Objective: Describe patient and physician characteristics, and physician recommendations for ambulatory care visits for dizziness in the US. Study Design: Cross-sectional analysis of visits for dizziness from the National Ambulatory Medical Care Survey (2013–2015). Setting: Ambulatory care clinics in the US. Patients: 20.6 million weighted adult visits [mean age 58.7 (1.0)] for dizziness, identified using ICD-9-CM codes (386.00–386.90, 780.40). Main Outcome Measures: Patient, clinical, and physician characteristics and physician diagnostic and treatment recommendations. Prevalence rates for benign paroxysmal positional vertigo (BPPV), unspecified dizziness, and other vestibular disorders were estimated, and descriptive statistics were used to characterize patients, physicians, and physicians’ recommendations. Results: The prevalence rate for dizziness visits was 8.8 per 1,000 (95% confidence interval [CI]: 7.5, 10.3). Most visits were for unspecified dizziness (75%), made by women (65%), whites (79%), and were insured by private insurance (50%). Visits for dizziness were to primary care physicians (51.9%), otolaryngologists (13.3%), and neurologists (9.6%). Imaging was ordered and medication prescription was provided in 5.5% and 20.1% of visits. Physical therapy (PT) was used for a higher percentage of BPPV visits (12.9%), than for other diagnoses (<1.0%). Physician treatment recommendations for vestibular diagnoses varied by physician specialty. Conclusions: A large percentage of visits had an unspecified diagnosis. A low number of visits for vestibular disorders were referred to PT. There are opportunities to improve care by using specific diagnoses and increasing the utilization of effective interventions for vestibular disorders.

Purpose of review Rehabilitation for persons with vertigo and balance disorders is becoming commonplace and the literature is expanding rapidly. The present review highlights recent findings of both peripheral and central vestibular disorders and provides insight into evidence related to new rehabilitative interventions. Risk factors will be reviewed to create a better understanding of patient and clinical characteristics that may effect recovery among persons with vestibular disorders. Recent findings Clinical practice guidelines have recently been developed for peripheral vestibular hypofunction and updated for benign paroxysmal positional vertigo. Diagnoses such as persistent postural-perceptual dizziness (PPPD) and vestibular migraine are now defined, and there is growing literature supporting the effectiveness of vestibular rehabilitation as a treatment option. As technology advances, virtual reality and other technologies are being used more frequently to augment vestibular rehabilitation. Clinicians now have a better understanding of rehabilitation expectations and whom to refer based on evidence in order to improve functional outcomes for persons living with peripheral and central vestibular disorders. Summary An up-to-date understanding of the evidence related to vestibular rehabilitation can assist the practicing clinician in making better clinical decisions for their patient and hopefully result in optimal functional recovery.

Background Everyday ambulation requires navigation of variable terrain, transitions from wide to narrow pathways, and avoiding obstacles. While the effect of age on the transition to a narrow path has been examined briefly, little is known about the impact of fear of falling on gait during the transition to a narrow path. The purpose was to examine the effect of age and fear of falling on gait during transition to a narrow path. Methods In 31 young, mean age = 25.3 years, and 30 older adults, mean age = 79.6 years, step length, step time, step width and gait speed were examined during usual and transition to narrow pathway using an instrumented walkway. Findings During the transition to narrow walk condition, fearful older adults compared to young had a wider step width (.06 m vs. .04 m) prior to the narrow path and took shorter steps (.53 m vs .72 m, p<.001). Compared to non-fearful older adults, fearful older adults walked slower and took shorter steps during narrow path walking (gait speed: 1.1 m/s vs .82 m/s, p=.01; step length: .60 m vs .47 m, p=.03). In young and non-fearful older adults narrow path gait was similar to usual gait. Whereas older adults who were fearful, walked slower (.82 m/s vs .91 m/s, p=.001) and took shorter steps (.44 m vs .53 m, p=.004) during narrow path walking compared to usual walking. Interpretation Changes in gait characteristics with transitioning to a narrow pathway were greater for fear of falling than for age.

Background and Purpose: Persons with vestibular disorders are known to have slower gait speed with greater imbalance and veering during dual-task walking than healthy individuals, but the cerebral mechanisms are unknown. The purpose of this study was to determine whether individuals with visual vertigo (VV) have different cerebral activation during dual-task walking compared with control subjects. Methods: Fourteen individuals with VV and 14 healthy controls (CON) were included (mean 39 years old, 85% women). A cross-sectional experimental study consisting of 4 combinations of 2 surfaces (even and uneven) and 2 task conditions (single- and dual-task) was performed. Participants walked over an even (level flooring) or uneven (wood prisms underneath carpeting) surface, either quietly or while reciting every other letter of the alphabet. Changes in cerebral activation over the bilateral prefrontal cortices were recorded using functional near-infrared spectroscopy during 4 task conditions relative to quiet standing. Gait speed and cognitive performance were recorded. Results: There were no between-group differences in cognitive performance. Both groups slowed when walking on an uneven surface or performing a dual-task; participants in the VV group walked more slowly than those in the CON group in all conditions. Participants with VV had decreased cerebral activation in the bilateral prefrontal regions in comparison to CON participants in all conditions. Discussion and Conclusions: Participants with VV had lower prefrontal cortex activation than CON participants during dual-task walking. Lower cortical activity in those with VV may be due to shifted attention away from the cognitive task to prioritize maintenance of dynamic balance. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A303).

Benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder, is often diagnosed in primary care settings. 1 Clinical practice guidelines published by the American Academy of Otolaryngology-Head and Neck Surgery Foundation in 2008 and 2017 recommend against imaging for the diagnosis of BPPV and vestibular suppressant medications for the treatment of BPPV. 2,3 Despite these recommendations, physicians' diagnostic and treatment choices for dizziness vary, with medications being the most frequent treatment prescribed in primary care settings. 4 We examined 12 years of data (January 1, 2004, to December 31, 2015) from the National Ambulatory Medical Care Survey to evaluate the prevalence of visits to ambulatory care clinics for BPPV and whether physicians' diagnostic and treatment recommendations, stratified by specialty, adhered to clinical practice guidelines over time. Methods | We identified adult visits (patients aged >18 years) for BPPV by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code (386.11), classified them by physician specialty (primary care, otolaryngology, or neurology), and investigated whether imaging (computed tomography, magnetic resonance imaging, or positron emission

Objective The purpose of this study was to determine the association between fear-avoidance beliefs and disability in 3 months in people with vestibular disorders while accounting for demographic and clinical characteristics. Methods This prospective cohort study included people aged 18 to 100 years who reported dizziness. Participants were recruited from a balance disorders clinic and outpatient physical therapy clinics. All participants completed the Vestibular Activities Avoidance Instrument (VAAI) and the Hospital Anxiety and Depression Scale (HADS) at baseline and the Vestibular Activities and Participation measure (VAP), dizziness Visual Analogue Scale (VAS), and 12-item Short Form Health Questionnaire (SF-12) at baseline and 3-month follow-up. A modified version of the VAAI included 9 items abstracted from the 81-item VAAI. The relationships between 9-item VAAI scores and follow-up measures of disability were assessed using Spearman’s correlation coefficients. Linear regression models were analyzed to determine the effect of fear-avoidance beliefs on follow-up VAP score while accounting for baseline outcome measures. Results All participants (404) completed the baseline assessment (mean age = 54 y), and 286 (71%) completed the 3-month assessment. The mean 9-item VAAI score was 25 (SD = 14) at baseline and was significantly associated with VAP (ρ = 0.54), SF-12 component scores (ρ = −0.53; −0.44), and dizziness VAS at follow-up (ρ = 0.37). Approximately 38% of the variation in VAP score at follow-up was predicted by 9-item VAAI score, dizziness VAS, and HADS-D score when considered together (R2 = 0.38). Conclusions Fear-avoidance beliefs are associated with measures of disability at 3 months and are predictive of activity limitations and participation restrictions at 3 months when controlling for age, medications, baseline dizziness and depression symptom severity in people with vestibular disorders. Impact Measurement of fear-avoidance beliefs may provide important prognostic information, suggesting that an assessment of fear-avoidance beliefs could be used by clinicians to identify individuals at greater risk of disability after a vestibular disorder. Lay Summary Fear-avoidance beliefs in people who have vestibular disorders are associated with disability at 3 months and predict limitations in daily activities at 3 months.

Background: Concussion can cause vestibular dysfunction and oculomotor abnormalities which can lead to dizziness and protracted recovery time. There are few clinically useful, functional measures of the vestibulo-ocular reflex (VOR) post-concussion. Purpose:The purpose of this study is to examine the gaze stabilization test (GST) in those referred for vestibular physical therapy following concussion, to determine the association between the GST and other measures of recovery following concussion, and to examine the effect of demographic variables on GST performance. Research Design: Retrospective chart reviewStudy Sample: 158 individuals who sustained a concussion and were referred to vestibular physical therapy. Data Collection and Analysis:Horizontal and vertical GST scores (HGST and VGST), neurocognitive testing results, and demographic data were extracted retrospectively from the patient health record. Correlations between GST velocity and neurocognitive test results and between the GST and patient-reported outcomes were examined. Differences in GST performance among patient subgroups were examined using one-way ANOVA.Results: Subjects included individuals aged 12 to 43 years (M=20, SD=7), with most having sport-related concussion (67%). The mean time from injury to GST was 215 days (SD=241) and mean time from physical therapy evaluation to GST was 48 days (SD=54). HGST and VGST had a weak positive correlation to the Activities-specific Balance Confidence Scale (r=0.20, r=0.21) and weak negative correlation to the Dizziness Handicap Inventory (r=−0.18, r=−0.22). HGST had a weak positive correlation to the visual motor processing speed domain of the Immediate Post-Concussion Assessment and Cognitive Test (r=0.20). Male patients achieved significantly higher velocities than female patients on horizontal and vertical GST (p=.02, p=.01).

Background and Purpose: Falls are a major healthcare concern in individuals with Alzheimer Disease (AD) and their caregivers. Vestibular impairment is a known risk factor for falls, and individuals with AD have been shown to have an increased prevalence of vestibular loss compared to age-matched controls. Vestibular physical therapy (VPT) is effective in improving balance and reducing fall risk in cognitively-intact persons with vestibular impairment. However, the effectiveness of VPT in improving balance and reducing falls in individuals with AD who have vestibular loss has never been explored.