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BackTable / ENT / Article
Vestibular Therapy: What to Expect When You Refer
Taylor Spurgeon-Hess • Dec 11, 2021 • 300 hits
Many physicians recognize the benefits of sending their patients to physical therapy, and today, ENTs utilize vestibular therapy specifically to help treat a variety of conditions, including vertigo, benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and vestibular hypofunction. But what can a new patient expect when walking through the doors of a vestibular rehabilitation clinic?
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• A thorough history, including details about the psychosocial aspects of a condition, creates the foundation for treatment and indicates when a patient may be better treated through primary care management instead of through vestibular therapy.
• During a typical physical exam, the vestibular therapist will conduct a thorough oculomotor exam, a HINTS test, balance testing, and positional testing.
• Each vestibular therapy physical is individually tailored to patient mobility, tolerance, and symptom presentation.
• Subjective assessment often plays a role in determining a vestibular therapy treatment plan, as many physical exam findings may not provide enough concrete direction to base the plan of action on the objective findings alone.
Table of Contents
(1) Step 1: Patient Evaluation for Vestibular Therapy
(2) Step 2: The Vestibular Therapy Physical Exam
(3) Step 3: The Subjective Assessment’s Role in Vestibular Therapy
Step 1: Patient Evaluation for Vestibular Therapy
When meeting with a new patient, the vestibular therapist first solicits a detailed history with some typical questions about symptoms and onset but also may dive deeper into the psychosocial aspects of the condition. This may include a discussion of the patient’s fears or anxieties around the condition or symptoms. The medical history often forms the basis upon which the physical exam is built. Sometimes a patient may be turned away from vestibular therapy based on a “red flag” indicating their condition would be better treated through a primary care office or the emergency department. Johnston explains that the issues he usually sees include high blood pressure, concerning vertical eye movements, or, rarely, a central finding indicating a lesion or tumor.
[Ashley Agan MD]
So maybe we can jump into the evaluation process and kind of what things look like in your clinic. So I sent you a dizzy patient, so maybe I've made the diagnosis of, you know, something like BPPV, benign paroxysmal positional vertigo, or maybe I, you know, we're suspecting some sort of a similar hypofunction or something, but regardless, or, or maybe I'm just like, you're dizzy and your workup is negative.
…Maybe this person can help you. What do things look like once they meet you? I usually tell patients that you guys will do an initial evaluation and kind of make a treatment plan. What does that look like?
[Matthew Johnston PT]
That's a great question. And I think the best answer is it kind of looks like a thorough process, and there needs to be a solid framework. And I think the best way to do that is get a lot of reps in treating these patients. First and foremost, a very thorough long history taking, trying to understand when this happened, was it sudden, you know, what their symptom patterns are looking like.
The duration of symptoms can tell you a lot about what type of thing we're dealing with, what provokes it, what makes it better, you know, trying to rule out some red flags in the process. So that subjective history really getting that patient's story is extremely important. It kind of sets up the next part of the exam, which is that physical exam, but the subjective history, we're really kind of talking with the patient, understanding their story.
But also getting something like the psychosocial aspects of their care, you know, are they really nervous about this? Are they like, I haven't gone out, and bike ride, you know, in a year because I was afraid, that's when it all started, you know? So those kinds of things where, it's not just like, this makes it worse and this makes it better.
But some of those other things that are going to kind of nuance our treatment, a lot of that comes from like the history taking and the story that the patients tell. The next part is more of that physical exam, and that might be something the ENT may be more familiar with. a very thorough ocular motor exam, you know, a head impulse test, the dynamic static balance testing, and then the positional tests.
That's probably what we see most often actually. ENTs will put patients on the table, and most of the patients will come back and say, well, they put me on the table and this happened, I got really dizzy. And then they sent me to you. So that's usually like the most kind of common thing that we see or hear, I guess, from patients. But the subjective history is really important to kind of set up the next step.
[Gopi Shah MD]
What are some of the red flags you mentioned?
[Matthew Johnston PT]
A lot actually is blood pressure relief related. More often than not, we send patients away because their blood pressure is inappropriate for us to see. It's sending them back to their primary care for further management. Sometimes in rare occasions, it's like, you need to go to the hospital. We call the primary care and they say, no, send them, send them right over to the emergency department.
That's probably the biggest thing that we kind of stop session for. And then other things, we'll see some vertical eye movements that might be concerning for us. We might see some things that like, everything is negative. We've done maybe some initial treatment and still quite aren't sure it's vestibular oriented.
So that might be something that might warrant at least further imaging or further workup might not be “a red flag,” but something that we need a little more collaboration with. But by and large, at least in my experience with the patients, I see some sort of cardiovascular suspected stroke or blood pressure issue.
And then, rare occasions, we might see some central findings that might indicate some sort of lesion or tumor or some sort of malignancy that, you know, we might be concerned.
[Ashley Agan MD]
Is it usually high blood pressure. Blood pressure that you guys are seeing that's concerning?
[Matthew Johnston PT] Probably 95% of the time, anywhere, 190 or higher, you know, two hundreds. Yeah. Just, you know, something over 120, but things that are… I'm nervous for you to be here, or are you taking, you know, some of those kinds of things like that. Like not just are you not taking your medications, but things that--
[Ashley Agan MD]
Do you feel okay?
[Matthew Johnston PT]
Yeah. And,
[Ashley Agan MD]
Do you have a headache?
[Matthew Johnston PT]
Right, right, right, right. And especially when they come in with complaints of dizziness, you know, that combination kind of gets us a little nervous. But by and large, you know, that's on the rare occasion.
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Step 2: The Vestibular Therapy Physical Exam
While a thorough history provides a foundation, the vestibular physical exam can definitively indicate which treatments are most appropriate. The majority of patients will receive a thorough oculomotor exam first. While Frenzel lenses yield the most accurate results, the exam can also be done with something as simple as a pen. The PT may conduct a HINTS test which when positive indicates a stroke, and when negative can help to rule out cerebrovascular or stroke events, especially in high-risk patients. The HINTS acronym represents a head impulse test, nystagmus testing, and a test of skew. Based on patient tolerance and mobility, a balance screening and positional test will likely also be conducted. Various maneuvers in positional testing for BPPV or vertigo allow a vestibular therapist to assess eye movement or nystagmus which can shed light on a patient’s horizontal ear canal function.
[Gopi Shah MD]
So can we get it to the [vestibular therapy] physical exam in a little bit more detail? Like, I don't have Frenzel lenses. Okay. And I see kids, I probably see maybe two dizzy kids a year. and they're usually teenagers, although I've had as young as eight.
That being said, my physical exam, I don't know. I'll do a little, as long as they don't have any neck issues, like head shake, head thrust, you know. I'll make sure they can do tandem walk, check their cerebellar function. I'll do a dix hallpike. Is that the kind of stuff or? Go through it with me. Tell me exactly what you're doing.
[Matthew Johnston PT]
What you just said is a lot of what we do. I think the systematic approach is important, obviously screening vitals first, but then a thorough ocular motor exam. Like how does, how well do their eyes track, you know, can they hit one target to the next target to look at saccades?
What is their vestibular ocular reflex look like? Can they maintain that vestibular ocular reflex for 30 seconds? Horizontally, vertically. We're going to do a VOR cancellation test. Pretty much all my patients will get a very thorough ocular motor exam.
[Ashley Agan MD]
Do you use any equipment to help you with your oculomotor exam or is it all just like follow my finger? I'm looking at your eyes kind of thing.
[Matthew Johnston PT]
It's usually a pen. A pen and my hand. We don't have Frenzel lenses or goggles at our office. I've worked with those in the past and they are definitely gold standard. Something that is kind of best practice, something that's going to get us the most accurate answer. And sometimes we do refer patients out for that specific type of testing.
But in a setting or practice that I work at it's really just follow the pen. Now let me cover one eye or the other for, you know, occluding vision or the cross-cover test. That HINTS to infarct test. I don’t know if you guys are familiar with that but that's something we use on a daily basis.
[Gopi Shah MD]
I'm not familiar with it, please explain.
[Matthew Johnston PT]
Sure. Sure. It's so it's a HINTS to infarct.
So it's looking for a stroke in patients that might present with acute onset of dizziness. So it's an acronym that is pretty sensitive for ruling out cerebrovascular or stroke events. And it's something that used, I think it was originally developed in the emergency department. It has become a really good tool.
Not something that, usually by the time they make it to see me, unless they're coming under, what's called direct access or without a prescription, or they're our current patient that we're seeing, you know, “Oh my God, I woke up yesterday and had a horrible dizziness,” and we're seeing them for evaluation, most of the time that ends up being negative.
I don't think I've ever had anyone that's like, “Oh my God, you need to be sent to the emergency department.” But it's a really good exam. It's a really good, thorough thing that you can put into an examination, especially for patients that might be more at risk.
[Ashley Agan MD]
What are some of the items on that?
[Matthew Johnston PT]
Sure. So we're looking at a head impulse test. If the head impulse test is negative, we are looking at a skew deviation, like, did they have any vertical movement of the eye? Do they have a head tilt? Thinking about someone who's uncompensated for hypofunction, they might present that way. But if some of the testing is negative, that might be leading us to more a stroke-like condition.
… So, after the ocular motor exam, most of the time we're going to screen their balance, statically. The modified CTSIB is the test that we follow. So looking at them in, you know, feet together, tandem balance, single leg, eyes open, eyes closed. And then on the foam or compliant surface, especially foam eyes closed can tell us the most about the vestibular system so that— If someone like falls right over with that, okay maybe I'm thinking, is there something more acute happening or is there something that definitely is pointing towards the vestibular system with this type of person.
[Ashley Agan MD]
Do you ever have to modify that? You know, I'm imagining some of these older patients that, you know, are barely just standing on hard ground sometimes, and putting them on foam and seeing what happens.
[Matthew Johnston PT]
Yeah, absolutely. Obviously all of this is patient dependent and what they tolerate, you know, someone who might have some knee pain or some back pain or can't stand for too long. We're going to modify some of these things with, you know, instead of feet together, it might be feet apart. Instead of standing on one leg, we might go for a tandem or a semi tandem. We might skip the foam for that day until they build up some tolerance. So a lot of it is what they come in with and matching, our exam, you know, we're not trying to fit patients into like, here's our box and we have to do everything just because it's what we have to do. There are some important information that we need to get, just to make sure this is like a person that's safe to be here and there's no red flags happening.
But by and large, we can modify these exam points and start where the patient's ready. Like it's all adapted to what they're capable of and what they're kind of bringing with them in terms of past medical history or social history and stuff like.
[Ashley Agan MD]
Yeah, that makes sense.
[Gopi Shah MD]
And the foam test, it's literally, you're getting like one of those egg crate foams, putting it on the ground and having the patient do some of the balance work, tandem, leg ups, standing on the foam. Is that what you're saying with that?
[Matthew Johnston PT]
Essentially. Yeah, we’ve used these like blue AIREX pads, they’re kind of a squishier compliant surface. Most of the time, it's like feet together, eyes open, eyes closed. Kind of a basic screening, for someone like maybe you might see, Gopi, is like a younger person, athlete, we might make them do like single leg or, single leg with head movements or something like more advanced.
But again, it's kind of like adapting what we're doing and scaling it up or scaling it down depending on what the patient's capable of doing. Or what their goals are. You know, if their goal is to be flipping in the air, doing gymnastics, we're going to do something more aggressive and something that might be more challenging to them.
[Ashley Agan MD]
Yeah. And if I remember correctly, way, way back in the day, when we were learning about all of the vestibular tests, when someone is standing on foam and their eyes are closed, they are purely relying on their vestibular system for their balance. Right. Cause they don't have proprioception.
[Matthew Johnston PT]
That's exactly right.
[Ashley Agan MD]
And they don't have visual cues. So you're kind of able to isolate.
[Matthew Johnston PT]
That's it. Good memory.
[Ashley Agan MD]
That's about as far as it goes.
[Gopi Shah MD]
Clearing that cobweb.
[Ashley Agan MD]
Yeah. That's very dusty information.
[Matthew Johnston PT]
Yeah. And that, to me, to me, that's like the most, the one that I want to get to the most, because it's going to give me like pass or fail. Can they make 30 seconds? Can they not? If they, if they can, if they only make one or two seconds and they're right over, okay, that's going to give me a lot of information of like how functioning or how functional this system is.
[Ashley Agan MD]
That makes sense. Any, any other physical exam maneuvers that we missed?
[Matthew Johnston PT]
I think the most important and maybe the things that you guys are most familiar with are positional testing for BPPV, or the positional vertigo. Usually, we'll have patients go from sitting to supine first we're assessing eye motion or nystagmus in that position. That's going to tell us about horizontal canal function.
I have a preference for just turning patients on their side, either left or right, for a roll test. Some therapists will just move the head. I've just never had good experience getting patients all the way to the degrees that I want them to. So I generally just have them, just like turn on their side, so it’s usually easier.
So I'm assessing for their geotropic or apogeotropic nystagmus there. And symptom reproduction, of course. And then finally, it's those dix hallpikes positions off the edge of the table, or in a modified position to see if their posterior or anterior canals are involved.
Step 3: The Subjective Assessment’s Role in Vestibular Therapy
After completing a comprehensive physical exam with no concrete findings, the vestibular therapist may rely more heavily on the subjective assessment to aid in diagnosis and treatment. The subjective assessment includes judgments made based on the elicited history as well as conclusions drawn from physical exam findings that deviate from the “textbook presentation.” Since many patients come in with debilitating dizziness, and others may have mobility concerns, it is not uncommon for a vestibular therapy physical exam to yield false-negative or false-positive results. The subjective assessment allows the physical therapist to remain adaptable in the absence of “textbook presentations” of symptoms.
[Gopi Shah MD]
How important is the subjective? So you don't see any nystagmus, but you sit him back up and there, the remiss thinning for them. How important is that to you in your evaluation?
[Matthew Johnston PT]
So we're always constantly weighing, the positional tests can be tricky I think. You know, the speed of movement, you know, is the head in the right position. I think the anatomy books, or maybe what people learn in school as the canal system is oriented exactly 45 is not quite right. Because you might have to give that person maybe 55 degrees of rotation or 10 degrees of rotation, or they may can't get into the position.
Sometimes you have to, you might have to do the positional testing more than once, and it kind of depends on what the person's coming into the clinic with in terms of their mobility. And, not only joint wise, like neck, can they move it, but like their body mechanics, can they, do they have hard time going from laying down to sitting up normally? Now you add this dizziness component to it.
So you might get false positives or false negatives. And you might have to kind of think about what's the most likely cause of things. Every time patient says, “Every time I turn to my right and it happens,” I get a left positive. So you have to kind of weigh these factors.
And if someone sits up and I'm seeing no nystagmus throughout the whole process, usually with sitting up symptoms, I'm more thinking towards a hypofunction or something else. Usually I'm looking for that dissent symptoms and that's going to tell me, at least personally, where I'm going to start. Sometimes I'll treat something and send a patient home and say, well, let's see how that goes.
[Ashley Agan MD]
Yeah, I think that makes sense.
[Matthew Johnston PT]
But that's a really good question because they don't always have nystagmus.
[Ashley Agan MD]
They frequently don't. Like when people actually have the perfect, you know, rotary nystagmus, like, I feel like I almost cheer.
[Gopi Shah MD]
I'm excited. I’m like, wow.
[Ashley Agan MD]
I’m like, “Alright!” We definitely, we found it, you know, they're like, whoa, like this is a great type of dizziness to have. We're going to cure you. It's going to be great.
But yeah, a lot of the times, you know, they might feel a little dizzy or it's just, they don't quite have it.
[Gopi Shah MD]
Well, and that's why they're coming to us right?
[Ashley Agan MD]
And then I send them to you guys and I say, “You're going to figure it out.”
[Matthew Johnston PT]
Yeah. And I think it's validated for patients to like, “Oh, my gosh, you're actually seeing it. You know, this is what the ENT saw.” They couldn't make it happen, but then therapy gets it to happen or vice versa. So I think them knowing that it's actually having the nystagmus is very validating, but on the other side, it can be very tricky to navigate when you put patients down and be like, well, the ENT did this and I was really dizzy.
And then they get to you a week later, or two weeks later, whenever. Nothing happens.
[Gopi Shah MD]
Yeah.
[Matthew Johnston PT]
And so that can become tricky to navigate. And some patients just clear on their own by the time they get to see us, so. And sometimes you can't make it happen, but they still have ongoing dizziness. And then you might have to course correct with that whole different plan of care.
So it's all very, very, very adaptable and very, you know, I won't say complicated cause that's not the right word, but,
[Ashley Agan MD]
I would say it's complicated. It's complicated for me sometimes.
[Gopi Shah MD]
For sure.
[Matthew Johnston PT]
I think once, you know, the rules and that like once you know, the rules and have the framework in place, I think it becomes a little more simple, but there is, there is some nuance, you know, I won't totally discredit my profession, but like there is, there is a lot of nuance happening. And there's a lot of weighing of factors, because it's not always going to look the same and things can fatigue, like nystagmus can fatigue in certain cases. Yeah, it can be totally variable in the day. You might bring them in for an eval on Monday and find nothing. And then second visit on Wednesday is when they have like the worst dizziness all the time.
So it can be surprising sometimes.
Podcast Contributors
Matthew Johnston, PT
Matthew Johnston, PT is the clinic director at Excel Physical Therapy and Fitness in Philadelphia, Pennsylvania.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 9). Ep. 36 – Vestibular Rehab: A Physical Therapist's Perspective [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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