Paul Vidal, PT, MHSc, DPT, OCS, MTC
Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT
Abstract: Physical therapy (PT) differential diagnosis of patients complaining of dizziness centers on distinguishing those patients who might benefit from sole management by the physical therapist from those patients who require referral for medical-surgical differential diagnosis and (co) management. There is emerging evidence that PT management may suffice for patients with benign paroxysmal positional vertigo, cervicogenic dizziness, and musculoskeletal impairments leading to dysequilibrium. This article provides information on the history taking and physical examination relevant to patients with a main complaint of dizziness. The intention of the article is to enable the therapist to distinguish between patients complaining of dizziness due to these three conditions amenable to sole PT management and those patients who likely require referral. Where available, we have provided data on reliability and validity of the history items and physical tests described to help the clinician establish a level of research-based confidence with which to interpret history and physical examination findings. The decision to refer the patient for a medical-surgical evaluation is based on our findings, the interpretation of such findings in light of data on reliability and validity of history items and physical tests, an analysis of the risk of harm to the patient, and the response to seemingly appropriate intervention.
Key Words: Dizziness, History, Physical Examination, Physical Therapy
To facilitate differential diagnosis and screening of patients with a complaint of dizziness, we discussed in an earlier article1 a diagnostic classification system based on symptomatology and pathophysiology. This classification system included four subtypes of dizziness: vertigo, presyncope, dysequilibrium, and other dizziness. Many tests and measures that are needed for a full dif- ferential diagnostic work-up of patients presenting with dizziness are obviously outside of the physical therapy (PT) scope of practice. Many causes of dizziness discussed in that earlier article require medical-surgical management rather than or in addition to PT management. However, there is mounting evidence that conservative measures may be beneficial for a select subset of patients with dizziness. Repositioning maneuvers may decrease symptoms in patients with benign paroxysmal positional vertigo (BPPV) involving the posterior, horizontal, and anterior semicircular canals2-6. Manual therapy interventions may positively affect cervicogenic dizziness7. Musculoskeletal impairments, such as decreased muscle strength and endurance, joint stability and mobility, and posture, which are implicated in patients with the dysequilibrium subtype of dizziness, are dysfunctions traditionally addressed by PT1. Habituation exercises have proven beneficial for patients with acute unilateral vestibular loss, and adaptation and balance exercises have produced positive outcomes in patients with chronic bilateral vestibular deficits4. For the latter two patient groups, PT management, of course, is preceded by a medical differential diagnostic work-up. An isolated otolith dysfunction may theoretically also be amenable to conservative management, but as no clinical tests exist to identify this dysfunction, we cannot make any evidence-based recommendations at this time.
This article provides the orthopaedic physical therapist with current knowledge on the history items and physical tests within the PT scope of practice that are required for identifying previously undiagnosed patients complaining of dizziness and who:
- May respond to conservative interventions within the PT scope of practice, specifically patients with BPPV, cervicogenic dizziness, and musculoskeletal impairments leading to dysequilibrium.
- Require referral for medical differential diagnosis and medical-surgical (co)management. In keeping with the evidence-based practice paradigm, we have attempted to provide, where available, data on reliability and validity of history items and physical tests by way of a Medline search over the period 1995- March 2005 of English-language articles with a title containing search terms relevant to these tests and items. The complete list of search terms is available upon request from the authors. In addition, we performed a hand search of articles in our personal libraries.