Differential Diagnosis of Dizziness
&
Treatment of Unilateral Peripheral Vestibular Hypofunction
By Megan Eyler, SPT
Introduction
Dizziness affects an estimated 20-30% of the population.1 A US National Healthcare survey found that 7.5 million patients with dizziness are examined in ambulatory care settings each year.2 Dizziness can decrease one’s functional mobility, balance and quality of life. Patients reporting to the clinic with dizziness can have many different underlying pathophysiologic mechanisms, making differentiation between vestibular or nonvestibular etiology critical to provide appropriate treatment.3,4 During an early clinical experience, I observed a patient present to outpatient physical therapy with severe dizziness and thenwitnessed her remarkable reversal of symptoms after she received treatment. This experience sparked my interest in peripheral vestibular disorders and I have continued to research and seek out clinical experiences as a student physical therapist, cumulating with my capstone project. I developed an educational module for third year entry-DPT and transitional–DPT students enrolled in the Advanced Neuromuscular Intervention course (PHYT 855) who have interest in learning about clinical applications of differential diagnosis of dizziness and evidenced based treatment of unilateral peripheral vestibular hypofunction. The module is designed to be self-paced and include illustrations and links to videos and online resources to enhance learning.
Student Learning Objectives
The following learning objectives are utilized to guide and evaluate student’s understanding of materials. Upon completion of module the student will be able to:
- Describe the anatomy and physiology of vestibular system and peripheral sensory apparatus.
- Differentiate vestibular pathologies from other systemic pathologies in patients reporting with symptoms of “dizziness”.
- Identify and list common etiologies of unilateral peripheral vestibular hypofunction (UPVH).
- List and describe the best evidence-based treatments for UPVH.
Module Components
The module begins with an introduction to learning objectives and module outline.
There are three main segments:
- Part 1: Basic Anatomy and Physiology of the Vestibular System
- Part 2: Differential Diagnosis of the Dizzy Patient
- Part 3: Etiologies, Efficacy and Treatment of Unilateral Peripheral Vestibular Hypofunction (UPVH)
The module also includes condensed 1-2 page clinical reference sheets that can be utilized in the clinic environment.
Supplementary documents that are referred to throughout the module include:
- A variety of questionnaires, outcome measures and exercises that would be useful to include during evaluation and treatment of patients with vestibular dysfunction.
- An original flow-chart/table demonstrating one way the “Tempo-Symptoms- Circumstances” approach to taking history can assist differential diagnosis.
- An evidence table addressing the efficacy of vestibular rehabilitation compared to no treatment in improving balance and mobility.
The module ends with a quiz (and answers) that allows student to self-assess progress on learning objectives.
Evaluation of the educational module
I advertised my module to the students currently enrolled in the Advanced Neuromuscular Intervention course. Students who completed the module filled out a short post-module survey as a form of evaluation. This survey included 60% content questions (quiz) to access participant’s retention of content and to access learning objectives stated above. The remaining 40% of questions (module feedback) highlighted strengths and weaknesses of the module itself and allowed participants to offer suggestions on how it could be improved. Results of quiz revealed all students receiving 100% correct on content questions. All students reported that content was of appropriate length and depth. Reported strengths: clinical usefulness of material, detailed but concise presentation of material, clear guidelines for how to perform tests and interpret findings and conduct interventions. Suggestions for improvement: including case examples in a variety of setting (acute and outpatient) to augment learning of evaluation and intervention components of material.
Acknowledgements
I want to extend a very special -Thank You- to my advisor Karen McCulloch for her continual guidance and to my wonderful committee members, Beth Connell, Regina Emmett and Tricia Agnoli, for their invaluable feedback and support!!
References
1. Chan Y. Differential diagnosis of dizziness. Curr Opin Otolaryngol Head Neck Surg. 2009;17:200-203.
2. Burt CW, Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United states, 1999–2000. Vital Health Stat. 2004;13:1–70
3. Herdman SJ. Vestibular Rehabiliation. 3rd ed. Philadelphia, PA: F.A. Davis Company; 2007.
4. Tusa RJ, Gore R. Dizziness and vertigo: emergencies and management. Neurol Clin. 2012;30:61-74, vii-viii
*Complete list of references are listed at the end of each part of module*
6 Responses to “Differential Diagnosis of Dizziness”
Megan E.
Kmac,
Thank you for all your guidance during the completion of my capstone and flexibility at the end due to our service-learning trip in Guatemala. The trip was amazing, an experience I will never forget. Even though I was not able to get any feedback from transitional DPT students I did send it out to most of the 3rd year e-DPT students enrolled in the advanced nueromuscular elective so I was able to get about 7 student’s feedback. But please send it out again (perhaps people will be less busy now) and share it with the transitional students this summer! Thanks again for all your help!
Megan
Megan E.
Christina,
Thank you for the feedback! You are correct that pediatric patients also are affected by vestibular disorders and often they are not as readily recognized because children have a harder time communicating that they are experiencing symptoms.(1) Many of the etiologies are the same as those that affect adults but infants and children are also susceptible to problems manifesting from incorrect development of vestibular apparatus.(1) As in adults, vestibular rehabilitation has been shown to be effective in the pediatric population.(1) In fact Children generally respond more quickly to vestibular rehabilitation than adults because they are generally less fearful of movement and have greater potential plasticity.(1) As with all pediatric patients, education of family is paramount and for older children vestibular rehabilitation exercises can be integrated into school activities as well as a home-exercise programs.(1) If you are interested in learning more check out the resource below published by the Vestibular Disorders Association; it has a lot of additional information about several of the etiologies and evaluation strategies for pediatric patients with vestibular dysfunction. Thanks for your response! Good luck on your last clinical!
Megan
1.Cronin GW. Pediatric vestibular disorders: recognition, evaluation and treatment.Vestibular Disorders Association. Available at: http://vestibular.org/sites/default/files/page_files/Pediatric%20Vestibular%20Disorders_1.pdf and http://vestibular.org/pediatric-vestibular-disorders
Megan E.
Megan C.,
Thank you very much for your comments. I really appreciate you taking the time to go through the module as I know this is a very busy time for all of us! Since you are a 3rd year DPT student who has interest in vestibular disorders, you are the perfect person to give me feedback because you are part of my target audience, so thank you! I am glad that you felt you gained something from it and you can definitely use anything you’d like in the future! Also, thank you for the feedback and suggestions on formatting, I will make sure I fix those.
Good luck with this last rotation and studying! 🙂
Megan E.
Karen McCulloch
Hi Megan – I know you’re away, but wanted to post a note about how well I think you did on this project. I’m sorry that we weren’t able to get comments back to your from students who were in the neuro elective on the timeline you would have liked. I will ask for folks to take a look – they have been dealing with their own deadlines recently…and may revisit this in the educational course that the transitional students do in the summer with me, when they will have more time and will be thinking specifically about an educational offering they will develop. Nice work!!! Hope your trip to G was great.
kmac
Chritina Aluri
Hi Megan! I think all of these materials are great, you did a great job of providing a lot of detailed information in an accessible manner. Overall this is very thorough and clinically useful for seeing a patient with complaints of dizziness. I wish I had these materials for every pathology we have learned so far! I am interested in pediatric practice and imagine some of this information will be very helpful in evaluating and treating children with complaints of dizziness after concussions or head injury as well as for children with complaints of dizziness due to brain tumors and treatment. Thanks for all of your hard work!
mlchrist
Hi Megan!
I’ve been excited to look over your project since vestibular dysfunction is also of interest to me. And I was not disappointed 🙂 Your module is very well put together, and manages to convey a lot of information without feeling overwhelming. I appreciated the ability to move at my own speed, and liked your “outline format” which allowed me to choose the level of detail in which I wanted to read (very effective!).
Your Anatomy section was both a good review and an extension of what we learned in the vestibular unit of Neuro last year. The Diff Dx section was nicely arranged, and gave great pointers on how to conduct a thorough examination of the dizzy patient. Your inclusion of how to question the patient, and explanation of what various answers might indicate was VERY helpful, and I thought you also gave a nice summary of measures/tests as well. After reviewing your module, I feel far more confident about my ability to perform a successful evaluation for a dizzy patient!
You have put a great amount of effort into the literature review for your Capstone, and it shows! Excellent commentary on interventions (thank you for including guidelines for how to start and progress them). The clinical sheets and supplemental documents are resources that I would love to save for future use (with your permission).
Feedback:
– Good length (lots of good info, nicely broken down)
– Good depth (I think you have presented a great summary here without going overboard on the details)
– Module is thorough and gives good structure for how to “eval & treat” the dizzy patient – a nice complete package! Language and explanations are clear and easily understood.
– Just a few formatting details: the Figure 1 pie graph in your Diff Dx section showed up without the sections clearly marked (it was just a bunch of percentages); and the Quiz Answers document has an empty 3rd page attached (this is minor, but just thought I’d mention it in case!)
Fantastic work, and thanks for sharing! Good luck on your last rotation. ~ Megan C.