After the person presents to the physical therapist, an in-depth examination begins with a thorough history of the dizziness. Just as in the physician’s examination, the history is critical for the physical therapist in determining the optimal interventions. Sharing pertinent health information, examination results, and laboratory findings with the treating therapist will expedite and enhance patient care. Typically, the therapist will ask the patient questions regarding the frequency, duration, timing, and intensity of the symptoms; other comorbid medical conditions; medications; requirements of work; and living status (78).

Positions or movements that increase or decrease symptoms are very important in developing the treatment plan for the person with a vestibular disorder. Often, questions are asked related to movements that increase dizziness such as bending, getting out of bed, or even walking in a grocery store. A quick neurologic exam is also performed to assess the integrity of the smooth pursuit and saccadic eye systems and cranial nerves III, IV and VI. The integrity of the VOR, VOR cancellation, and the vergence system are also clinically assessed. The therapist may perform the head thrust test (79, 80, 81, 82, 83, 84, 85), dynamic visual acuity (35, 36, 37, 85, 86, 87, 88, 89, 90), and vibration-induced nystagmus test (91, 92, 93, 94). All of the above assist the therapist in treatment planning and determining if additional testing is required as some patients may be self-referred or have not seen an otolaryngologist prior to seeing the physical therapist.

Strength, range of motion, sensation, and coordination are assessed at baseline. Range of motion of the cervical spine is particularly important to determine prior to performing the Dix-Hallpike maneuver. The physical therapist performs the Dix-Hallpike and the roll test ideally with infrared goggles, to determine if the patient has BPPV. If the Dix-Hallpike or roll test are positive, the appropriate canalith repositioning maneuver (CRM) will be performed based on the patients health and medical comorbidities.

Balance testing is an integral part of the typical physical examination including Romberg, semitandem standing, and tandem standing. Semitandem standing consists of having the patient stand with one foot in front of the other but not heel to toe. It is a transitional balance test between standing feet together (Romberg position) and heel to toe (tandem standing) and is often a difficult position for older adults to maintain. The patient’s gait, as described above, will be assessed, and determination will be made whether an assistive device is in order to improve gait and safety. An attempt is made to avoid providing an assistive
device unless it is necessary, as many older adults will never stop using the assistive device once it has been prescribed. Persons who often do need an assistive device are those with bilateral vestibular loss because they fall frequently (95), especially on uneven surfaces or low light/no light conditions. If the person is very frail and afraid of falling, occasionally a rollator walker will be suggested. Rollators have four wheels, brakes, and a seat. The rollators allow patients to walk safely at a much faster gait speed than a standard walker. Gait speed has been shown to be an overall indicator of health (96). Walking at a more normal speed may have long-term cardiovascular and respiratory benefit. Standard canes are also used to provide support for persons with vestibular disorders and have been shown to decrease postural sway (97).

Once the examination is complete, the physical therapist will develop a plan of care. Patients are seen anywhere between one and three times per week, with frailty, depression, light sensitivity, a history of migraine, fear of falling, and anxiety being important factors in how often the patient is seen. Persons who are afraid to exercise, who are depressed, or very anxious may be unable or unwilling to perform the exercises at home without supervision/encouragement.

Patients are provided with written home exercises to perform between visits in order to speed their recovery. Typically the number of exercises provided is kept within reason, as patients often have difficulty finding the time to perform the exercises at home, especially if they are currently working. Often the therapist will attempt to build the exercise program into the patient’s daily routine, such as standing on one leg while washing the dishes. Even retired adults will complain if it takes too long for them to perform the home exercise program, so patient education and negotiation is often required in order to have the patient “buy into” performing the exercise program at home. The therapist attempts to “dose” the exercises appropriately so that the movements increase the patient’s symptoms, yet do not disable them.

If the exercise prescription is too aggressive, the patient will become too dizzy or might become fearful of the falling during the exercise and will stop performing the exercises. If the program is too easy, it will not be effective at maximizing the patient’s recovery. Therapist experience and dialogue with the patient will maximize the interaction resulting in an exercise program that is individualized and appropriate for the patient. Individualized exercise programs appear to be superior to generic exercise programs and better meet the needs of the patient (77).

Exercises consist of eye/head movements in every conceivable position progressing to gait, exercises that incorporate head movements during gait, and standard balance exercises. Most people are asked to begin a walking program in order to increase their endurance, strength, and tolerance to movement. Exercises can be simple or very complex. A simple example might include having a person stand on one leg progressing to standing on one leg while tossing a ball or moving the head to the right and left following a moving target with the eyes and/or head. Exercises are individualized based on the patients’ comorbid medical conditions and physical/mental health.

The DHI is often used to quantify subjective impairment and to report changes over time in the self-perceived handicapping effects of dizziness (72). Scores range from 0 to 100 with 0 the best score and 100 the worst score possible. Change of 18 or more has been suggested to be clinically significant (72). Scores of greater than 60 on the DHI have been related to increased reports of falling (98).

Balance confidence is also frequently reported as an outcome measure. Generally when patients feel less dizzy and have better self-reported dizziness, they are better. The Activities-specific Balance Confidence (ABC) scale is the most commonly used balance confidence measure used with persons with dizziness (99). For the ABC scale, a percentage score is reported that ranges from 0% to 100% with 100% the best score and 0% the worst score. Scores of 67% or lower on the ABC appear to represent significant fall risk (100).

Verbal and visual analog scales (101) are also frequently reported as outcome measures, which should improve as the patient begins to feel better (less dizziness, improved balance, and better quality of life). The analog scale scores can be compared across time to suggest that the patient is feeling worse, the same or better as a result of the intervention.

Measures of gait and balance often used include the dynamic gait index (DGI) (102), gait speed (96), the functional gait assessment (FGA) (103, 104), the clinical test of sensory integration and balance (CTSIB) (105), the Timed Up and Go test (TUG) (106, 107), the five times sit to stand test (FTSST) (108), and simple measures such as timed standing in Romberg, single-leg stance or tandem Romberg (67, 78). The DGI includes eight walking tasks, two of which require head movements in the pitch and yaw planes. Scores are based on an ordinal scoring algorithm with 24 the optimal score. Scores of 19 or less have been related to increased fall risk (109, 110).

Gait speed is probably the best overall gait measure, as slower gait speed has been related to increased mortality and morbidity and shortened life expectancy (96, 111). According to Studenski et al. gait speed, age, and gender are the optimal combination for predicting life expectancy. Patients who walk slower are also at greater risk for falling. Often one of the goals of the physical therapist intervention is to increase gait speed.

The FGA includes many of the original DGI items but was designed to be more difficult with the inclusion of
walking with eyes closed, walking backward, and walking heel to toe. Scores on the FGA vary between 0 and 30 with 30 the optimal score. Scores of ≤22 demonstrated the optimal sensitivity and specificity for fall risk (103). Scores ≤22 indicate that the person is at risk for falling.

The modified CTSIB is often performed in the physician office as well as by the physical therapist to determine fall risk and to assess vestibular function (112, 113). The modified CTSIB includes standing in the Romberg position eyes open and closed plus standing on foam eyes open and closed (114). Persons who fall on foam are more likely to fall when walking on uneven surfaces. The modified CTSIB should be performed with caution because many patients fall off the foam. Careful guarding is required in order to assure that the patient and physician are safe while performing the examination. Cass et al. (114) suggested timing how long the person can maintain each of the four positions.

The TUG is a simple measure of balance that has been related to increased fall risk. The patient stands from a chair with armrests upon command and is asked to walk at their normal pace 3 m, turn, and return to sitting in the chair. Scores of 13.5 seconds or longer have been related to falling in older persons (115), and a score of 11.1 seconds has the optimal sensitivity and discriminative properties in persons with vestibular disorders (107). The TUG is extremely easy to test because one only requires 3 m of space, a chair with armrests, and a stop watch. Patients can perform the test with an assistive device (cane, walker). Generally, persons who present to the clinic with a cane or walker are more likely to have fallen, so careful guarding is advised in examining those patients who present with an assistive device.

The FTSST has been used to determine lower extremity strength and balance in persons with vestibular disorders (108). They are asked to stand as quickly as they can five times from a standard height chair (116). The test provides a good overall measure of function (116), especially in older persons with vestibular disorders.