you depressed?
{
{
{
F24. Does your problem interfere with your job or
house responsibilities?
{
{
{
P25. Does bending over increase your problem?
Jacobson GP and Newman CW. The development of the Dizziness Handicap Inventory. Arch
Otolaryngol Head Neck Surg. 1990; 116:424-427
The Activities-specific Balance Confidence (ABC) Scale
Administration
The ABC can he self-administered or administered via personal or telephone interview. Larger
typeset should be used for self-administration, while an enlarged version of the rating scale on an
index card will facilitate in-person interviews. Regardless of method of administration, each
respondent should be queried concerning their understanding of instructions, and probed
regarding difficulty answering specific items.
Instructions to Participants
For each of the following, please indicate your level of confidence in doing the activity without
losing your balance or becoming unsteady by choosing one of the percentage points on the scale
from 0% to 100%. If you do not currently do the activity in question, try and imagine how
confident you would be if you had to do the activity. If you normally use a walking aid to do the
activity or hold onto someone, rate your confidence as if you were using these supports. If you
have any questions about answering any of these items, please ask the administrator.
Instructions for Scoring
The ABC is an 11 point scale and ratings should consist of whole numbers (0 to 100) for each
item. Total the ratings (possible range 0 to 1600) and divide by 16 to get each subject’s ABC
score. If a subject qualifies his/her response to items #2, #9, #11, #14 or #15 (different ratings for
“up”vs “down” or “onto” vs “off’), solicit separate ratings and use the lowest confidence of the
two (as this will limit the entire activity, for instance likelihood of using the stairs).
*Powell LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol
Med Sci 1995; 50 (1):M28-34 (Used with permission)
The Activities-specific Balance Confidence (ABC) Scale
For each of the following activities, please indicate your level of self-confidence by choosing a
corresponding number from the following rating scale:
How confident are you that you will not
lose your balance or become unsteady
when you…
0
10
20
30
40
50
60
70
80
90
100
1. …walk around the house?
{
{
{
{
{
{
{
{
{
{
{
2. …walk up or down the stairs ?
{
{
{
{
{
{
{
{
{
{
{
3. …bend over and pick up a slipper
from the front of a closet floor?
{
{
{
{
{
{
{
{
{
{
{
4. …reach for a small can off a shelf at
eye level?
{
{
{
{
{
{
{
{
{
{
{
5. …stand on your tip toes and reach for
something above your head?
{
{
{
{
{
{
{
{
{
{
{
6. …stand on a chair and reach for
something?
{
{
{
{
{
{
{
{
{
{
{
7. …sweep the floor?
{
{
{
{
{
{
{
{
{
{
{
8. …walk outside the house to a car
parked in the driveway?
{
{
{
{
{
{
{
{
{
{
{
9. …get into and out of a car?
{
{
{
{
{
{
{
{
{
{
{
10. …walk across a parking lot to the
mall?
{
{
{
{
{
{
{
{
{
{
{
11. …walk up or down a ramp?
{
{
{
{
{
{
{
{
{
{
{
12. …walk in a crowded mall where
people rapidly walk past you?
{
{
{
{
{
{
{
{
{
{
{
13. …are bumped into by people as you
walk through the mall?
{
{
{
{
{
{
{
{
{
{
{
14. …step onto or off of an escalator
while you are holding onto a railing?
{
{
{
{
{
{
{
{
{
{
{
15. …step onto or off an escalator while
holding onto parcels such that you
cannot hold onto the railing?
{
{
{
{
{
{
{
{
{
{
{
16. ..walk outside on icy sidewalks?
{
{
{
{
{
{
{
{
{
{
{
Vestibular Disorders Activities of Daily Living Scale
Name/ID
Rater
Date
Instructions
This scale evaluates the effects of vertigo and balance disorders on independence in routine activities of daily living. Please rate your performance on
each item. If your performance varies due to intermittent dizziness or balance problems please use the greatest level of disability. For each task
indicate the level which most accurately describes how you perform the task. If you never do a particular task, please check the box in the column NA.
The rating scales are exlained on bottom of page.
In
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Independence Rating
Task
F-1 Sitting up from lying down
1
2
3
4
5
6
7
8
9
10
NA
F-2 Standing up from sitting on the bed or chair
F-3 Dressing the upper body (e.g., shirt, brassiere, undershirt)
F-4 Dressing the lower body (e.g., pants, skirt, underpants)
F-5 Putting on socks/stockings
F-6 Putting on shoes
F-7 Moving in/out of the bathtub or shower
F-8 Bathing yourself in the bathtub or shower
F-9 Reaching overhead (e.g., to a cupboard or shelf)
F-10 Reaching down (e.g., to the floor or a shelf)
F-11 Meal preparation
F-12 Intimate activity (e.g., foreplay, sexual activity)
A-13 Walking on level surfaces
A-14 Walking on uneven surfaces
A-15 Going up steps
A-16 Going down steps
A-17 Walking in narrow spaces (e.g., corridor, grocery store aisle)
A-18 Walking in open spaces
A-19 Walking in crowds
A-20 Using an elevator
A-21 Using an escalator
I-22 Driving a car
I-23 Carrying things while walking (e.g., package, garbage bag)
I-24 Light household chores (e.g., dusting, putting items away)
I-25 Heavy household chores (e.g., vacuuming, moving furniture)
I-26 Active recreation (e.g., sports, gardening)
I-27 Occupational role (e.g., job, child care, homemaking, student)
I-28 Traveling around the community (car, bus)
Explanation of Independence Rating Scale
This scale will help us to determine how inner ear problems affect your ability to perform each task. Please indicate your current performance on
each task, as compared to your performance before developing an inner ear problem, by checking the one of the columns in the center of the page.
Pick the answer that most accurately describes how you perform the task.
1. Am not disabled, perceive no change in performance from before developing an inner ear impairment
2. Am uncomfortable performing the activity but perceive no difference in the quality of my performance
3. Perceive a decrement in the quality of my performance, but have not changed the manner of my performance
4. Have changed the manner of my performance, e.g., I do things more slowly or carefully than before, or I do things without bending
5. Prefer using an ordinary object in the environment for assistance (e.g., stair railing) but I am not dependent on the object or device to do the
activity
6. Must use an ordinary object in the environment for assistance, but I have not acquired a device specifically designed for the particular activity
7. Must use adaptive equipment designed for the particular activity (e.g., grab bars, cane, reachers, bus with lift, reachers, wedge pillow)
8. Require another person for physical assistance or, for an activity involving two people, I need unusual physical assistance
9. Am dependent on another person to perform the activity
10. No longer perform the activity due to vertigo or a balance problem
NA Not an activity that I usually perform or I prefer not to answer this question
Reprinted from: Cohen H and Kimball KT. Development of the Vestibular Disorders Activities of Daily Living Scale. Arch Otolaryngol Head Neck Surg 2000;126:881-887
The Clinical Test of Sensory Interaction and Balance (CTSIB)
This test is the low cost version of the sensory organization test of computerized dynamic
posturography which measures a person’s ability to use vision, vestibular and somatosensation to
maintain balance. The test was developed by Shumway-Cook and Horak in 1986 (Phys Ther and
further discussed as a clinical tool in 1987 (Phys Ther,). Patients with uncompensated unilateral
vestibular deficits and older adults at risk for falling have been shown to have difficulty when
visual and support surface information are manipulated (Nashner, 1982;Annacker and DeFabio,
1992).
General Instructions:
Have the subject stand erect without moving, looking straight ahead as long as possible or
until the trial is over, and if possible have the subject remove their shoes.
Condition One: Normal vision, fixed support
Instructions for Condition One:
Stand on the floor with arms across your chest and your hands touching your shoulders,
feet together with ankle bones touching, and hold for 30 sec (Horak, 87)
Condition Two: Absent vision, fixed support
Instructions for Condition Two:
Stand on the floor with arms across your chest and your hands touching your shoulders,
feet together with ankle bones touching with your eyes closed, and hold for 30 sec (Horak, 87)
Condition Three: Sway-referenced vision, fixed support
Instructions for Condition Three:
Stand on the floor with arms across your chest with your hands touching your shoulders,
feet together with ankle bones touching, the visual conflict dome on your head with your eyes
open, and hold for 30 sec (Horak, 87)
Condition Four: Normal vision, sway-referenced support
Instructions for Condition Four:
Stand on a 3 inch high density foam cushion with your arms crossed and touching your
shoulders, feet together with the ankle bones touching, and your eyes open, holding for 30 sec
(Horak, 87)
Condition Five: Absent vision, sway-referenced support
Instructions for Condition Five.
shoulders, feet together with ankle bones touching, and your eyes closed, holding for 30 sec
(Horak, 87)
Condition Six: Sway-referenced vision, sway-referenced support
Instructions for Condition Six:
shoulders, feet together with ankle bones touching, and your eyes open looking into the dome,
holding for 30 sec (Horak. 87)
In Horak’s article (1987) she suggests that each test be performed 3 times. She also suggested
that a sway grid could be used to quantify motion in addition to documenting the time that the
subject could maintain the position. Shumway-Cook and Horak (1986) also suggest that sway
may be quantified in the following manner:
1= minimal sway
2= mild sway
3= moderate sway
4=fall
Criteria to stop timing the task:
The subject’s arms moved from the original position, the subject’s foot moved, or they
opened their eyes during an eyes closed trial.
Weber and Cass (1993) determined that falls on Condition Five correlated with the results
of the EquiTest 90% of the time. The Clinical Test of Sensory Organization and Balance can
help to provide information that will assist the therapist in developing the patients’ treatment
plan.
The Modified Clinical Test of Sensory Interaction and Balance
Many therapists have modified the above test to include only Conditions 1, 2, 4,and 5.
They are not using the dome. The above 4 tests appear to provide sufficient data to determine the
treatment goals and plan for the patient.
Recent research has demonstrated the neither foot position or footwear make a significant
difference in scores on the modified Clinical Test of Sensory Interaction and Balance (Wrisley
and Whitney 2004; Whitney and Wrisley 2004).
Selected references:
Allison L. Balance Disorders. In: Umphred DA, editor. Neurological Rehabilitation. St. Louis,
MO: Mosby Year Book, 1995: 802-837.
Anacker SL, Di Fabio RP. Influence of sensory inputs on standing balance in communitydwelling elders with a recent history of falling. Phys Ther 1992;72:575-584.
Baloh RW, Spain 5, Socotch TM, Jacobson KM. Bell T. Posturography and balance problems
in older people. JAm Geriatr Soc 1995;43:638-644
Cohen H, Blatchly CA, Gombash LL. A study of the clinical test of sensory interaction and
balance. Phys Ther 1993;73:346-351.
Crowe TK, Dietz JC, Richardson 2K, Atwater SW. Interrater reliability of the pediatric clinical
test of sensory interaction for balance. Physical and Occupational Therapy in Pediatrics
1990; 10: 1-27.
Di Fabio RP, Badke MB. Relationship of sensory organization to balance function in patients
with hemiplegia. Phys Ther 1990;70:542-548.
El-Kashlan HK, Shepard NT, Asher AM. Smitli-Wheelock M, Telian SA. Evaluation of
clinical measures of equilibrium. Laryngoscope 1998:108:31 1-319.
Gill J, AlIum JFI, Carpenter MG, Held-Ziolkowska M, Adkin AL. Honegger F et al. Trunk
sway measures of postural stability during clinical balance tests: effects of age. JGerontolA
Biol Sci Med Sci 2001 ;56:M438-M447.
Gunter KB, White KN, Hayes WC, Snow CM. Functional mobility discriminates nonfallers
from one-time and frequent fallers. JGerontol 2000;55A:M672-M676.
HorakFB. Clinical measurement of postural control in adults. Phys Ther 1987;6’7:1881-1885.
Richardson PK, Atwater SW, Crowe TK, Deitz JC. Performance of preschoolers on the
Pediatric Clinical Test of Sensory Interaction for Balance. Am J Occup Ther 1992;46:793800.
Shumway-Cook A, Bahling Horak F. Assessing the influence of sensory integration on
balance. Suggestions from the field. Phys Ther 1986;66:1548-1549.
Weber PC, Cass SP. Clinical assessment of postural stability. Am J Otol 1993; 14:566-569.
Whitney SL, Wrisley DM. The Influence Of Footwear On Timed Balance Scores of the
Clinical Test of Sensory Interaction and Balance. Archives of Physical Medicine and
Rehabilitation 2004;85:439-443.
Wrisley DM, Whitney SL. Effect Of Foot Placement On Clinical Test Of Sensory Interaction
And Balance Outcome In People With Vestibular Disorders. Archives of Physical
Medicine and Rehabilitation 2004;85:335-338.
Directions for the Timed “Up & Go”
The timed “Up & Go” test measures, in seconds, the time taken by an individual to stand up from
a standard arm chair (approximate seat height of 43-46 cm, arm height 65 cm), walk a distance
of 3 meters (approximately 10 feet), turn, walk back to the chair, and sit down again. The subject
wears his/her regular footwear and uses his customary walking aid (none, cane, or walker). No
physical assistance is given. They start with their back against the chair, their arms resting on the
arm rests, and their walking aid at hand. They are instructed that, on the word “go” they are to
get up and walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return
to the chair, and sit down again. The subject walks through the test once before being timed in
order to become familiar with the test. Either a wrist-watch with a second hand or a stop-watch
can be used to time the performance.
Instructions to the patient: “When I say ‘go” I want you to stand up and walk to the line, turn
and then walk back to this chair and sit down again. Walk at your normal pace
You may want to also have the patient walk at a fast pace to see how quickly they can
ambulate. In addition, have them turn to the right and the left to see how the patient performs
(O’Neill, Gill-Body and Krebs, 1998). In people with peripheral vestibular disorders, the timed
“Up & Go” test correlated with the Sensory Organization Test 4 (O’Neill, Gill-Body and Krebs,
1998). The TUG had a sensitivity (81%) and specificity (56%) for a positive fall history in
persons with vestibular disorders and the cut-off was maximized at TUG 11.1 seconds.
Speed of gait has been correlated with falls in older adults and many of our older adults
walk slowly (Bendall MJ, Bassey EJ, Pearson MB, 1989). In older adults, there is value in
having some measure of their speed of gait. The timed “Up & Go” test also provides valuable
information to the clinician about the ability to rise out of a chair. Scores of 14 or greater indicate
high risk for falling in older adults (Shumway-Cook et al, 2000).
Reference List
(1)
Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and
laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil
1992; 73(11):1073-1080.
(2)
Brown KE, Whitney SL, Wrisley DM, Furman JM. Physical therapy outcomes for persons
with bilateral vestibular loss. Laryngoscope 2001; 111(10):1812-1817.
(3)
Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple
falling older adults. Arch Phys Med Rehabil 2002;83(11):1566-1571.
(4)
Freter SH, Fruchter N. Relationship between timed up and go and gait time in an elderly
orthopaedic rehabilitation population. Clin Rehabil 2000; 14(1):96—101.
(5)
Gill-Body KM, Beninato M, Krebs D. Relationship among balance impairments,
functional performance, and disability in people with peripheral vestibular hypofunction.
Phys Ther 2000; 80(8):748-758.
(6)
McMurdo ME, Millar AM, Daly F. A randomized controlled trial of fall prevention
strategies in old peoples’ homes. Gerontology 2000; 46(2):83-87.
(7)
Medley A, Thompson M. The effect of assistive devices on the performance of community
dwelling elderly on the Timed Up and Go test. Issues on Aging 1997; 20:3-7.
(8)
Morris 5, Morris ME, Iansek R. Reliablity of measurements obtained with the Timed “Up
& Go” test in people with Parkinson Disease. Phys Ther 2001; 81(810):818.
(9)
Newton RA. Balance screening of an inner city older adult population. Arch Phys Med
Rehabil 1997; 78(6):587-591.
(IC) Podsiadlo D, Richardson S. The Timed “Up & Go”: A test of bask functional mobility for
frail elderly persons. Journal of the American Geriatric Society 1991; 39(142):148.
(11) Rockwood K, Await E, Carver D, MacKnight C. Feasibility and measurement properties of
the functional reach and the timed up and go tests in the Canadian study of health and
aging. J Gerontol A Biol Sci Med Sci 2000; 55(2):M7C-M73.
(12) Shumway-Cook A, Woollacott M. Attentional demands and postural control: The effect of
sensory context. J Gerontol A Biol Sci Med Sci 2000; 55 A(I):M1C-M16.
(13) Shumway-Cook A, Brauer 5, Woollacott M. Predicting the probability for falls in
community-dwelling older adults using the Timed Up & Go Test. Phys Ther 2000;
80(9):896-903.
(14) Siggeirsdottir K, Jonsson B, Jonsson H, Iwarsson S. The timed ‘Up & Go’ is dependent on
chair type. Clinical Rehabilitation 2002; 16:609-616.
(15) Whitney SL, Poole JL, Cass SF. A review of balance instruments for older adults. Am J
Occup Ther 1998; 52(8):666-671.
(16) Wolf B, Feys H, DeWeerdt W, van der Meer J, Aufdemkampe G. Effect of a physical
therapeutic intervention for balance problems in the elderly: a single-blind, randomized,
controlled multicentre trial. Clinical Rehabilitation 2001; 15(6) :624-636.
RELIABILITY OF DYNAMIC GAIT INDEX, Wrisley
1529
Table 1: Dynamic Gait Index6
1. Gait Level Surface.
Instructions: Walk at your normal speed from here to the next mark (20⬘)
Grading: Mark the highest category which applies.
(3) Normal: Walks 20⬘; no assistive devices, good speed, no evidence for imbalance, normal gait pattern.
(2) Mild Impairment: Walks 20⬘; uses assistive device, slower speed, mild gait deviations.
(1) Moderate Impairment: Walks 20⬘; slow speed, abnormal gait pattern, evidence for imbalance.
(0) Severe Impairment: Cannot walk 20⬘ without assistance, severe gait deviations or imbalance.
2. Change in Gait Speed.
Instructions: Begin walking at your normal pace (for 5⬘), when I tell you “go,” walk as fast as you can (for 5⬘). When I tell you “slow,” walk as
slowly as you can (for 5⬘).
(3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds
between normal, fast, and slow speeds.
(2) Mild Impairment: Is able to change speed but demonstrates mild gait deviations or no gait deviations, but unable to achieve a significant
change in velocity, or uses an assistive device.
(1) Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations or
changes speed but loses balance but is able to recover and continue walking.
(0) Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught.
3. Gait with Horizontal Head Turns.
Instructions: Begin walking at your normal pace. When I tell you to “look right,” keep walking straight but turn your head to the right. Keep looking
right until I tell you “look left,” then keep walking straight but turn your head to the left. Keep your head to the left until I tell you, “look straight,”
then keep walking straight, but return your head to the center.
(3) Normal: Performs head turns smoothly with no change in gait.
(2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, ie, minor disruption to smooth gait path or uses walking
aid.
(1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.
(0) Severe Impairment: Performs task with severe disruption of gait, ie, staggers outside 15” path, loses balance, stops, reaches for wall.
4. Gait with Vertical Head Turns.
Instructions: Begin walking at your normal pace. When I tell you to “look up,” keep walking straight, but tip your head and look up. Keep looking up
until I tell you, “look down.” Then keep walking straight and turn your head down. Keep looking down until I tell you, “look straight,” then keep
walking straight, but return your head to the center.
(3) Normal: Performs head turns with no change in gait.
(2) Mild Impairment: Performs task with slight change in gait velocity, ie, minor disruption to smooth gait path or uses walking aid.
(1) Moderate Impairment: Performs task with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.
(0) Severe Impairment: Performs task with severe disruption of gait, ie, staggers outside 15” path, loses balance, stops, reaches for wall.
5. Gait and Pivot Turn
Instructions: Begin with walking at your normal pace. When I tell you, “turn and stop,” turn as quickly as you can to face the opposite direction and
stop.
(3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance.
(2) Mild Impairment: Pivot turns safely in ⬎3 seconds and stops with no loss of balance.
(1) Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop.
(0) Severe Impairment: Cannot turn safely, requires assistance to turn and stop.
6. Step over Obstacle.
Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep walking.
(3) Normal: Is able to step over box without changing gait speed; no evidence for imbalance.
(2) Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box safely.
(1) Moderate Impairment: Is able to step over box but must stop, then step over. May require verbal cueing.
(0) Severe Impairment: Cannot perform without assistance.
7. Step Around Obstacles.
Instructions: Begin walking at your normal speed. When you come to the first cone (about 6⬘ away), walk around the right side of it. When you
come to the second cone (6⬘ passed first cone), walk around it to the left.
(3) Normal: Is able to walk around cones safely without changing gait speed; no evidence of imbalance.
(2) Mild Impairment: Is able to step around both cones, but must slow down and adjust steps to clear cones.
(1) Moderate Impairment: Is able to clear cones but must significantly slow speed to accomplish task or requires verbal cueing.
(0) Severe Impairment: Unable to clear cones, walks into one or both cones, or requires physical assistance.
8. Steps
Instruction: Walk up these stairs as you would at home (ie, using the rail if necessary). At the top turn around and walk down.
(3) Normal: Alternating feet, no rail.
(2) Mild Impairment: Alternating feet, must use rail.
(1) Moderate Impairment: Two feet to a stair; must use rail.
(0) Severe Impairment: Cannot do safely.
Total Score
(Score ⱕ19/24 indicates increased risk of fall).
Reprinted with permission: Shumway-Cook A, Woollacott MH. Motor control: theory and practical applications. Baltimore: Williams & Wilkins;
1995. p 323– 4, tbl 14.2.6 http://www.lww.com
Arch Phys Med Rehabil Vol 84, October 2003
ўўўўўўўўўўўўўўўўўўўўўўўўўўў
Appendix.
Functional Gait Assessmenta
Requirements: A marked 6-m (20-ft) walkway that is marked with a 30.48-cm (12-in) width.
______1. GAIT LEVEL SURFACE
Instructions: Walk at your normal speed from here to the next mark (6 m
[20 ft]).
Grading: Mark the highest category that applies.
(3) Normal—Walks 6 m (20 ft) in less than 5.5 seconds, no assistive
devices, good speed, no evidence for imbalance, normal gait
pattern, deviates no more than 15.24 cm (6 in) outside of the
30.48-cm (12-in) walkway width.
(2) Mild impairment—Walks 6 m (20 ft) in less than 7 seconds but
greater than 5.5 seconds, uses assistive device, slower speed,
mild gait deviations, or deviates 15.24 –25.4 cm (6 –10 in)
outside of the 30.48-cm (12-in) walkway width.
(1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnormal gait pattern, evidence for imbalance, or deviates 25.4 –
38.1 cm (10 –15 in) outside of the 30.48-cm (12-in) walkway
width. Requires more than 7 seconds to ambulate 6 m (20 ft).
(0) Severe impairment—Cannot walk 6 m (20 ft) without assistance,
severe gait deviations or imbalance, deviates greater than 38.1
cm (15 in) outside of the 30.48-cm (12-in) walkway width or
reaches and touches the wall.
______2. CHANGE IN GAIT SPEED
Instructions: Begin walking at your normal pace (for 1.5 m [5 ft]). When
I tell you “go,” walk as fast as you can (for 1.5 m [5 ft]). When I tell you
“slow,” walk as slowly as you can (for 1.5 m [5 ft]).
(3) Normal—Able to smoothly change walking speed without loss of
balance or gait deviation. Shows a significant difference in
walking speeds between normal, fast, and slow speeds. Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm
(12-in) walkway width.
(2) Mild impairment—Is able to change speed but demonstrates
mild gait deviations, deviates 15.24 –25.4 cm (6 –10 in) outside
of the 30.48-cm (12-in) walkway width, or no gait deviations but
unable to achieve a significant change in velocity, or uses an
assistive device.
(1) Moderate impairment—Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant
gait deviations, deviates 25.4 –38.1 cm (10 –15 in) outside the
30.48-cm (12-in) walkway width, or changes speed but loses
balance but is able to recover and continue walking.
(0) Severe impairment—Cannot change speeds, deviates greater
than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width,
or loses balance and has to reach for wall or be caught.
_______3. GAIT WITH HORIZONTAL HEAD TURNS
Instructions: Walk from here to the next mark 6 m (20 ft) away. Begin
walking at your normal pace. Keep walking straight; after 3 steps, turn
your head to the right and keep walking straight while looking to the
right. After 3 more steps, turn your head to the left and keep walking
straight while looking left. Continue alternating looking right and left
every 3 steps until you have completed 2 repetitions in each direction.
(3) Normal—Performs head turns smoothly with no change in gait.
Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in)
walkway width.
(2) Mild impairment—Performs head turns smoothly with slight
change in gait velocity (eg, minor disruption to smooth gait
path), deviates 15.24 –25.4 cm (6 –10 in) outside 30.48-cm
(12-in) walkway width, or uses an assistive device.
(1) Moderate impairment—Performs head turns with moderate
change in gait velocity, slows down, deviates 25.4 –38.1 cm
(10 –15 in) outside 30.48-cm (12-in) walkway width but recovers, can continue to walk.
(0) Severe impairment—Performs task with severe disruption of gait
(eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway
width, loses balance, stops, or reaches for wall).
_______4. GAIT WITH VERTICAL HEAD TURNS
Instructions: Walk from here to the next mark (6 m [20 ft]). Begin walking
at your normal pace. Keep walking straight; after 3 steps, tip your head
up and keep walking straight while looking up. After 3 more steps, tip
your head down, keep walking straight while looking down. Continue
alternating looking up and down every 3 steps until you have completed
2 repetitions in each direction.
(3) Normal—Performs head turns with no change in gait. Deviates
no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway
width.
(2) Mild impairment—Performs task with slight change in gait
velocity (eg, minor disruption to smooth gait path), deviates
15.24 –25.4 cm (6 –10 in) outside 30.48-cm (12-in) walkway
width or uses assistive device.
(1) Moderate impairment—Performs task with moderate change in
gait velocity, slows down, deviates 25.4 –38.1 cm (10 –15 in)
outside 30.48-cm (12-in) walkway width but recovers, can
continue to walk.
(0) Severe impairment—Performs task with severe disruption of gait
(eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway
width, loses balance, stops, reaches for wall).
_______5. GAIT AND PIVOT TURN
Instructions: Begin with walking at your normal pace. When I tell you,
“turn and stop,” turn as quickly as you can to face the opposite direction
and stop.
(3) Normal—Pivot turns safely within 3 seconds and stops quickly
with no loss of balance.
(2) Mild impairment—Pivot turns safely in ⬎3 seconds and stops
with no loss of balance, or pivot turns safely within 3 seconds
and stops with mild imbalance, requires small steps to catch
balance.
(1) Moderate impairment—Turns slowly, requires verbal cueing, or
requires several small steps to catch balance following turn and
stop.
(0) Severe impairment—Cannot turn safely, requires assistance to
turn and stop.
_______6. STEP OVER OBSTACLE
Instructions: Begin walking at your normal speed. When you come to the
shoe box, step over it, not around it, and keep walking.
(3) Normal—Is able to step over 2 stacked shoe boxes taped
together (22.86 cm [9 in] total height) without changing gait
speed; no evidence of imbalance.
(2) Mild impairment—Is able to step over one shoe box (11.43 cm
[4.5 in] total height) without changing gait speed; no evidence
of imbalance.
(1) Moderate impairment—Is able to step over one shoe box (11.43
cm [4.5 in] total height) but must slow down and adjust steps to
clear box safely. May require verbal cueing.
(0) Severe impairment—Cannot perform without assistance.
(Continued)
Physical Therapy . Volume 84 . Number 10 . October 2004
Wrisley et al . 917
Appendix.
Continued
_______7. GAIT WITH NARROW BASE OF SUPPORT
Instructions: Walk on the floor with arms folded across the chest, feet
aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number
of steps taken in a straight line are counted for a maximum of 10 steps.
(3) Normal—Is able to ambulate for 10 steps heel to toe with no
staggering.
(2) Mild impairment—Ambulates 7–9 steps.
(1) Moderate impairment—Ambulates 4 –7 steps.
(0) Severe impairment—Ambulates less than 4 steps heel to toe or
cannot perform without assistance.
_______8. GAIT WITH EYES CLOSED
Instructions: Walk at your normal speed from here to the next mark (6 m
[20 ft]) with your eyes closed.
(3) Normal—Walks 6 m (20 ft), no assistive devices, good speed,
no evidence of imbalance, normal gait pattern, deviates no more
than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.
Ambulates 6 m (20 ft) in less than 7 seconds.
(2) Mild impairment—Walks 6 m (20 ft), uses assistive device,
slower speed, mild gait deviations, deviates 15.24 –25.4 cm
(6 –10 in) outside 30.48-cm (12-in) walkway width. Ambulates
6 m (20 ft) in less than 9 seconds but greater than 7 seconds.
(1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnormal gait pattern, evidence for imbalance, deviates 25.4 –38.1
cm (10 –15 in) outside 30.48-cm (12-in) walkway width.
Requires more than 9 seconds to ambulate 6 m (20 ft).
cm (15 in) outside 30.48-cm (12-in) walkway width or will not
attempt task.
a
______9. AMBULATING BACKWARDS
Instructions: Walk backwards until I tell you to stop.
(3) Normal—Walks 6 m (20 ft), no assistive devices, good speed,
no evidence for imbalance, normal gait pattern, deviates no
more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway
width.
(2) Mild impairment—Walks 6 m (20 ft), uses assistive device,
slower speed, mild gait deviations, deviates 15.24 –25.4 cm
(6 –10 in) outside 30.48-cm (12-in) walkway width.
(1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnormal gait pattern, evidence for imbalance, deviates 25.4 –38.1
cm (10 –15 in) outside 30.48-cm (12-in) walkway width.
cm (15 in) outside 30.48-cm (12-in) walkway width or will not
attempt task.
________10. STEPS
Instructions: Walk up these stairs as you would at home (ie, using the rail
if necessary). At the top turn around and walk down.
(3) Normal—Alternating feet, no rail.
(2) Mild impairment—Alternating feet, must use rail.
(1) Moderate impairment—Two feet to a stair; must use rail.
(0) Severe impairment—Cannot do safely.
TOTAL SCORE: ______ MAXIMUM SCORE 30
Adapted from Dynamic Gait Index.1 Modified and reprinted with permission of authors and Lippincott Williams & Wilkins (http://lww.com).
918 . Wrisley et al
Physical Therapy . Volume 84 . Number 10 . October 2004

What Is Cervicogenic Dizziness?

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