Screening of Dizziness in Orthopedic Physical Therapy Practice -Teaching experience for PT students and practicing PTs-

Screening of Dizziness in Orthopedic Physical Therapy Practice
Teaching experience for PT students and practicing PTs
By: Takumi Kato, PT, MS

I have developed my curiosity of cervicogenic dizziness since I learned the advanced orthopedic physical therapy and vestibular rehabilitation in the post-professional program. Despite that it is not uncommon that a patient with musculoskeletal impairment complains of dizziness as a concomitant symptom, dizziness might be considered as something that physical therapy cannot help or just ignored. I was fortunate that I went through the vestibular certification course coordinated by Emory University and APTA and have gained experience in vestibular rehabilitation and cervicogenic dizziness over the last few years. Through this experience, I started to realize how strong the vestibular examination is to make differential diagnosis in both vestibular and orthopedic population.

As the current evidence says that cervicogenic dizziness is a diagnosis of exclusion, physical therapist is responsible for ruling out other competing diagnosis including vestibular pathologies. A commentary by Treleaven et al. published in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) supported a routine screening process of dizziness for the evaluation of patients with cervical spine impairment.⁵ Screening process in orthopedic physical therapy practice is important for another reason where JOSPT “strongly recommends” for differentiating serious pathologies such as arterial insufficiency, upper cervical ligamentous insufficiency, unexplained cranial nerve dysfunction, and fracture, which might present with neck pain and dizziness.¹ Additionally, a present of dizziness and signs of sensorimotor control disturbances in the patients with neck pain might indicate poorer prognosis, which evidence might imply that there might a missing piece to assess or intervene or a room for improving treatment outcome when assessment of dizziness was performed.⁵ Referring the Critically Appraised Topic (CAT) performed during the PHYT 752 Evidence-based Practice II, there was the evidence supported that orthopedic approach, particularly a combination of manual therapy intervention and exercises, offered reduction of symptoms of dizziness when cervicogenic dizziness was appropriately identified. 

Over the transitional DPT coursework at UNC Chapel Hill, particularly PHYT 830 PT Education Seminar and PHYT 839 Advanced Practice Issues, I gained motivation to improve my teaching skill and share my clinical expertise to the other. Therefore, my capstone project was proposed to enhance awareness of cervicogenic dizziness and screening process both in students and clinicians and to improve my teaching skills with sharing this topic of expertise. 

Dizziness is a common complain that can influence on physical, emotional and economic cost to individuals, the community and the healthcare system.³ Despite of this fact, differential diagnosis of dizziness is challenging not only in physical therapy practice but also in medicine in general. In orthopedic physical therapy practice, differential diagnosis should be made in any musculoskeletal condition, particularly in cervical spine impairment due to a concern of the serious pathologies or red flags as mentioned above. Even though such serious pathologies are ruled out, differentiating competing diagnosis is critical to provide an appropriate intervention and favorable outcome. Given that diagnosis of cervicogenic dizziness is made by exclusion of other causes of dizziness, the screening process to rule out all the potential diagnosis is a key to diagnose it. For example, it has reported that up to 35% of traumatic neck pain may have concomitant peripheral vestibular damage which could have identified by vestibular examination and intervened by the particular treatment.⁵ Additionally, the diagnostic accuracy and power of clinical examination for cervicogenic dizziness doesn’t seem strong. Rather, the tests to identify vestibular or CNS dysfunction have stronger clinical utility compared with ones of cervicogenic dizziness.⁵ These reports from the evidence are consistent with what my clinical experience tells such that I realized that some vestibular and oculomotor examinations are relatively simple, less time consuming, but powerful to make differential diagnosis. Therefore, sharing information of the current evidence of  clinical reasoning approaches and technique that orthopedic physical therapists can implement in their practice is believed to be able to impact their practice. The survey performed before teaching was reported that the students who are taught had only 34% of comfortability when it comes to treating patients with neck pain and dizziness. This implied that they would not have a chance to learn and/or clinically practice with cervicogenic dizziness and supported my assessment of need of this capstone project.

The predominant portion of this capstone project is the expansion of my work conducted in the PHYT 830 PT Education Seminar from the summer term 2017. During this course, the first draft of the presentation was created and reviewed by the course coordinator. Teaching strategy and presentation guidance were also reviewed with the Shepard’s textbook⁴ and Plack’s textbook². As a guest lecture in the University of Pittsburgh was planned in March 2017 as a final course assignment of the PHYT 830, the presentation had revised with an input from the recent published evidences, feedback from committee members and academic advisors, and additional learning of teaching strategy until providing the lecture. The guest lecture (2.5 hours) was provided to the post-professional physical therapy students (19 students as total) in the University of Pittsburgh on Thursday, March 22nd, 2018 as a part of the course of “Advanced Clinical Practice: The Upper Quarter” in the spring term in 2018.

The learning objectives of this guest lecture were:

1. Describe diagnosis, etiology/mechanics, prevalence, and common signs and symptoms of conditions which cause dizzineswith focusing on cervicogenicdizziness and reviewing other competing conditions (vestibular, CAD/VBI, central pathology) (cognitive)
2. Discuss the current available scientific evidence of screening and examination tools to make differential diagnosis between the competing conditions (cognitive)
3. Demonstrate clinical decision-making process with a pragmatic, step-by-step approach, to make PT diagnosis and consider potential intervention (cognitive/psychomotor)
4. Approach clinical examination techniques (CCFT, head and neck differentiation) through lab session to understand how to interpret and achieve sufficient competency (psychomotor)

Additionally, a cheat sheet for clinical resource and case series were developed based on the academic advisor’s suggestion during this project (these documents are available in the following section). Along with the one of the goals of this capstone project, I decided to provide an in-service to practicing physical therapists at my workplace so that I would be able to improve my teaching skills by reflecting the previous teaching experience and exposing myself to the different target of audience, needing me to reconsider what information is expected by them and what modification should be made in content and delivery method of teaching. The in-service (45 mins) was provided in MossRehab, Philadelphia on April 17th, 2018.

The learning objectives of 2 and 4 were replaced with the follows:

1. Discuss the current available scientific evidence of screening and examination tools (especially oculomotor and vestibular exams) to make differential diagnosis between the competing conditions (cognitive)
2. Approach how to document oculomotor and vestibular findings in EMR (psychomotor)

1. Educational Presentation for Students – Screening of Dizziness in Orthopedic PT Practice (Download link in Dropbox)
2. Educational Presentation for Clinician – Screening of Dizziness in Orthopedic PT Practice (Download link in Dropbox)
3. Cheat Sheet of Clinical Decision-Making Process in CGD (PDF)
4. Case Series -Differential Diagnosis of Dizziness- (Download link in Dropbox)

The audience of the guest lecture, post-professional students, received Teaching Feedback Form which included survey of their confidence treating cervicogenic dizziness, their feedback on satisfaction of the learning objectives, and several quizzes. Overall, they showed an improved score on the question “Please rate your comfort level to treat patients with neck pain and dizziness?” from 3.4/10 and 5.9/10 rated at pre- and post-lecture. The survey about satisfaction of the four proposed learning objectives was scored 4.2/5, 4.4/5, 4.2/5, 3.9/5 on average respectively. Moreover, there were 5 competency quizzes provided and was scored 75.6% on average, which was close to preset goal (i.e. 80%).

I reflected that this teaching experience was fairly successful as the objective evaluation showed above. The teaching strategy used in this experience, especially distributing the presentation into several modules with placing review slides in between as well as question techniques, went well and seemed to bring the students’ attention and improve their learning experience. 

Objective evaluation for the in-service was made only by one of the committee member who attended it. The positive feedback was about the information provided in the background section with comprehensive review of currently available evidence and overall organization of the presentation. She provided me advice on time management and/or limiting the contents covered and resource of oculomotor examinations to be modified. Overall feedback by attendees were positive toward the topic selection and comprehensive article review and negative toward the volume/speed of the presentation.

Although I reduced the volume of topic covered during in-service give the time difference (1.5 hrs in lecture component of guest lecture and 45 mins in in-service), I was forced to talk too fast, which would have made the listeners difficult to follow the presentation. Based on my performance in two teaching opportunities where there are huge time difference, I was able to learn that selection or limitation of the topic cover relative to the time assigned is the most determinant teaching strategy to improve learning experience at my current teaching level. 

This capstone project would not have been possible and successful without the support of many people. I wish to express my special gratitude to committee members, Dr. Patricia Crane, PT, DPT, OCS, FAAOMT, Cert. MDT, CLT and Dr. Carolyn Murphy, PT, DPT, NCS who provided me invaluable assistance, support and guidance in developing the presentation. Special appreciation also to Prof. Michael Timko PT, MS, FAAOMPT for kindly accommodating the guest lecture in his course and providing me constructive feedback for clinical expertise and teaching. Additionally, I am thankful for the supervision and feedback for the project and support and encouragement for entire tDPT coursework by Dr. Karen McCulloch, PT, PhD, NCS.

1. BlanpiedPR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017. J OrthopSports Phys Ther. 2017;47(7):A1-A83.
2. Plack M, Driscoll M. Teaching and Learning in Physical Therapy: From Classroom to Clinic. Thorofare NJ. SLACK Incorporated, 2011
3. Reid SA, Callister R, KatekarMG, TreleavenJM. Utility of a Brief Assessment Tool Developed from the Dizziness Handicap Inventory to Screen for CervicogenicDizziness: A Case Control Study. MusculoskeletSciPract. 2017;30:42-48.
4. Shepard KF, Jensen GM. Handbook of Teaching for Physical Therapists (2 ed). Woburn, MA: Butterworth Heinemann, 2002.
5. Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017 Jul;47(7):492-502.