What are the key questions to ask when evaluating a patient with balance issues, specifically to identify the underlying cause of disequilibrium (loss of balance)?

From the Guidelines

When evaluating a patient with balance issues, it is crucial to ask about the onset, duration, and characteristics of their symptoms, including vertigo, lightheadedness, or unsteadiness, to identify the underlying cause of disequilibrium and guide appropriate management strategies. The key questions to ask include:

• Onset and duration of symptoms
• Characteristics of symptoms, such as vertigo, lightheadedness, or unsteadiness
• Associated symptoms like nausea, vomiting, hearing changes, or tinnitus
• Precipitating factors, such as position changes, head movements, or specific activities
• History of falls and risk factors, including age, diabetes, hypertension, and previous stroke
• Functional impact on daily activities and compensatory strategies developed by the patient
• Recent illnesses, ear infections, head trauma, or neurological symptoms
• Medication use, particularly those that can affect balance, such as antihypertensives, sedatives, or anticonvulsants
• Cardiovascular symptoms, such as palpitations or syncope

According to the clinical practice guideline on Meniere's disease 1, a thorough otologic history and physical examination are essential to evaluate for neurologic, neurotologic, otologic, oncologic, inflammatory, or infectious causes of balance issues. The guideline also emphasizes the importance of differentiating between peripheral vestibular disorders, central nervous system issues, medication effects, and cardiovascular causes.

The clinical practice guideline on benign paroxysmal positional vertigo (BPPV) 1 provides additional guidance on diagnosing and managing BPPV, including the use of the Dix-Hallpike test and supine roll test to diagnose posterior and lateral semicircular canal BPPV. The guideline also recommends patient education on the impact of BPPV on daily life, risk of falls, and importance of follow-up.

In patients with stroke, balance impairment is common and can result in falls, low balance confidence, and reduced activity 1. Evaluation of balance abilities is essential to determine the risk of falling and guide balance-specific interventions. Balance training programs have been shown to be beneficial, but no specific approach or program has been demonstrated to be superior.

Overall, a comprehensive evaluation of balance issues requires a thorough history, physical examination, and diagnostic testing to identify the underlying cause and guide appropriate management strategies, prioritizing morbidity, mortality, and quality of life as the outcome.

From the Research

Key Questions to Ask When Evaluating a Patient with Balance Issues

To identify the underlying cause of disequilibrium (loss of balance), the following key questions should be asked:

• What is the type and duration of the vertigo or dizziness? 2
• What are the triggering factors for the vertigo or dizziness? 2
• Are there any accompanying symptoms? 2
• What is the patient's medical history, including any previous balance or vestibular disorders?
• Are there any red flags that may indicate a more serious underlying condition? 3

Clinical Assessment

A thorough clinical assessment is essential to evaluate a patient with balance issues. This includes:

• A detailed history-taking to categorize the patient's complaint, such as using the Drachman type 4
• Physical tests, including provocative maneuvers to reproduce the patient's complaint 4
• Ordinal scales to enable detailed quantitative assessments of balance activity 4
• Hearing assessment, as it is an integral part of the assessment of patients with dizziness 3
• Examination for spontaneous nystagmus and positioning examination to search for benign paroxysmal positional vertigo (BPPV) 2

Diagnostic Frameworks

Several diagnostic frameworks can be used to evaluate balance dysfunction, including:

• The Framework for Movement Analysis developed by the Academy of Neurologic Physical Therapy's Movement Analysis Task Force 5
• The HINTS (head impulse, nystagmus, test of skew) test to differentiate between peripheral and central disorders 2
• Instrument-based receptor-specific examinations, such as the caloric examination and the 3-D video head impulse test (vHIT) 2

Movement System Diagnoses

The Academy of Neurologic Physical Therapy's Movement System Task Force has developed 10 distinct movement system diagnoses that reflect balance dysfunction, which can aid in clinical decision-making regarding intervention 5