HINTS Exam: Determining the Cause of Acute Vestibular Syndrome
Christie Clem, SPT
During my acute care rotation at WakeMed in Raleigh I saw many patients that had been diagnosed with a stroke or vestibular pathologies. Some of the patients with vestibular signs and symptoms were initially misdiagnosed, but the vestibular evaluation done by the physical therapist gave insight that supported a different diagnosis and different medical management. Misdiagnosis could be due to practitioners not having a great understanding of the clinical presentation of various vestibular problems, not administering an exam technique correctly, not completely understanding what the exam results are meaning or not correctly identifying subtle eye movements. I was fortunate to work with a clinical instructor, Dana Thomas, MS, PT, who had completed the Susan Herdman Vestibular Rehabilitation Competency Course, in addition to, using evidence to guide her daily practice. It was during this time that I began to better understand the information that could be gathered from a bedside vestibular exam, how different vestibular pathologies can present and that some strokes can mimic peripheral vestibular problems. Acute vestibular syndrome (AVS) is a clinical condition characterized by a group of signs and symptoms: dizziness or vertigo that develops over seconds to hours and persists for at least 24 hours, nausea/vomiting, nystagmus, head motion intolerance and gait instability.1 AVS can be caused by a peripheral or central pathology, but can have the same presentation no matter the cause. It was with these patients that I learned the HINTS exam, a three-part bedside oculomotor exam, can be used to differentiate between a peripheral and central cause of AVS.1,2
If it were not for this rotation, I would not have been introduced to the HINTS exam or have realized how valuable physical therapists can be in helping to diagnosis vestibular pathologies in an acute setting. I also witnessed my CI use evidence based research to educate others (PTs, physicians, physician assistants) in how to perform vestibular tests and interpret the results including the HINTS. This rotation increased my interest in vestibular pathologies, clinical presentations and exam techniques. I decided to make this topic the focus of my literature review during my 3rd year of the PT program with the goal of presenting the information to other UNC PT students.
During the Evidence Based Practice II course, I began gathering research related to the PICO question, “in a 70 year old man with acute vestibular syndrome, is a clinical bedside exam or MRI more accurate in determining if the cause is central or peripheral?” The information gathered was used to create a critically appraised topic that concluded the HINTS exam is better at ruling out a stroke than MRI performed within 48 hours of symptom onset. The following semester I gathered additional information about the specific arteries of the brain’s posterior circulation that cause AVS, vestibular rehabilitation and identified new studies that included the HINTS exam. I created a VoiceThread presentation and presentation handout from the information I gathered. The eDPT and tDPT students in the PHYT 885 Advanced Neuromuscular Intervention course were selected to be the audience for the presentation materials. The main goal of the presentation was to make PT students aware that a dangerous cause of AVS, such as a stroke, can have the same clinical presentation as a benign peripheral cause of AVS. The specific learning objectives included being able to recognize the clinical presentation of AVS, describe the 3 components of the HINTS exam and interpret the results of the HINTS exam to determine if the cause is central or peripheral.
Those that viewed the presentation were asked to complete a 10-question pre- and post-test assessment and a presentation feedback form. The pre- and post- assessments allowed me to evaluate if the learning objectives had been met. The pre-test average was 50% while the post-test average improved to 80%. There was only one question that every person answered correctly in the pre-test assessment, where as seven of the questions were answered correctly by everyone on the post-test assessment. Overall, the presentation feedback was positive. The average rating for each question ranged from 4.33 to 5 on a 5-point scale. The highest ratings were for the information being of important clinical relevance, a thorough explanation of the content and that the included videos enhanced understanding. Some changes have already been made to the VoiceThread based on the questions that were consistently missed on the post-test assessment. I also plan to update the handout based on feedback in order to make it more beneficial and user friendly.
It would not have been possible for me to complete this project without the support of my Capstone committee members. I would like to thank Dana Thomas, my CI at WakeMed, for helping me gain a better understanding of vestibular anatomy, vestibular examination techniques and how to interpret the results. She modeled how to be an evidence-based practitioner while stressing the importance of not making the patient fit the diagnosis you have in mind, but to instead “let the exam speak for itself.” In addition to the eight weeks of guidance Dana provided as a CI, she also provided valuable insight and feedback throughout this project. I would also like to thank Dr. Karen McCulloch for her assistance throughout this process. I appreciate the feedback while creating the materials, her willingness to allow the students in her PHYT 885 class to be the intended audience this year and suggesting it be viewed in upcoming years by PT students before going on their acute clinical rotation. Finally, I would like to thank Gabrielle Scronce, PT for taking time out of her busy schedule to provide valuable feedback on the presentation and handout. Gabrielle was able to give useful feedback from the prospective of a recent UNC PT graduate that was not familiar with HINTS exam.
Materials Associated with this Project
HINTS Exam Pre-Test: 10 Questions (link to SurveyMonkey; PDF version is above)
HINTS Exam Post-Test: 10 Questions (link to SurveyMonkey; PDF version is above)
HINTS Exam Presentation Feedback (link to SurveyMonkey; PDF version is above)
- Kattah JC, Talkad A V, Wang DZ, Hsieh Y-H, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510. doi:10.1161/STROKEAHA.109.551234.
- Tarnutzer A a., Berkowitz AL, Robinson K a., Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. Cmaj. 2011;183(9):571-592. doi:10.1503/cmaj.100174.
- http://clipart.me/free-vector/dizzy [picture]
- http://clinicalgate.com/the-cerebellum [picture]