CHAPTER 30: Physical Therapy Management of People with Non-vestibular Dizziness

Introduction

Dizziness is among the most prevalent complaints for which people seek medical help, and the incidence increases with advancing age.¹ Dizziness represents a diagnostic and treatment challenge, because it is a subjective sensation, refers to a variety of symptoms (unsteadiness or imbalance, spinning, sense of motion, or lightheadedness), and has many potential contributory factors. As many as 45% of individuals with dizziness are diagnosed with peripheral vestibular disorders;² therefore, the majority of individuals have non-vestibular causes for their dizziness and imbalance. Although these patients have similar signs and symptoms to those with inner ear dysfunction, vestibular function testing does not reveal vestibular pathology. It is essential that patients with non-vestibular dizziness and imbalance be referred to specialists in vestibular rehabilitation to achieve optimal outcomes. Many assessments that we recommend, including a thorough oculomotor exam in both room light and with fixation removed, are identical to those used to evaluate vestibular patients. Although they are not commonly performed in inpatient or outpatient settings, they provide important information to the clinician. There is considerable evidence that vestibular exercises are important in the rehabilitation of patients with vestibular pathology.³ There is also evidence that vestibular rehabilitation is beneficial for patients with non-vestibular dizziness.^4–11

After excluding patients who have dizziness caused by cardiovascular pathology or medication side effects, patients with non-vestibular dizziness can be divided into two major categories: those with neurological pathology and those without. Individuals with neurological involvement include peripheral neuropathy affecting large fibers with impaired proprioception or kinesthesia in toes or ankles, cerebellar/brainstem disorders (e.g., spinocerebellar ataxia, multiple sclerosis, and stroke), ischemic white matter disease (leukoaraiosis), and mild head injuries and concussions. (See Chapter 26 for assessment and management of individuals with head injuries and concussions; see Chapter 29 for medical management of patients with non-vestibular dizziness.) Individuals with non-vestibular dizziness without neurological involvement include older adults with disuse disequilibrium and/or fear of falls and individuals with motion sensitivity caused by migraines and/or anxiety.

This chapter identifies components of the physical therapy assessment that are the most important as well as outcome measures which are appropriate. Secondly, we discuss therapeutic interventions for patients with non-vestibular dizziness including gait and balance training, vestibular rehabilitation including habituation and gaze stability exercises, and dual-task activities. We suggest recreational activities that are both enjoyable and challenging for the patient to continue after discharge to maintain gains achieved with formal physical therapy. Each section identifies specific treatments that have been shown to improve balance and mobility, as well as dizziness. Finally, we discuss expected recovery time and factors that may limit functional progress.

Assessment

A comprehensive evaluation is essential to identify the underlying impairments and functional deficits and determine the best treatment approach for patients with non-vestibular dizziness. Our dizziness and balance clinic uses a six-page questionnaire (that is mailed to each patient before the first appointment). ...