The sensory mismatch associated with dizziness or spinning, may require stimulation and rehabilitation of sensory systems other than the vestibular system. This observation may explain why standard approaches to vestibular rehabilitation sometimes fail.

Diagnostic procedures include a thorough Neurological evaluation including Video Electronystagmography.

Vertigo Programs
-Fifteen (15) sessions of Advanced Oculomotor (Eye) and Vestibular (Balance) training.

Treatment

Treatment for vertigo depends on identifying and eliminating the underlying cause. If a particular medication is responsible for the condition, lowering the dosage or discontinuing the drug may eliminate vertigo.

Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy (VRT) is a type of physical therapy used to treat vertigo. The goal of treatment is to minimize vertigo, improve balance, and prevent falls by restoring normal function of the vestibular system.

In VRT, the patient performs exercises designed to allow the brain to adapt to and compensate for whatever is causing the vertigo. The success of this treatment depends on several factors including the following:

• Age of the patient
• Cognitive function (e.g., memory, ability to follow directions in order)
• Coordination and motor skills
• Overall health of the patient (including the central nervous system)
• Physical strength

Vestibular rehabilitation therapy is designed by a physical therapist under the direction of a physician. In most cases, patients visit the therapist on a limited basis and perform custom-designed exercises at home, several times a day. As the patient progresses, difficulty of the exercises increases until the highest level of balance is attained during head movement, eye movement (i.e., tracking with the eyes), and walking.

Causes

Vertigo usually results from a disorder in the peripheral vestibular system (i.e., structures of the inner ear). It also may occur as a result of a disorder in the central vestibular system (i.e., vestibular nerve, brainstem, and cerebellum). In some cases, the cause of vertigo is unknown.

Peripheral vestibular disorders include the following:

• Benign paroxysmal positional vertigo (BPPV; most common peripheral disorder; may be accompanied by hearing loss, reduced cognitive function, and facial muscle weakness)
• Ménière disease (fluctuating pressure of inner ear fluid [endolymph]; results in severe vertigo, ringing in the ears [tinnitus], and progressive hearing loss)
• Ototoxicity (i.e., ear poisoning)
• Vestibular neuritis (inflammation of vestibular nerve cells; may be caused by viral infection)

Benign paroxysmal positional vertigo occurs when debris made up of calcium carbonate and protein (called otoliths or ear crystals) builds up in and damages the inner ear. Inner ear degeneration (usually occurs in elderly patients), head trauma, and inner ear infection (e.g., otitis media, labyrinthitis) can cause BPPV.

Some medications and environmental chemicals (e.g., lead, mercury, tin) can cause ototoxicity (i.e., ear poisoning), which may result in damage to the inner ear or the 8th cranial nerve (acoustic nerve) and cause vertigo. The damage can be permanent or temporary.

Long-term use or high doses of certain antibiotics (e.g., aminoglycosides [streptomycin, gentamicin]) and antineoplastics (e.g., cisplatin, carboplatin) can cause permanent ototoxicity.

Medications that may cause temporary ototoxicity include the following:

• Anticonvulsants (e.g., phenytoin, carbamazepine)
• Antidepressants (e.g., clomipramine, amoxapine)
• Antihypertensives (e.g., labetalol, enalapril)
• Loop diuretics (e.g., bumetanide, furosemide)
• Pain relievers (e.g., aspirin)
• Prescription and over-the-counter cold medicines
• Quinine (e.g., chloroquine, quinidine)

Alcohol, even in small amounts, can cause temporary vertigo in some people.

Central vestibular disorders that may cause vertigo include the following:

• Cardiovascular disorders (e.g., bradycardia [slowed heart rate], tachycardia [rapid heart rate])
• Central nervous system (CNS) disorders (e.g., stroke, brain hemorrhage)
• Head trauma
• Migraine (30–50% of patients experience vertigo)
• Multiple sclerosis (MS; may occur when demyelination affects the brainstem or cerebellum)
• Orthostatic hypotension (sharp decrease in blood pressure upon rising from a lying or sitting position to a standing position; caused by diabetes, dehydration, and anemia)
• Systemic diseases (e.g., kidney disease, thyroid disorders)
• Tumors that affect the central vestibular system (e.g., acoustic neuroma)

Overview

Diagnosis

It is important to diagnose the cause of vertigo as quickly as possible to rule out serious conditions such as cardiovascular disease, stroke, hemorrhage, or tumor. Diagnosis includes clinical history, physical and neurological examination, blood tests, and imaging tests (e.g., CT scan, MRI scan).

Important considerations include the following:

• What triggers the vertigo?
• What other symptoms occur?
• How long do they last?
• What improves or worsens symptoms?

Physical examination includes measuring blood pressure and heart rate . Neurological examination includes testing facial and vestibular nerves and muscles, strength, coordination, balance, and walking (gait).

The positional vertigo test is used to help distinguish peripheral from central vestibular disorders. In this test, the patient sits on a table with the head turned to the side. The physician then supports the head and lowers it gently below the table while the patient lies back. The patient reports symptoms of vertigo while the physician looks for circular movement of the eyes (called nystagmus).

A delay between the onset of nystagmus and the sensation of vertigo usually indicates a peripheral vestibular disorder. Lack of a delay may indicate a central vestibular disorder. The test is repeated with the head turned in the opposite direction.

Electronystagmography (ENG) is a neurological test used to evaluate the vestibular system. It involves testing hearing in both ears (audiometry tests), testing eye movements, and evaluating responses to changes in posture and position.

Blood tests include a complete blood count (CBC) and kidney and thyroid panels to rule out systemic diseases (e.g., kidney disease, hypothyroidism). If the patient is taking medication, drug levels are obtained.

Imaging tests may be used to detect brain abnormalities (e.g., stroke, tumor). Computed tomography (CT scan) produces x-ray images of the brain and magnetic resonance imaging (MRI) uses a magnetic field to produce detailed images of brain tissue and arteries in the neck and brain.

Signs and Symptoms

Vertigo refers to the sensation of spinning (subjective vertigo) or the perception that surrounding objects are moving or spinning (objective vertigo). Some patients describe a feeling of being pulled toward the floor or toward one side of the room. Moving the head, changing position, and turning while lying down often worsen vertigo.

The sudden onset of vertigo usually indicates a peripheral vestibular disorder (e.g., BPPV, Ménière disease, vestibular neuritis).

Symptoms of benign paroxysmal positional vertigo (BPPV) usually last a few seconds to a few minutes and are intermittent (i.e., come and go). They also may include lightheadedness, imbalance, and nausea, usually as a result of a change in position (e.g., rolling over in bed, getting out of bed).

Symptoms of Ménière disease and vestibular neuritis include vertigo, hearing loss, ringing in the ears (tinnitus), and ear pressure that often lasts hours to days.

Peripheral vestibular disorders also may cause the following symptoms:

• Blurred vision
• Fatigue and reduced stamina
• Headache
• Heart palpitations (rapid fluttering of the heart)
• Imbalance
• Inability to concentrate
• Increased risk for motion sickness
• Muscle ache (especially of the neck and back)
• Nausea and vomiting
• Reduced cognitive function (i.e., thinking and memory)
• Sensitivity to bright lights and noise
• Sweating

Vertigo caused by a central vestibular disorder usually develops gradually. In addition to vertigo, central vestibular disorders (e.g., stroke, migraine) may cause the following symptoms:

• Double vision (diplopia)
• Headache (may be severe)
• Impaired consciousness
• Inability to speak due to muscle impairment (dysarthria)
• Lack of coordination
• Nausea and vomiting
• Weakness

Complications

Severe vertigo can be disabling and may result in complications such as irritability, loss of self-esteem, depression, and injuries from falls. Falls are the leading cause of serious injury in people over the age of 65.

 What is a Neurological Exam?

The human nervous system is an intricate and complex network of fibers that impenetrates the entire body and functions in complicated and often mysterious ways. Sophisticated imaging and laboratory tests do not always provide sufficient information about how the nerves are functioning -- or not functioning, as the case may be. The neurological examination is a series of simple questions and tests that provide crucial information about the nervous system. It is an inexpensive, noninvasive way to determine what might be wrong.

The neurological examination is divided into several components, each focusing on a different part of the nervous system:

• mental status
• cranial nerves
• motor system
• sensory system
• the deep tendon reflexes
• coordination and the cerebellum
• gait

The exam requires skill, patience, and intelligence on the part of the physician, and cooperation from the patient. Incomplete or inaccurate exams can lead to incorrect diagnoses.

Mental status
The mental status examination is a series of detailed but simple questions designed to test cognitive ability, including the patient's:

• state of consciousness (awareness and responsiveness to the environment and the senses);
• appearance and general behavior;
• mood;
• content of thought; and
• intellectual resources (orientation with reference to time, place, and person; comprehension; ability to pay attention; insight; memory; judgment; abstract reasoning power; speech and language function; and intellectual capacity).

The patient may be asked to remember objects that had been listed earlier in the course of the exam; repeat sentences; solve simple mathematical problems; copy a three-dimensional drawing; and draw a clock and place the numbers and hands appropriately. When speech and language are tested, the examiner listens to the character of the speech, the fluency (smoothness of speech), and the patient’s ability to understand and carry out simple or complex commands, and to read and write.

In addition to specific questions that make up the actual mental status exam, the neurologist obtains important information by observing the patient’s general behavior during the examination.

Many neurological diseases, such as dementia, cause changes in intellectual status or emotional responsiveness, and specific personality features. These changes and features can be detected during the mental status portion of the neurological exam.

The mental status exam is especially important when the other parts of the neurological exam reveal no abnormalities. Sometimes, slight changes in memory or other intellectual resources may be the only indication that something is wrong. Evaluating a person’s intellectual capacity can also be helpful in determining a course of treatment and making a prognosis.

Cranial nerves
The cranial nerves are a set of 12 nerves that relay messages between the brain and the head and neck and control motor and sensory functions, including vision, smell, and movement of the tongue and vocal cords.

The cranial nerve exam involves testing the function of all 12 sets of cranial nerves. It is an essential part of the neurological exam, and helps localize central nervous system dysfunction and aids in diagnosing systemic disease. Some of the functions that are commonly tested as part of the cranial nerve exam include: eyelid strength and function; visual function; peripheral vision; pupillary light reflexes; eye muscle movements; strength of facial musculature; the gag reflex; tongue and lip movements; ability to smell and taste; hearing; and sensation in the face, head, and neck.

Motor system
The motor system includes the brain and spinal cord motor pathways, and all the motor nerves and muscles throughout the body. Abnormalities in the motor system can often be detected by assessing muscle strength and tone and by looking for a variety of characteristic signs.

The patient is usually asked to undress, so the neurologist can see the muscles and look for atrophy (shrinkage), twitching, or abnormal movements. Tests are done to evaluate strength in all the major muscle groups.

Evaluating Babinski response is an important part of testing the motor system. The neurologist strokes or scratches, heel-to-toe, the outer side of the sole of the foot and in patients over the age of 2, the toes normally curl downward in response. If the toes fan upward, a brain or spinal cord injury is indicated. A number of neurological disorders can lead to Babinski response.

Sensory system
Sensation depends on impulses that occur as a result of stimulation of receptors located in the skin, muscles, tendons, and so on, and are sent along nerve fibers to the central nervous system (brain and spinal cord). The sensory exam is used to determine areas of abnormal sensation, the quality and type of sensation impairment, and the degree and extent of tissue involvement.

A sensory exam involves evaluating different types of sensation, including pain, temperature, pressure, and position. For example, pinpricks may be used to test the patient's response to pain and compare the response in different parts or opposite sides of the body. A cold or warm object may be used to test the sensation of temperature. To test position, patients may be asked to close their eyes and determine in which direction the examiner is moving a part of their body (e.g., big toe). Patients also may be asked to identify objects with their eyes closed or identify numbers or letters traced on their body.

The sensory exam should be repeated to provide accurate results. Responses may be affected by how alert, aware, and well-rested the patient is, so this part of the neurological exam is usually performed early in the course of testing.

Deep tendon reflexes
Reflexes are actions performed involuntarily in response to impulses sent to the central nervous system. Alterations in reflexes are often the first sign of neurological dysfunction. Observing reflexes is the most objective part of the neurological exam, since the reflexes are not under voluntary control and testing does not depend on the patient’s cooperation, attitude, or awareness.

Hundreds of reflexes have been identified, but the neurological exam generally involves testing only the deep tendon reflexes. Deep tendon reflexes, also known as muscle stretch reflexes, are reflexes elicited in response to stimuli to tendons. Normally, when a specific area of the muscle tendon is tapped with a soft rubber hammer, the muscle fibers contract. Abnormal responses may indicate injury to the nervous system pathways that produce the deep tendon reflex.

Coordination and the cerebellum
The cerebellum is the part of the brain that controls voluntary movement and motor coordination, including posture. Testing coordination provides clues about conditions that affect the cerebellum.

The neurologist may ask patients to move their finger from their nose to the neurologist’s finger, going back and forth from nose to finger, touching the tip of each. Patients also may be asked to tap their fingers together quickly in a coordinated fashion or move their hands one on top of the other, back and forth, as smoothly as they can. Coordination in the lower limbs can be tested by asking patients to rub one heel up and down smoothly over the other shin.

Gait
Most of us take our ability to walk for granted. But as simple as it may seem, walking is a very intricate physiological process. How we walk – our gait - is influenced by a number of bodily mechanisms and nervous system reflexes. The body must be held erect; the limbs, head, and trunk must be held in the right position; the person must be oriented to the position of all body parts; parts of motor control involved with moving must be integrated; and so on. Because walking depends on so many different parts of the nervous system, it can be affected by a variety of neurological disorders.

By observing gait, the neurologist can gather important clues about what might be wrong. The patient is usually asked to walk in different ways (e.g., heel-to-toe in a straight line, turning abruptly, walking on the toes, walking on the heels, running).

References
Haerer, A.F., 1992, The Neurological Exam, J.B. Lippincott Co.,(Courtesy of the Neurology Channel)