Getting Better: Diagnosis and Treatment.

Goebel JA. Portland, OR 97208-4467, Vestibular Disorders Association, 2001, VHS, 55 min, ISBN: 0-9632611-7-7, $25.

Getting Better: Diagnosis and Treatment is a videotape developed by the Vestibular Disorders Association and features Dr Joel A Goebel, a renowned neuro-otologist who is the Director of the Vestibular and Oculomotor Laboratory at the Washington University School of Medicine in St Louis. The tape is the second in a series of videotapes dealing with vestibular disorders, and its purpose is "to help people with vestibular disorders, their families, and professionals understand diagnosis and treatment."

The videotape is divided into 5 main topic areas with corresponding subtopics. In each topic area, Dr Goebel presents a clear, concise discussion of the main points. Brief comments from patients or caregivers are interspersed throughout the video and at the beginning and end of the tape. In addition to the tape's detailed information on the background of diagnosis and management strategies for vestibular disorders, the overall impression one gains from the video is 2-fold: (1) the remarkable and amazing capacity of the nervous system to compensate and heal following injury and (2) because vestibular disorders are difficult to diagnose, patients should persevere throughout the diagnostic process until the proper diagnosis is formed, and they should remain hopeful that they will get better.

The first part--"Defining the Difference"--gives a brief explanation of the differences among dizziness, vertigo, and dysequilibrium and emphasizes the importance of clarifying the symptoms that the patient describes.

Part 2 talks about finding medical help and emphasizes the importance of starting with the primary care physician to rule out some common causes of dizziness. This part then explains when an otolaryngologist should be consulted and when and why a neurologist or a neuro-otologist, a practitioner of a subspecialty of otolaryngology, should be consulted. This discussion leads smoothly into part 3, which talks about "diagnostic dilemmas." Dr Goebel points out the dilemma presented by the many factors that could be involved in producing symptoms of dizziness, vertigo, or dysequilibrium. Solving this problem requires a thorough patient history, medical examination, and laboratory testing. Goebel points out that this solution is complicated because, in order to maintain balance, the human organism must be able to sense the environment and integrate or make sense of this sensory information. The medical history and tests must be used to determine if the musculoskeletal system is able to respond to commands from the brain.

Part 4 talks about how important it is that the patient provide complete information and test results from previous examinations. It also recommends that the patient bring a support person along to help clarify information.

Part 5, "Elements of the Medical Exam," then discusses briefly 5 key parts of the medical approach: patient history, physical examination, laboratory testing, differential diagnosis, and treatment. The patient history is the most critical element because many times it may show a pattern when the examination results do not reveal any disabilities. The discussion of the physical examination includes looking at eye movements, gait, the Hallpike maneuver, and positioning. In my opinion, patients viewing this tape would find it beneficial to have pictures or demonstrations of some of these procedures, especially the Hallpike maneuver. In the coverage of laboratory testing, pictures of electronystagmography, posturography, and rotary chair testing were provided along with brief descriptions and the potential limitations of each test. In his discussion of differential diagnosis, Goebel covers what the physician looks for in the test results. He states that the results may come back negative and the patient may then receive a "therapeutic trial." If the patient gets better, then a diagnosis can be made. Goebel makes clear that patients cannot realistically expect a diagnosis the first time, because magnetic resonance imaging or computed tomography scans may be needed. Once a preliminary diagnosis is made, the final element, treatment, can begin.

A major portion of the video is spent on treatment. In the first segment, "Consult With the Doctor," Dr Goebel describes 4 major diagnoses--benign paroxysmal positional vertigo (BPPV), Meniere disease, vestibular neuritis, and migraine headaches--and details their causes, symptoms, time course, and prognosis. The next major segment discusses 5 approaches to management or treatment. In his discussion of the first approach, medication, Goebel explains what happens when a person loses function on one side of the vestibular system and why and when medication may be necessary. Medications are usually indicated during the static compensation phase following loss of nervous system function. Dr Goebel argues that the second approach to treatment, vestibular rehabilitation, is one of the most valuable treatment tools to arise in the past 10 years because of the progress of the research. Toward the end of the video, when he discusses how treatment and diagnosis bridge many different specialties, he notes that physical therapists and occupational therapists play pivotal roles in the rehabilitative process. The third approach, diet, is very briefly touched on and was mentioned in the discussion on Meniere disease and migraine. Monitoring is the fourth approach discussed. Finally, Goebel discusses when a surgical approach is needed, which he estimates occurs only 5% of the time.

The final segments of the video discuss the role of the physician or balance specialist as a "conscience" or sounding board for the patient to help get through difficult times. The video again emphasizes that "treatment is a process" and that the patient's recovery is the ultimate goal of this process. Finally, the role of the family is discussed, and the video ends with patients and family members providing their interpretation of the diagnostic and treatment process and what it has meant to them.

This is an excellent video that would be useful for general practice physicians and as an introductory overview for physical therapists who are working or will be working with a patient who has a vestibular disorder. Therapists who are already specializing in vestibular rehabilitation may find it helpful as a review or as general clarification of the sequence of the medical examination and the difficulties inherent in arriving at a definitive diagnosis. Patients and their families would find this video extremely informative as well as hopeful and positive.

Robert M Kantner, PT, PhD, GCS
Mobility Rehabilitation Specialists Inc
Sylvania, Ohio

Dr Kantner is Co-director and owner of Mobility Rehabilitation Specialists Inc. His clinical expertise is in working with geriatric patients and patients with neurological problems. He has a special interest and practice in vestibular rehabilitation.