What is the diagnostic workup for a patient with balance issues lasting greater than 1 month?

Diagnostic Workup for Balance Issues >1 Month Duration

Begin with a structured clinical assessment using validated screening questions and standardized balance tests, followed by targeted vestibular examination and risk stratification, while avoiding routine imaging or vestibular testing unless red flags are present. 1, 2

Initial Clinical Screening

Start with the three rapid screening questions recommended by the American Academy of Otolaryngology-Head and Neck Surgery: 2

• "Have you fallen in the past year?"
• "Do you feel unsteady when standing or walking?"
• "Are you worried about falling?"

A positive response to any question mandates formal balance testing. 2

Standardized Balance Assessment

Perform the Timed Up and Go (TUG) test as your primary objective measure: 2

• Patient rises from chair, walks 3 meters, turns, returns, and sits
• Time >12 seconds indicates increased fall risk and warrants comprehensive evaluation 2
• This provides quantifiable, reproducible data for monitoring progression 3, 4

If TUG is abnormal or clinical suspicion remains high, proceed to Berg Balance Scale: 2

• 14-item assessment scoring 0-56 (higher scores = better balance)
• Score <41 indicates need for assistive device 2
• More comprehensive than TUG but requires 15-20 minutes 3

Vestibular-Specific Examination

For patients with vertigo or spinning sensations, perform positional testing: 1

Dix-Hallpike maneuver (for posterior canal BPPV): 1

• Bring patient from upright to supine with head turned 45° to one side, neck extended 20°
• Positive test shows torsional, upbeating nystagmus with vertigo
• Repeat with opposite ear if initial maneuver negative 1

Supine roll test (for lateral canal BPPV): 1

• Perform if Dix-Hallpike shows horizontal or no nystagmus
• Essential to avoid missing lateral canal involvement 1

Head impulse test: 4, 5

• Assesses vestibulo-ocular reflex function
• Abnormal test suggests peripheral vestibular pathology 5

Neurological Assessment

Conduct focused neurological examination to differentiate peripheral from central causes: 1, 2

• Gait evaluation with walking speed measurement (>0.8 m/s = community ambulation, 0.4-0.8 m/s = limited community, <0.4 m/s = household only) 2
• Motor and sensory examination for stroke or CNS pathology 1, 2
• Cerebellar testing (dysmetria, dysdiadochokinesia) 1
• Cranial nerve examination, particularly for dysarthria, dysphagia, or Horner's syndrome suggesting brainstem involvement 1

Risk Factor Assessment Using P-SCHEME

Systematically evaluate modifiable contributors: 2

• Pain affecting mobility
• Shoes (inappropriate footwear)
• Cognitive impairment
• Hypotension (check orthostatic vital signs)
• Eyesight problems
• Medications (particularly vestibular suppressants, sedatives)
• Environmental hazards 2

What NOT to Order

Do not obtain routine imaging in patients meeting diagnostic criteria for BPPV without additional concerning signs: 1

• Red flags warranting imaging include: new neurological deficits, severe headache, inability to stand/walk, direction-changing nystagmus, or symptoms inconsistent with peripheral vestibular pathology 1

Do not order vestibular function testing (VNG, rotary chair, VEMP) initially unless: 1

• Diagnosis remains unclear after clinical examination
• Symptoms persist despite appropriate treatment
• Suspicion for bilateral vestibular loss or central pathology 1, 6

Documentation Requirements

Record the following for comprehensive assessment: 2

• Subjective symptoms with onset timing and triggers
• Vital signs including orthostatic blood pressure
• Specific balance test scores with dates (TUG time, Berg score)
• Gait aid requirements
• Fall history with circumstances 2

Follow-Up Timeline

Reassess within 1 month after initial evaluation or treatment: 1, 7

• Document resolution or persistence of symptoms
• If symptoms persist, evaluate for unresolved vestibular pathology or underlying CNS disorders 1, 6
• Consider repeating vestibular function tests if progression suspected 6

Common Pitfalls to Avoid

Do not prescribe vestibular suppressants (antihistamines, benzodiazepines) for chronic balance issues: 1, 6

• These medications delay central vestibular compensation
• Reserve for acute vertigo episodes only, not maintenance therapy 6, 7

Do not overlook fall risk assessment in elderly patients: 1

• 9% of geriatric patients have undiagnosed BPPV, with three-fourths having fallen in prior 3 months 1
• Balance disorders increase fall risk 12-fold in symptomatic older adults 1

Do not assume single pathology: 6

• Multiple concurrent vestibular disorders are common
• Discordance between test results is typical, particularly in Ménière's disease 6