What Is Cervicogenic Dizziness?
Transcription
What Is Cervicogenic Dizziness?
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 VPTA 2012 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” Dizziness, Imbalance, and the 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) Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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) Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 1 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. Dizziness, Imbalance, and the Cervical Spine VPTA 2012 2 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. Dizziness, Imbalance, and the Cervical Spine VPTA 2012 3 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 4 Otoliths Anatomy of Otoliths Furman JM and Cass SP. Vestibular Disorders: A Case Study Approach. Oxford University Press, Oxford 2003:7 Otoconia Dizziness, Imbalance, and the Cervical Spine VPTA 2012 5 Otoliths: Haircells and Otoconia Otoliths Dizziness, Imbalance, and the Cervical Spine VPTA 2012 6 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) Dizziness, Imbalance, and the Cervical Spine VPTA 2012 7 Vestibular Ocular Reflex Vestibular Ocular Reflex Young PA, Young PH. Basic Clinical Neuroanatomy. Williams and Wilkins, Baltimore, MD. 1997:121. Dizziness, Imbalance, and the Cervical Spine VPTA 2012 8 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 9 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) Dizziness, Imbalance, and the Cervical Spine VPTA 2012 10 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) Dizziness, Imbalance, and the Cervical Spine VPTA 2012 11 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 12 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? Dizziness, Imbalance, and the Cervical Spine VPTA 2012 13 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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? Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 Iglarsh. Clinical Orthopedic Physical Therapy. WB Saunders, Philadelphia,PA 1994, p15) 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 Vertebral body rotation (From Richardson and Iglarsh. Clinical Orthopedic Physical Therapy. WB Saunders, Philadelphia,PA 1994, p16) 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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? Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance, and the Cervical Spine VPTA 2012 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 VPTA 2012 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) Dizziness, Imbalance and the Cervical Spine VPTA 2012 Symptom Duration How long do symptoms last? Cervicogenic dizziness Minutes to hours BPPV < 60 seconds VBI Persists as long as position maintained Symptom Frequency Cervicogenic dizziness 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 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 •13 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) •14 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 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) Dizziness, Imbalance and the Cervical Spine VPTA 2012 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 Tests/Measures: Cervical Spine Active range of motion Nodding Flexion, Extension Rotation Sidebending Non-functional: head rotates contralaterally Functional: head follows neck Dizziness, Imbalance and the Cervical Spine VPTA 2012 Tests/Measures: Cervical Spine 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) Dizziness, Imbalance and the Cervical Spine VPTA 2012 Tests/Measures: Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 Tests/Measures: Cervical Spine Strength Deep cervical flexors Longus colli Longus capitis Craniocervical flexion test (CCF) (Jull, 1997; Falla et al., 2003) Motor control vs. strength Dizziness, Imbalance and the Cervical Spine VPTA 2012 Tests/Measures: Cervical Spine Flexibility/Palpation (Wrisley et al., 2000) Upper trapezius Sternocleidomastoid Sub-occipital muscles Any tenderness, pain, fullness, or reproduction of symptoms? X X X Tests/Measures: Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 Dizziness, Imbalance and the Cervical Spine VPTA 2012 C2 Tests/Measures: Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 Dizziness, Imbalance and the Cervical Spine 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? Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 5 Subjective Assessment of Dizziness 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 Subjective Assessment of Dizziness 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 Subjective Assessment of Dizziness 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 6 Subjective Assessment of Dizziness 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 Ocular Motor Function 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 http://library.med.utah.edu/neurologicex am/movies/cranialnerve_n_10_x2.mov Abnormal smooth pursuit and saccades http://library.med.utah.edu/neurologicex am/movies/cranialnerve_ab_11_x2.mov Dizziness, Imbalance and the Cervical Spine VPTA 2012 7 Saccadic Disorder Ocular Motor Function 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 Ocular Motor Function 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 Dizziness, Imbalance and the Cervical Spine 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 9 Clinical Measures of Vestibular Function Eye Head Coordination Testing 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 Clinical Measures of Vestibular Function Eye Head Coordination Testing 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 Clinical Measures of Vestibular Function Eye Head Coordination Testing 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 Dizziness, Imbalance and the Cervical Spine 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 Clinical Vestibular Evaluation 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? Clinical Vestibular Evaluation Functional and Balance Assessment 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 Dizziness, Imbalance and the Cervical Spine VPTA 2012 11 Clinical Vestibular Evaluation Functional and Balance Assessment 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 Dizziness, Imbalance, and the Cervical Spine 2007 Dr. D. M. Wrisley Dizziness, Imbalance, and the Cervical Spine 2007 Dr. D. M. Wrisley Dizziness, Imbalance and the Cervical Spine VPTA 2012 12 Clinical Vestibular Evaluation Functional and Balance Assessment 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? Dizziness, Imbalance and the Cervical Spine 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 de pe nd en t Un co no m f ch or an tab ge le De in , ab no crea ili s ty of cha ed a pe nge bi rfo in lity rm m , Sl a a o m wer nce nner or , c e c au are tio fu us, Pr l efe ob r u jec si t f ng or an he M lp us t fo us rh e elp an ob jec M t us eq t us ui e pm sp en eci t al Ne ed as p sis hy tan sic ce al De pe nd en t To od lo if ng fic er ul pe t, n rfo o rm 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. Stand on a 3 inch high density foam cushion with your arms crossed and touching your 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: Stand on a 3 inch high density foam cushion with your arms crossed and touching your 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⬘). Grading: Mark the highest category which applies. (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. Grading: Mark the highest category which applies. (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. Grading: Mark the highest category which applies. (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. Grading: Mark the highest category which applies. (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. Grading: Mark the highest category which applies. (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. Grading: Mark the highest category which applies. (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. Grading: Mark the highest category which applies. (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]). Grading: Mark the highest category that applies. (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. Grading: Mark the highest category that applies. (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. Grading: Mark the highest category that applies. (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. Grading: Mark the highest category that applies. (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. Grading: Mark the highest category that applies. (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. Grading: Mark the highest category that applies. (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. Grading: Mark the highest category that applies. (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). (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 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. Grading: Mark the highest category that applies. (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. (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 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. Grading: Mark the highest category that applies. (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