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Physical therapist John Corsino discusses his article, “Lifelong learning: a game-changer in diagnosing dizziness.” He highlights how often the answers to complex cases, like acute dizziness, are present in the exam room but can be missed due to an over-reliance on diagnostic testing and systemic pressures that undervalue thorough physical examination. John champions the importance of lifelong learning for clinicians and the effective use of specific physical exam techniques, such as the HINTS exam, which can differentiate between peripheral vestibular issues and central nervous system insults with high accuracy, sometimes even outperforming imaging. The conversation delves into how misperceptions about dizziness persist and how a commitment to skilled examination can prevent diagnostic delays, reduce health care costs, and significantly improve patient outcomes. The key takeaway is: Investing time in honing physical examination skills and fostering a culture of continuous learning is crucial for clinicians to provide high-value, accurate diagnoses, especially for challenging symptoms like dizziness, ultimately transforming patient care.

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Transcript

Kevin Pho: Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome John Corsino. Today’s KevinMD article is “Lifelong learning: a game changer in diagnosing dizziness.” John, welcome to the show.

John Corsino: Glad to be with you, Kevin. Thanks for having me.

Kevin Pho: Alright, so tell us a little about yourself and the events that led you to write this KevinMD article.

John Corsino: Sure. So, I’m an acute care physical therapist. I practice at a community hospital and started mostly spending my time in the ICU just before COVID. But besides PT and critical care, which I think is this important and underused tool, my big interest—and the thing that drove me into becoming a PT in the first place—is the idea that we can understand so much about what’s going on with our patients with just a skillful physical exam. In the case of PT, we can often even treat the problem with physical interventions, and I think there’s no better example of this than evaluating an acutely dizzy patient. So that became, by necessity, an area of natural interest to me. It’s something that I get to talk about and teach to different groups. It’s something I’ve really enjoyed working on.

But even broader than that, sometimes the fundamentals of exercise, particularly in other parts of preventative care, which maybe don’t drive as much revenue generation but which are clearly good for patients. The underuse of those ideas in health care seems to create this opportunity to create real impact for somebody excited about bringing those things to the forefront. So, PT is this great opportunity to do that.

Besides my clinical work, I use writing as a tool to explore the systems problems that we all encounter in American health care. And again, I’m really grateful that you’ve published so much of my work despite its kind of wandering format sometimes, between looking at clinical situations and financial structures that create these care inefficiencies and then often peppering in an opinion about policy. I also have a newborn son. I’m actually home with him now on paternity leave, so if I come across as anything less than coherent, I’m going to blame that on the state of exhaustion which comes with being a new parent.

Kevin Pho: Fantastic. Dizziness is one of the most common reasons why I send my patients to physical therapists, so we’re excited to hear the latest on that. Your KevinMD article is “Lifelong learning: a game changer in diagnosing dizziness.” Tell us about the article for those who didn’t get a chance to read it.

John Corsino: So in this short piece, I kind of look at the intersection of what are generally common themes for me, and then the specific example of dizziness as a springboard for all of those. So really, what I talk about is this really important standard for reasoning through and examining a patient with acute dizziness—someone walking into the ED with new, undifferentiated dizziness. It also covers how, as clinical people, we’re kind of committed to lifelong continuous improvement because, over time, evidence changes, and when we enter a patient’s room, we represent not just our own experience but this entire body of professional knowledge and expertise.

So in this brief article, I try to tackle some big topics: the importance of looking at diagnostic accuracy as something best performed by a team rather than an individual. And then certainly, though always biased, I emphasize how useful PTs can be as members of that diagnostic team. I try to communicate that even though diagnostic accuracy in patients with dizziness is, as you mentioned, this known area for potential improvement, it’s not people, but really systems factors that have created this insufficiency. And clinical people are better positioned than anyone, I think, to engage with and help guide the future of our systems.

But that’s a big list of ideas, so I’ll back up just to the first point of the reasoning framework. So dizziness is always an area where diagnostic accuracy can be improved. And as a brand new grad PT in the hospital, I was being consulted to see folks for, quote, “vertigo,” who ended up having all different kinds of etiologies for their symptoms, some dangerous, some truly emergent. I had been taught this sort of bottom-up approach, as PTs sometimes are, meaning how to test for certain pathologies like BPPV and, of course, how to treat that, which is a big thing that PTs do. But I was taught much less about how to start from square one, which is really what was needed for these patients that I was being asked to see.

So this notion of reasoning through and examining patients in this specific sequence was developed by David Newman-Tocher and Jonathan Edlow. I’ll just run through their ideas quickly. First, understanding the timing of a patient’s symptoms, specifically whether they’re persistent or episodic, and then whether or not there’s a specific movement or position trigger for their symptoms. If you answer those two questions precisely, even a novice clinician will get down to just a handful of diagnostic possibilities in one bucket, so to speak. And saying it out loud, it sounds pretty straightforward, like that’s how we evaluate every patient with a new complaint: questions about onset, timeframe, and aggravating factors. Sometimes, especially in the ED, when we hear the words “room spinning,” folks tend to maybe get a little excited and jump ahead to looking at vestibular problems rather than work sequentially.

And then this word “vertigo” creeps in, which, like all kinds of labels, is just a different name for the symptom that isn’t really any closer to a diagnosis than the word “dizziness.” It turns out the subjective complaint of “room spinning” isn’t even really associated with a particular cause to a meaningful degree. It’s this outdated perception, one perhaps still taught in some places. But if you’re any kind of clinician who evaluates dizzy patients, you can implement this framework. TiTrATE is the acronym for it: Timing, Triggers, and Targeted Examination. And if you understand how to interpret the answers to these questions and then perform just a few relatively simple hands-on physical exam techniques, you can become this really valuable resource in your institution for identifying the cause of a dizzy patient’s symptoms or, at a bare minimum, guiding the next steps of diagnostic evaluation. So in writing this, I just want to help share awareness about this practice standard and also explore the systems factors that lead to this situation of sometimes delayed or incomplete diagnosis in patients presenting with dizziness. And I think it’s something that we can all be a part of and something that we can all work together to drive improvement on. And PTs are, again, I’m biased, but I think a really important and useful part of that team.

Kevin Pho: So can you walk us through a typical case that you would be consulted on and maybe use this algorithm that you mentioned so we can see it in action?

John Corsino: I’m going to give you a slightly complex one, but it’s one of my very favorite cases to talk about. So this 80-something-year-old woman came into the emergency department in the evening with dizziness and actually boarded in the ED overnight. And I came in to see her the following morning, and she was wearing sneakers with her hospital gown. She was really eager to get up and get moving, an active walker who didn’t want to lose any ground in the hospital. And the evening attending who first encountered her had observed some nystagmus, maybe with some provocation testing. It wasn’t totally clear from the record, but the patient had been signed out to the morning provider, and they consulted PT for a vestibular assessment, which is great.

So I went down, talked to the patient, and she was a super sharp historian. I credit her great history and the reliability of her information with alluding to a complicated diagnosis. But she described to me episodes of dizziness. They came on spontaneously, out of the blue, and were short-duration, short-lived. She was hypertensive; her systolic was in the 180s. She did have a history of hypertension and hadn’t had her morning antihypertensives yet at this time. So in speaking with the patient, she describes spontaneous episodes of dizziness without a movement or position trigger. These are just coming out of the blue. They’re short in duration. This doesn’t lead me to think of the typical peripheral vestibular problems. I’m not thinking about BPPV, which is always provoked by movement or position. I’m not thinking about vestibular neuritis, which can come on spontaneously but in which dizziness is persistent, often accompanied by nystagmus, and which the rest of our exam cluster can help confirm.

Because the initial attending had reported seeing nystagmus, I did perform some tests that I might have skipped otherwise. I did perform vestibular provocation testing, so I did a Dix-Hallpike test bilaterally to look for posterior canal BPPV, which was negative. I then did a supine roll test, which, interestingly enough, was positive for horizontal canal BPPV. It turns out, it was previously thought to be relatively uncommon. It turns out in patients dizzy enough to come to the ED, it’s almost as common as posterior canal BPPV. But in any case, so I treated this patient for her horizontal canal BPPV. She was walking around the room independently; she was feeling like herself. But again, this relatively elderly patient, active at baseline, quite hypertensive, telling me about new spontaneous dizziness.

So I circled back to the new attending and said, “Hey, I examined this patient and treated them. They did actually have BPPV, the thing I was consulted to treat. But she’s a really reliable historian. She’s telling me she has spontaneous dizziness coming out of the blue. I think you need to admit this patient for further workup.” And the patient ultimately had a transthoracic echo, which demonstrated critical aortic stenosis, and the patient was recommended for a TAVR that admission. And I think if I weren’t aware of this reasoning framework, this is a diagnosis that could have been missed. If I didn’t know that this spontaneous episodic dizziness, even in a patient who, coincidentally enough, turned out to have BPPV, also had this sinister diagnosis, I think this would’ve been something really easy for any system to overlook. So I was really glad that I got to encounter this patient in this way and help her reach the outcome that she did.

Kevin Pho: Sometimes when I see patients with vertigo or dizziness, there is always a question. At what point should we refer to physical therapy or refer to otolaryngology? So what kind of signs and symptoms do I need to listen for in a story to steer me in one direction or the other?

John Corsino: I think if a patient has episodic dizziness provoked by movement or position and the specific type—torsional nystagmus, upbeat toward the affected ear, for example, in posterior canal BPPV—that very often PTs are well equipped to manage BPPV. It depends certainly on your area, but many therapists are very skilled and experienced in treating that. If a patient has spontaneous, persistent dizziness with nystagmus, then what we would do at that point is the HINTS exam cluster. We want to see every sign consistent with a peripheral problem to not raise concern for a central problem. So in this case, if a patient, say, comes in with persistent dizziness and has, let’s say, right horizontal nystagmus, what you want to see is nystagmus that doesn’t change direction at all. It should be unidirectional and horizontal. That can sometimes still be caused by a central problem, and so the exam cluster has this redundancy built in.

The next thing is to perform a horizontal head impulse test. And what you really want to see is an abnormal left horizontal head impulse test in this patient. You’re quickly turning the head to the left to stimulate the left vestibular apparatus. And then the additional redundancy comes from the cover-uncover test. You are looking for just a vertical skew deviation revealed by that. And then hearing asymmetry was once thought to signal a benign peripheral problem. It turns out that in nearly 50/50 of folks, they can have infarcts to this tiny branch of the anterior inferior cerebellar artery, reducing circulation to the vestibular apparatus itself. So, for that reason, hearing loss is considered a red flag for working up a central problem. But I bring up this example to say, in this patient, if you’re able to confirm through examination neuritis or a peripheral vestibulopathy, the clinical practice guideline is to have vestibular rehab available for accommodation for that patient. And so those folks are definitely worth referring to outpatient PT for sure.

Kevin Pho: Now for those people who aren’t familiar with benign positional vertigo, give us a little refresher in terms of what are the common causes and risk factors for this common presentation?

John Corsino: Absolutely. So benign paroxysmal positional vertigo, the root pathology is not so different from osteopenia. You have demineralization of part of the inner ear organ. You end up with debris in the fluid-filled semicircular canals of the inner ear. When a patient puts their head in a certain position or moves—accelerates, really—in a certain way, the density of that fluid is modulated by this debris, which is not normally in that fluid. And so the intact brainstem reflexes interpret this increased signal from the inner ear apparatus as though rapid movement is occurring. Patients feel very dizzy. And often the benign stuff patients report feels the most severe. But the good news is it can be confirmed and even treated, often on the spot, with just physical repositioning maneuvers. And again, it used to be thought that posterior canal BPPV, the thing tested for with the Dix-Hallpike test, was much more common than horizontal canal BPPV. It turns out, from a relatively recent dataset published from ED patients, that horizontal canal BPPV is nearly as common in those folks. It’s a little more common to treat. We use a different physical test and then a Gufoni maneuver typically to help resolve that problem. But again, it’s something that can often be treated right in the ED if it’s diagnosed promptly and everything else concerning is ruled out.

Kevin Pho: I know that you are speaking from the perspective of an inpatient clinician. So if I sent patients to an outpatient physical therapist for suspected BPPV, tell us what are some of the maneuvers that a physical therapist would do to specifically diagnose and treat that condition?

John Corsino: Absolutely. So all my experience comes from the inpatient side, but in general, if BPPV has been confirmed at some kind of visit and you’re referring to PT for treatment of that, sometimes it’s just education of patients for self-management, if they’re able to do so comfortably. But we test with the Dix-Hallpike test, which looks for posterior canal BPPV, and then the supine roll test, which looks for horizontal canal BPPV. And then we treat those in different ways. We use a Gufoni or sometimes a modified Gufoni maneuver for the horizontal canal BPPV, and then an Epley maneuver, which most folks have heard of, for posterior canal BPPV. After someone’s had an episode, recurrence is more likely for them than it is for a person off the street who’s never had BPPV. But oftentimes, PTs can counsel folks on what to be aware of, how they might attempt to treat it on their own, or when to pick up the phone and call and be seen so they can be treated promptly.

Kevin Pho: And in terms of outcomes, what type of success rates do these maneuvers have when it comes to BPPV?

John Corsino: That’s a great question. I’m actually not the person probably to speak definitively to the outcomes data for the outpatient folks. I know that physical exam maneuvers are pretty effective. Even in the ED practice, if patients come in with dizziness and are very appropriately concerned that something dangerous might be happening, we can often send them walking out of the ED after a treatment maneuver. I’m not as certain about the outpatient environment and recurrence and things like that.

Kevin Pho: Are there any other movement disorders or primary care conditions that we can send to physical therapy that are related to dizziness?

John Corsino: Definitely tons of movement disorders and other conditions for which physical therapy can be very, very impactful. In terms of specifically related to dizziness, nothing in particular jumps out at me, but anytime that a patient’s functional limitation is impacted by any kind of problem, PTs are trained to work through the sequence of observing the patient’s functional limitation, answering the question of what are the focal impairments or specific deficits leading to this limitation, and then determining if these deficits or impairments are adequately explained by the known medical context. On the inpatient side, we work through that sequence and we can be a valuable part of the diagnostic team just by saying, “Hey, there’s something here that isn’t explained by what we know about this patient.” And then on the outpatient side, even if we know precisely what’s causing something, very often we can help treat the underlying impairment or deficit or, at the bare minimum, teach accommodative strategies. So again, I’m always biased, but PT is a super effective and cost-effective thing in our American health care system.

Kevin Pho: Anything on the horizon in terms of newer modalities, treatments, and diagnostic techniques when it comes to treating dizziness?

John Corsino: I think the TiTrATE reasoning framework is a really good starting point, and I think the next step is probably just greater dissemination of that. There are kind of safety nets that have been worked in because a lot of, especially emergency physicians, are sort of aware of this reasoning framework but haven’t necessarily had the experience or training to feel super confident implementing it. So the safety nets are, anytime that you’re not totally certain that you’re looking at a peripheral problem, you can just err toward working up a central cause, and it’s better to have false positives in that phase than it is to miss something potentially dangerous.

And then there’s also a trial for which the acronym was STANDING, which is if a patient isn’t able to stand on their own, then again, it’s better to have a few false positives than one false negative. If they’re having balance deficits in that phase, then just work them up for a central problem. As far as new modalities or techniques or equipment or anything on the outpatient side, I’m not as familiar with that. I know outpatient therapists often have different equipment that they sometimes use to, especially in cases of complex BPPV, make sure they arrive at the right diagnosis and treatment, but that’s not something I’m as experienced with myself.

Kevin Pho: We’re with John Corsino. He’s a physical therapist. Today’s KevinMD article is “Lifelong learning: a game changer in diagnosing dizziness.” John, let’s end with some take-home messages that you want to leave with the audience.

John Corsino: Absolutely. So I guess my big two things are: if you’re someone who might be the first point of contact for a patient with acute dizziness, it’s really important to just be aware of what the care standard reasoning framework looks like. The TiTrATE reasoning approach, again, developed by Jonathan Edlow and David Newman-Tocher. Even if you’re not super experienced in using the exam techniques, if you reason through things in this way, you will, I think, save lives and help reduce disability among patients who might be presenting with an occult stroke.

But my even bigger point that I would make to what I presume is a mostly physician audience is to use your hospital PTs, especially to help improve the team-based activity of diagnostic accuracy. We think through problems in that sequence that I mentioned, and when we work together, we can help our patients reach better outcomes as a really effective diagnostic team, better than when we work separately, for sure.

Kevin Pho: John, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

John Corsino: Thanks for having me, Kevin.