Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Labyrinthitis, vestibular Download Section PDF Listen +++ ICD-9-CM Codes ++ 386.3 Labyrinthitis386.30 Labyrinthitis unspecified386.31 Serous labyrinthitis386.32 Circumscribed labyrinthitis386.33 Suppurative labyrinthitis386.34 Toxic labyrinthitis386.35 Viral labyrinthitis386.53 Hypoactive labyrinth, unilateral +++ ICD-10-CM Codes ++ H83.09 Labyrinthitis, unspecified earH83.2X1 Labyrinthine dysfunction, right earH83.2X2 Labyrinthine dysfunction, left earH83.2X3 Labyrinthine dysfunction, bilateralH83.2X9 Labyrinthine dysfunction, unspecified ear +++ Preferred Practice Patterns1 ++ Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and FallingPattern 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury +++ Key Features +++ Description ++ Disorder of the peripheral vestibular and auditory systems (inner ear)These systems consist of a complex series of interconnected tubes that are fluid filled (fluid called endolymph) and form a labyrinth. The peripheral vestibular sensory organs of each ear detect head position and head motion to provide input for gaze stability, orientation, and balance.The peripheral auditory sensory organs of each ear convert sound vibration into a neural impulse to provide input for hearing.Each system sends its respective sensory information, via the vestibulocochlear nerve (eighth cranial nerve), to the central nervous system for processing.Reduction or loss of function of one of the labyrinths due to an infection, which causes an imbalance of neural activity between the two inner earsResults in a spontaneous, severe attack of rotary vertigo (illusion of spinning motion of the room or self) that lasts from 48 to 72 hours as well as sudden hearing loss that can be permanent +++ Essentials of Diagnosis ++ Physical exam normalAudiogram abnormal Neurotologic exam abnormalThorough and detailed history is essential to distinguish vestibular labyrinthitis from other vestibular disorders and central pathology. +++ General Considerations ++ Similar in presentation to vestibular neuritis, however with labyrinthitis, patients also have hearing loss and/or tinnitus (ringing or noises in the ear), which can be permanentInitially, patients report persistent, severe feeling of rotary vertigo that occurs spontaneously but worsens with head movement.Patients complain of nausea and vomiting, difficulty standing and walking without assistance, and blurred vision due to oscillopsia (apparent movement of the environment).Initial symptoms improve over a period of a few days.After initial episode, patients typically continue to present with a general feeling of dizziness (disorientation, wooziness, off balance, etc.) and imbalance that mostly occurs with quick head movements and may continue to have difficulty reading.This phase may manifest for up to 6 weeks or longer, until recovery and compensation occur. +++ Demographics ++ More likely to occur after trauma or middle ear infections +++ Clinical Findings +++ Signs and Symptoms ++ Acute presentation: Report of persistent, prolonged episode of severe rotary vertigo, nausea and vomiting, unsteadiness, and/or jumping, bouncing visionImbalance manifested by inability to stand and walk without assistance.Increased risk of fallingSudden hearing loss and audiological exam abnormalObserve nystagmus in room light and with fixation removedAbnormal neurotologic exam (impulse test, headshake test, dynamic visual acuity test, caloric test, vestibular evoked myogenic potentials [VEMP] test, and/or subjective visual vertical [SVV test]) No central signs (diplopia, dysarthria, dysphagia, dysmetria, numbness or weakness)Chronic, or uncompensated presentation Report of general feelings of dizziness, unsteadiness, and/or jumping, bouncing visionPostural and gait instability when sensory input challengedMay have continued increased risk of fallingMay have continued nystagmus with fixation removedMay have continued abnormal neurotologic exam (impulse test, headshake test, dynamic visual acuity test caloric test, VEMP test, and/or SVV test) Hearing loss can be permanent +++ Functional Implications ++ Difficulty moving head quickly (turning, bending over, looking up) because of provoking symptoms Impedes balance and contributes to fallsDifficulty identifying objects in environment and readingReduced or lost ability to perform tasks in home, at work, and/or driving +++ Possible Contributing Causes ++ Generally, due to viral infections (measles, mumps, cytomegalovirus seen in the immune-compromised, and virus that causes Ramsay Hunt syndrome).Also, can be due to bacterial toxins (otitis media, suppuration, meningitis, neurosyphilis, Lyme disease). +++ Differential Diagnosis ++ Endolymphatic hydrops (Meniere’s disease)Multiple sclerosisAcoustic neuroma (vestibular schwannoma)Other posterior fossa tumorsBenign paroxysmal positional vertigoMigraineBrainstem stroke or transient ischemic attack (TIA)Superior canal dehiscencePerilymphatic fistulaBilateral vestibulopathyVestibular neuritisThyroid disease +++ Means of Confirmation or Diagnosis +++ Diagnostic Procedures ++ Imaging testsMRI or CT scan of brain, including posterior fossa and internal auditory canalsSpecial testsElectronystagmography (ENG) or videonystagmography (VNG)Rotational chairVEMPStatic and dynamic SVVAudiogramLaboratory testing +++ Referrals/Admittance ++ For suspected acute stroke or sudden hearing loss: emergency departmentFor disease management: neurologist, otolaryngologist (ear, nose, and throat doctor [ENT]) or neurotologist For rehabilitation: vestibular-trained PT or occupational therapist +++ Impairments ++ Perceived orientation (dizziness and vertigo)Postural controlGaze instability +++ Tests and Measures ++ Oculomotor exam: Non-vestibular: ocular motility, pursuit, saccades, optokinetic nystagmus testing (OKN), vergenceVestibularIn room light: spontaneous and gaze-holding nystagmus, head impulse test, dynamic visual acuityFixation removed: spontaneous and gaze-holding nystagmus, head shake, pressure-induced nystagmus, hyperventilation-induced nystagmusRinne and Weber testsVertebrobasilar insufficiency testingCervical spine special tests (Sharpe-Purser, alar ligament)Positioning tests: Dix-Hallpike maneuver, roll test, and sidelying testCoordinationCranial nerve integritySensationROM, including neckStrengthEndurancePostural alignment Postural control and balance GaitSymptom intensity rating (visual or verbal analog scale, UCLA dizziness questionnaire, motion sensitivity quotient)Perceived disability (dizziness handicap inventory, vestibular rehabilitation benefits questionnaire) +++ Intervention ++ Medical management: Depending on if viral or bacterial cause, immediate administration of corticosteroids (methylprednisolone) or antibiotics may improve the rate and extent of recovery.If viral agent is the cause, sometimes anti-virals are also prescribed.Vestibular suppressants and anti-emetic medications may be prescribed in the acute phase to help reduce the severe symptoms. Only indicated for short term use because can impair vestibular compensation.Bed rest is needed when symptoms are severe. Once severe symptoms subside, vestibular and balance rehabilitation is used to promote central nervous system compensation, which reduces dizziness, gaze instability and imbalance:Vestibular-ocular reflex (VOR) function exercises Habituation exercisesPostural control and balance trainingGait training +++ Functional Goals ++ The patient will:Report reduced frequency and intensity of dizziness (wooziness, lightheadedness, etc) during head movements for home- and work-related tasksDemonstrate normal standing and walking balance for home- and work-related tasks.Have decreased risk of falling when standing and walkingHave less than 2 lines difference with dynamic visual acuity testing making it possible to read, watch TV, and identify objects in the environment while walking. +++ Prognosis ++ In otherwise healthy individuals, reduction of dizziness, gaze instability, and imbalance and return to normal activities can be expected, especially for those that get adequate physical activity. For patients whose symptoms do not improve, vestibular and balance exercises may help promote recovery and compensation. Hearing may improve or recover in some patients, especially if receive immediate medical treatment. +++ References ++1. The American Physical Therapy Association. Interactive Guide to Physical Therapist Practice. Alexandria, VA: The American Physical Therapy Association; 2003. http://guidetoptpractice.apta.org/. Accessed July 20, 2012. +++ Resources ++Aw ST, Halmagyi GM, Curthoys IS, et al. Unilateral vestibular deafferentation causes permanent impairment of the human vertical vestibulo-ocular reflex in the pitch plane. Exp Brain Res. 1994;102:121-30. [PubMed: 7895788] ++Beasley NJ, Jones NS. Menière's disease: evolution of a definition. J Laryngol Otol. 1996;110(12):1107-13. [PubMed: 9015421] ++Dutton M. McGraw-Hill's NPTE (National Physical Therapy Examination). New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/56505184. Accessed December 19, 2012. ++Hain, TC, Fetter M, Zee DS. Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol. 1987;8:36-47. [PubMed: 3578675] ++Fetter M. Chapter 6: Vestibular System Disorders. In: Herdman SJ, editor. Vestibular Rehabilitation. 2nd ed. Philadelphia: F.A. Davis Company; 2000:98-107. ++Furman JM, et al. Vestibular disorders: a case study approach. Oxford, UK: Oxford University Press; 2003. ++Gianoli GJ. Chapter 19. DDX: Fixed Vestibular Deficits. In: Goebel JA, ed. Practical Management of the Dizzy Patient. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. ++Hay WW, Levin MJ, Sondheimer JM, Deterding RR, eds. CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/resource/14. Accessed March 14, 2012. ++Haybach PJ, Underwood J. Meniere's Disease: What You Need to Know. Portland, OR: Vestibular Disorders Association. 1998. ++Honrubia V. Quantitative evaluation of dizziness characteristics and impact of quality of life. Am J of Otology. 1996; 17(4):595-602. [PubMed: 8841705] ++ICD9Data.com. http://www.icd9data.com/2012/Volume1/default.htm. Accessed March 3, 2012. ++ICD10Data.com. http://www.icd10data.com/ICD10CM/Codes. Accessed March 3, 2012. ++Lempert T, Neuhauser H. Epidemiology of vertigo, migraine and vestibular migraine. J Neurol. 2008;256(3):333-8. doi: 10.1007/s00415-009-0149-2. [PubMed: 19225823] ++Waxman SG, ed. Clinical Neuroanatomy. 26th ed. New York, NY: McGraw-Hill; 2010. http://www.accessphysiotherapy.com/resource/22. Accessed December 5, 2011. + Legg-Calvé-Perthes disease Download Section PDF Listen +++ Condition/Disorder Synonyms ++ Juvenile osteochondrosis of hip and pelvis +++ ICD-9-CM Code ++ 732.1 Juvenile osteochondrosis of hip and pelvis +++ ICD-10-CM Code ++ M91.1 Juvenile osteochondrosis of head of femur +++ Preferred Practice Pattern ++ 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery1 +++ Key Features +++ Description ++ Impairment of blood flow to the hip resulting in destructive changesSelf-limiting disease of the hip +++ Essentials of Diagnosis ++ Age of onset or detection is best predictor of successful recovery +++ General Considerations ++ Four stages1. Condensation: bone stops and femoral head becomes necrotic 2. Fragmentation of necrotic bone; femoral head and acetabulum become deformed; revascularization begins3. Reossification of femoral head4. Remodeling of femoral head and acetabulum +++ Demographics ++ Children aged 3 to 13 years old, especially males aged 5 to 7 years oldMales 3 to 5 times more likely than femalesUsually unilateral; bilateral 10-20% of the timeUncommon in African Americans +++ Clinical Findings +++ Signs and Symptoms ++ PainAntalgic gaitTrendelenburg gaitReferred pain to groin, thigh, kneeMay have limited hip internal rotation, abduction, extensionMuscle spasm of hip flexors and adductors +++ Functional Implications ++ Difficulty with ambulation, stairsLimited hip mobilityAntalgic gait +++ Possible Contributing Causes ++ Avascular necrosis of hip (i.e., lack of blood flow to the capital femoral epiphysis) due toInjuryInfectionVascular anomalies (congenital or acquired)ThrombusSynovitis +++ Differential Diagnosis ++ InfectionDysplasiaSynovitisGaucher’s diseaseSickle cell anemia +++ Means of Confirmation +++ Imaging ++ X-ray of hip to evaluate for avascular necrosis +++ Referrals/Admittance ++ To orthopedic surgeon forAnti-inflammatory medicationTractionOrthotic prescriptionPetrie cast2Scottish-Rite brace3Surgical repair including osteotomy +++ Impairments ++ Referred pain from hipMuscle spasms of hip flexors and adductorsGait deviationsDecreased mobility due to pain and partial weight-bearing with crutchesDecreased hip internal rotation, abduction, extension ROM +++ Intervention ++ For when patient released by physician for physical therapy after casting or surgical repairModalities to decrease painAROM and PROM of hipStrengthening of hipHip abduction in standing or sidelyingHip extension in standing or proneBridgesSit-to-stand exercisesWall squatsGait training +++ Functional Goals ++ The patient will be able toIncrease hip AROM and PROM for internal rotation, abduction, extensionIncrease strength of hip musculature, especially hip extensors and abductorsAmbulate 150 feet independently with crutches, non-weight bearing on involved leg Ambulate independently without gait deviations or gait aides for 500 feet +++ Prognosis ++ Children under 8 years of age with least involvement of femoral head have best outcomes, as bone has time to reshapeChildren with complete involvement of femoral head have poorest outcomes, as bone may not heal properly3 +++ References ++1. The American Physical Therapy Association. Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery. Interactive Guide to Physical Therapist Practice 2003. DOI: 10.2522/ptguide.3.1_9. ++2. Perthes Disease. American Academy of Orthopedic Surgeons Web site. http://orthoinfo.aaos.org/topic.cfm?topic=A00070. Accessed October 8, 2011. ++3. Conservative Management of Legg-Calve-Perthes Disease. Netter Images Web site. http://www.netterimages.com/image/1205.htm. Accessed October 8, 2011. +++ Additional Resources ++Anatomy and Physiology Revealed. AccessPhysiotherapy Web site. http://www.accessphysiotherapy.com/APR. Accessed Sept 19, 2011. ++Barnes DV, Wood A. The Infant at Risk for Developmental Delay. In: Tecklin JS ed. Pediatric Physical Therapy. 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2008:101-178. ++Chandrasoma P, Taylor CR. Concise Pathology. 3rd ed. Stamford, CT: Appleton & Lang; 1998. http://www.accessphysiotherapy.com/content/187050. Accessed October 8, 2011. ++Dutton M. Orthopedic Examination, Evaluation, and Intervention, 2nd ed. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/content/5552001#5552001. Accessed September 8, 2011. ++Dutton M. Dutton's Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8654175#8654175. Accessed September 8, 2011. ++Gaucher disease. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001590/. Accessed October 8, 2011. ++Legg-Calve-Perthes disease. Mayo Clinic web site. http://www.mayoclinic.com/health/legg-calve-perthes-disease/DS00654. Accessed September 9, 2011. ++Malone TR, Hazle C, Grey ML. Imaging of the Pelvis and Hip. Imaging in Rehabilitation. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/content/5941118#5941118. Accessed September 8, 2011. ++Patel DR, Greydanus DE, Baker RJ. Overuse Injuries of the Hip, Pelvis, and Thigh. Pediatric Practice: Sports Medicine. http://www.accessphysiotherapy.com/content/6979768. Accessed September 8, 2011. ++Polousky JD. Orthopedics. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. eds. CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/6585839#6585839. Accessed September 8, 2011. ++Polousky JD. Orthopedics. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. eds. CURRENT Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/6586029#6586029. Accessed September 8, 2011. ++Stanger M. Orthopedic Management. In: Tecklin JS ed. Pediatric Physical Therapy, 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2008:417-450. + Lumbago Download Section PDF Listen +++ Condition/Disorder Synonyms ++ Low back painMechanical low back painNon-specific low back painLumbar sprain +++ ICD-9-CM Codes ++ 724.2 Lumbago847.2 Lumbar sprain +++ ICD-10-CM Codes ++ M54.5 Low back painS33.5 Sprain of ligaments of lumbar spine +++ Preferred Practice Pattern ++ 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders1 +++ Key Features +++ Description ++ Occurs in up to 80% of populationMost episodes are self-limitingLeading cause of disability for people under the age of 45 +++ Essentials of Diagnosis ++ Diagnosis made by clinical examinationUse of treatment (Impairment) based classification system is useful to determine evidence-based practice treatment planReproduction of symptoms in specific postures and activitiesRule out disease (red and yellow flags) +++ General Considerations ++ Presentation can vary significantly based on anatomical structures and psychosocial factorsOften difficult to determine patho-anatomical cause of pain +++ Demographics ++ Variable based on specific condition +++ Clinical Findings +++ Signs and Symptoms ++ Pain in lumbar or sacral area that can be mechanically reproducedUnilateral or bilateral referred or radiating pain in lower extremities possibleAltered sensation, motor control, reflexes in the distribution of involved nerve roots indicates nerve-root compression (see lumbar radiculopathy)Pain may centralize or become peripheralized with repeated movementLumbar segmental hypomobility may be present and indicate instabilityOften associated with poor core-muscle strength and postural deviations +++ Functional Implications ++ Leading cause of occupational disabilityMay impede ability to perform ADLs/IADLsMay impede participation in sports and other social activities +++ Possible Contributing Causes ++ Occupational factorsCongenital anomaliesPhysical conditionSmokingObesitySocio-economic factorsPsychosocial and behavioral factorsPostural changesWeakness of core musculatureTightness of hip flexors, external rotators, hamstrings +++ Differential Diagnosis ++ Vascular insufficiencyPeripheral nerve impairmentHip pathology with radiating pain patternMalignant spinal tumor or metastasisReferred pain from visceral structuresSystematic auto-immune diseases (RA, Reiter's)Ankylosing spondylitisAbdominal aortic aneurism +++ Means of Confirmation or Diagnosis +++ Imaging ++ Not necessary in most cases; only with persistent symptoms that do not respond to conservative management or if red/yellow flags are presentMRI helpful in diagnosis to visualize compressed or inflamed nerve root/disc pathologyX-ray/plain-film radiograph helps to assess alignment, fractures, stability (flexion/extension radiograph)CT to show herniation compressing the spinal canal or nerves or rule out abdominal pathologyElectrodiagnostic/nerve conduction testing can help determine specific impaired nerve functionDoppler ultrasound to examine vascular function +++ Findings and Interpretation ++ Physical ExaminationAlgorithm for examination of the lumbar spinePassive physiological intervertebral mobility testing (PPIVM)Lower extremity screening examPostural examinationMuscle length testing, including hamstrings, hip flexors, calf musclesQuadrant testStraight leg raise testSlump testLower limb nerve tension testProne instability test Lower extremity neurological screen (dermatome, myotome, reflexes)Repeated movement testingFear-Avoidance Beliefs Questionnaire (FABQ) +++ Referrals/Admittance ++ To hospital for imagingTo physician for surgical consult if myelopathy suspected (see Lumbar Radiculopathy)To physician for imaging and medical consult if disease suspectedTo other specialist if vascular insufficiency suspected +++ Impairments ++ Hypomobile lumbar spine Decreased lumbar stabilityWeakness of abdominals and other core-stabilizing musclesShortened hamstrings and hip flexorsPostural changesInability to walk, stand, or sit for prolonged time +++ Intervention ++ Joint manipulation indicated whenDuration of symptoms less than 16 daysHypomobility upon PIVM testingNo pain past the kneeFABQ work subscale score < 19 pointsLess than 35 degrees of internal rotation in at least one hip jointSpecific exercise when pain centralizes upon repeated movement/posture into flexion or extensionLumbar stabilization exercises to address core stability whenPositive prone instability testPresence of aberrant motionStraight leg raise > 91 degreesAge < 41 years oldTraction whenRadiculopathy findings presentPositive crossed straight leg raise (SLR)Pain becomes peripheralized with repeated extensionStretching exercises, myofascial mobilization for shortened musculatureUnweighted treadmill walkingAquatic exerciseModalities for short-term pain controlCognitive behavioral therapy +++ Functional Goals ++ Patient will be able to Sit with neutral lumbar spine posture for greater than 30 minutes with 0 out of 10 pain ratingSit at work station and perform computer work for 45 minutes with 0 out of 10 pain ratingRotate lumbar spine 25 degrees so as to reach into back seat of the car with 0 out of 10 pain rating in lower extremity Walk for 30 minutes with 0 out of 10 pain rating so as to go shoppingIncrease standing tolerance to greater than 30 minutes without pain so as to fulfill recreational activity requirements +++ Prognosis ++ Fair to very good depending on specific impairmentsChronic low back pain (LBP) prognosis significantly less +++ References ++1. The American Physical Therapy Association. Pattern 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders. Interactive Guide to Physical Therapist Practice 2003. DOI: 10.2522/ptguide.3.1_6. Accessed March 5, 2012. +++ Additional Resources ++Dutton M. Dutton's Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/resource/685. Accessed March 1, 2012. ++Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/612. Accessed March 1, 2012. ++Fritz JM, Cleland JA, Childs JD. Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. J Orthop Sports Phys Ther. 2007;37(6):290-302. [PubMed: 17612355] ++Liebenson, C. Rehabilitation of the Spine. Baltimore MD: Lippincott, Williams & Wilkins: 2007. ++Malone TR, Hazle C, Grey ML. Imaging in Rehabilitation. New York: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/613. Accessed February 28, 2012. ++Olsen KA. Manual Therapy of the Spine. St. Louis, MO: Saunders Elsevier: 2009.