CHAPTER 27: Physical Therapy Diagnosis: Clinical Decision-Making for Vestibular Disorders

Introduction

The advent of direct access for physical and occupational therapists means that clinicians must be able to screen for and identify for a multitude of problems and make decisions about treatment and referral. At a minimum, therapists need to know when they should refer the patient to a more qualified therapist or to a physician. Sometimes the decision to refer to another health-care provider is made easily, such as when the patient's problems are clearly not under the purview of a therapist (e.g., headache or hearing loss). In other situations, the patient's problem may or may not be something appropriate for physical or occupational therapy, but the underlying cause needs to be managed by a physician. “Dizziness” is one of those patient problems. “Dizziness” is one of the most prevalent complaints for which people seek medical help,¹ with an estimated 90 million Americans over the age of 16 years having experienced it.² It can have significant consequences for an individual, with 33% of patients reporting that their professional activities are affected by dizziness and 14% changing or abandoning their profession.² Although dizziness can be caused by many different medical conditions, it is estimated that as much as 45% is caused by vestibular disorders.²

In this chapter, we discuss an updated paradigm for helping the therapist arrive at the proper physical or occupational therapy diagnosis for a vestibular disorder or to the decision to refer the patient to a physician. The diagnostic schematic presented here is a “work in progress” and is meant as a guide only for the therapist. It is offered as a framework for arriving at a physical diagnosis for patients with vestibular problems. Each of the physical therapy diagnoses presented should demonstrate commonalities across all persons with that diagnosis. There are two phases to making the physical therapy (PT) diagnosis. The first is in the history of the patient's complaints; the second consists of some simple clinical tests of the vestibulo-ocular system.

Diagnosis can be defined as “the art of distinguishing one disease from another.”³ In medicine, the identification of a particular disease leads to specific medical and/or surgical treatment. A physical or occupational therapy diagnosis differs from a medical diagnosis in that, rather than attempting to identify a particular disease, a constellation of symptoms and signs toward which physical and occupational therapy will be directed is identified. Once the PT diagnosis is achieved, the vestibular exercise approach can be identified (Table 27-1). Certainly, there will be times when the medical diagnosis and the PT diagnosis are the same—for example, benign paroxysmal positional vertigo (BPPV). However, there will be times when the diagnoses will differ. For example, vestibular neuronitis would be a medical diagnosis. As therapists, however, we do not treat the inflammatory process of vestibular neuronitis. A more appropriate diagnosis for physical therapy is unilateral vestibular hypofunction.