Question
Can you walk us through an evalualtion session that you would have with one of your vestibular patients? Please give details of what tests you choose and the treatment that follows?
Answer
I always start the eval with a detailed history: frequency, intensity, duration of the dizziness, onset, and any background medical history. My favorite diagnosis to work with is unsteady gait. Unsteady gait has an ICD-9 code; dizziness also has an ICD-9 code. I start with that, and then I look at ocular motor control, pursuits, saccades and ability of the person to keep their eyes still. As I said earlier, impaired ocular motor control is an indication of a central lesion. You would want to rule that out first. Then, because I have such a long history of treating older patients, I do a falls history. Then we have to establish communication. Just like you use a pain scale of 0 to 10, 10 being the worst, you can do the same thing with dizziness. I say, "If your dizziness is on a scale from 0 to 10, 10 being the worst and 0 being none, what is your level right now? What makes it worse? What makes it better?" I get all of that information first.
Next, I normally test the VOR even if I am not sure of the cause of the dizziness. If the VOR is hypofunctioning, I am going to treat it. Then, I ask about the patient's symptoms. If they tell me they are having trouble walking, I assess gait. The DGI is great for that assessment. If the problems are more postural, maybe with some older patients who are having trouble standing in the kitchen, I might do a Berg or somehow assess standing balance. What I would do next would be based on how much time I have.
Just like with orthopedics, I send patients home with one item for a HEP. What is the most important thing? If I find that someone has impaired ocular motor control with smooth pursuits or saccades, I address that with their HEP. If I find that they had an impaired VOR, I would give them a VOR strengthening or head shaking activity. There is great information in the Herdman (2007) book. There are also free apps if you have an iPhone; you can download a metronome. I had a patient that downloaded a metronome onto his computer. He did his VOR strengthening and progressed himself over the week from the paper that I had given him. He was better in a week. If we diagnose a hypofunctioning VOR and we treat it really well, it can be very successful.
Herdman S. Vestibular Rehabilitation. 3rd Edition. Philadelphia, PA: F.A. Davis Company; 2000.
