Central causes of dizziness

Vestibular physical therapy has become a mainstay in the management of patients with balance disorders manifesting as dizziness and disequilibrium. Numerous concept papers,(1-20) case studies,(21-29) case series with no controls,(30-44) and controlled studies(45-49) support the use of rehabilitation techniques for patients with peripheral vestibular disorders. There is less evidence supporting the use of rehabilitation techniques for patients with central vestibular disorders. Several concept papers,(6,9,17,50-54) case studies,(4,23,55-59) and case series with no controls(17,23,30,31,33,36,38-40) have been published regarding central vestibular disorders. In addition, 2 textbooks on the subject of vestibular rehabilitation(60,61) provide ample evidence that this treatment for patients with balance disorders appears to be very promising (Tab. 1). Only a few controlled studies,(45-49) however, have addressed the efficacy of physical therapy for patients with peripheral vestibular disorders, and none of these controlled studies have addressed patients with central vestibular pathology. Articles that specifically addressed benign paroxysmal positional vertigo(62-65) are not included in Table 1. Most of the studies cited in the case series group in Table 1 had few patients with central dysfunction, and rarely were these patients differentiated from the patients with peripheral vestibular disorders, making it difficult to reach any definitive conclusions. Overall, patients with central vestibular disorders have worse outcomes of rehabilitation than do patients with peripheral vestibular disorders.(53) Patients with central disorders often cannot be progressed as quickly as patients with peripheral vestibular dysfunction; thus, overall treatment times are longer for patients with central disorders.(53) Outcomes of rehabilitation in patients with central vestibular disorders, for example, following head trauma, are not as good as outcomes following peripheral vestibular disorders.(39) Patients with only central vestibular disorders, however, have better outcomes than do patients with combined peripheral and central dysfunction.(39).