balance & dizziness

Question 1

dizziness medications

Answer 1

-Beta blockers
-Ace inhibitors
-Anticonvulsants (Gabapentin, Pregablin)
-Anti-depressants (Fluoxetine, Sertaline)

Question 2

BPPV test–> dix-hallpike manoevre

Answer 2

-Patient is sat upright
-Rotate their head to 45 degrees (challenges vestibular nerve)
-Push them back into plinth and extend their head 20-30 degrees extension
-Watch their eyes for around 30 seconds (signs of nystagmus= a positive sign)
-Must be tested bilaterally

Question 3

epley manoeuvre (BPPV treatment)

Answer 3

-Patient is sat upright
-Rotate their head to 90 degrees (challenges vestibular nerve)
-Push them back into plinth and extend their head 20-30 degrees extension
-Keep head down for 60-90 seconds
-Patient moves to sidelying for around 90 seconds

Question 4

dizziness assessment

Answer 4

-Observe eyes (for random uncontrolled movements), ears (for discharge, superficial obstruction), periphery (for signs of UMNL)
-Perform full neuro exam (consider cranial nerve 7/8) H test – Observe cranial nerve function but also observe for nystagmus)
-Perform a CV exam ((BP + full exam)
-Examine gait & coordination

Question 5

gait and stance

Answer 5

reliant upon many factors: Vision, Sensation, Proprioception, Motor output.
-Unsteadiness on standing with the eyes open is common in cerebellar disorders – Cerebellar Ataxia
-Cerebellar dysfunction leads to a broad-based, unsteady (ataxic) gait, which usually makes tandem walking (walking heel to toe in a straight line) impossible.
-Instability which only occurs, or is markedly worse, on eye closure is indicative of proprioceptive sensory loss, referred to as Sensory Ataxia
-Hemiplegic gait, due to a unilateral upper motor neuron lesion, is characterized by leg extension at the knee and ankle and circumduction at the hip, such that the plantar flexed foot describes a semicircle as the patient walks.
-Bilateral upper motor neuron damage causes a scissor-like gait due to spasticity (Spasticity – incr muscle tone & spasm)

Question 6

ataxia

Answer 6

= a term for a group of disorders that affect co-ordination, balance and speech. Any part of the body can be affected, but people with ataxia often have difficulties with balance and walking. speaking. swallowing
Characterised by:
-Loss of coordination
-Abnormal eye movements
-Slurred speech/ dysarthria
-Impairment of fine motor skills
-Dysphagia
-Impaired gait

Question 7

cerebellar ataxia

Answer 7

= Disruption of the cerebellum, cerebrum and brainstem’s ability to work together.
-the cerebrum initiates and coordinates movement and regulates temperature. Other areas of the cerebrum enable speech, judgment, thinking and reasoning, problem-solving, emotions and learning. Other functions relate to vision, hearing, touch and other senses
-Your brainstem helps regulate some body functions, including your breathing and heart rate. The brainstem also controls your balance, coordination and reflexes.
-The cerebellum controls voluntary movements such as: walking, posture, balance, coordination, eye movements, speech.
Symptoms–> dizziness, fatigue, headaches, tremors, dysarthria, gait impairment
Causes–> alcohol, hypothyroidism, infection, head trauma, SOLs, cerebral palsy

Question 8

sensory ataxia

Answer 8

= Impairment to the spinal cord/peripheral nerves- leading to an inability to receive efficient feedback from the periphery.
-loss of sensory input to the brain due to the involvement of the peripheral nerve and/or the posterior column of the spinal cord, the patients need to constantly look at their feet to know their location in space, leading to difficulty walking in the dark or imbalance when eyes are closed (Romberg’s sign) as well as difficulties with fine finger movements.
Symptoms–> finger-nose difficulty, loss of vibration sense, trouble walking without sight of the limb, heavy steps. In hands: pseudo-athetosis: the finger will not remain outstretched when the patient closes his eyes, clumsy finger movements, difficulty in recognising objects by touch, loss of touch and proprioception in the fingers. In the legs: Rombergism, the patient watches his legs when walking, loss of touch and proprioception in the feet and toes
Causes–> peripheral neuropathy, M.S, B12 deficiency, cervical myelopathy.

Question 9

vestibular ataxia

Answer 9

= Disruption to sense of balance resulting in difficulty with coordinating movement.
Symptoms–> Visual impairment, nausea, vomiting, difficulty standing, vertigo, staggering during gait
Causes–> vestibular neuritis, inner ear infections

Question 10

coordination assessment

Answer 10

-Romberg’s sign / Pronator drift
-Finger-nose test
-Heel/shin test
-Dysdiadochokinesis