Original research| Volume 101, ISSUE 10, P1747-1753, October 2020

Predictors of Physical Therapy Referral Among Persons With Peripheral Vestibular Disorders in the United States



      To determine the rate of physical therapy (PT) referral and patient and physician characteristics associated with PT referral for benign paroxysmal positional vertigo (BPPV) and other peripheral vestibular disorders (PVD) in ambulatory care clinics in the United States.


      Cross-sectional analysis of the National Ambulatory Medical Care Survey 2004-2015


      Ambulatory care clinics in the United States.


      We identified 5.6 million weighted adult visits for BPPV (International Classification of Diseases–9th Revision–Clinical Modifications (ICD-9-CM): 386.11) and 6.6 million weighted visits for other PVDs (ICD-9-CM: 386.1-386.9, excluding 386.11 and 386.2) made by patients 18 years and older from 2004 through 2015.


      Not applicable.

      Main Outcome Measures

      Patient, clinical, and physician characteristics were extracted, and descriptive statistics were stratified by referral to PT. Two multivariable logistic regression models were estimated for each diagnostic group (BPPV and other PVDs) to identify predictors of PT referral.


      PT referrals for BPPV increased from 6.2% in the period from 2004 to 2006 to 12.9% in the period from 2013 to 2015, whereas PT referrals for other PVDs decreased from 3.8% in the period from 2004 to 2006 to 0.5% in the period from 2013 to 2015. Other insurance coverage (versus private) and neurologists and other specialists (versus otolaryngologists) were associated with a greater odds of PT referral for BPPV. Visits made in the Midwest and West (versus the Northeast) and in rural versus metropolitan areas had greater odds of PT referral for BPPV. Relative to otolaryngologists, primary care physicians were less likely to refer to PT for other PVDs. Visits made in metropolitan versus rural areas and visits with 1 or more comorbidities (versus none) had greater odds of PT referral for other PVDs.


      PT referrals remain low for ambulatory care visits for BPPV and other PVDs in the United States. Referral to PT for BPPV and other PVDs varied by insurance type, physician specialty, and office location.


      List of abbreviations:

      BPPV (benign paroxysmal positional vertigo), CI (confidence interval), CRM (canalith repositioning maneuver), ICD-9-CM (International Classification of Diseases–9th Revision–Clinical Modifications), NAMCS (National Ambulatory Medical Care Survey), OR (odds ratio), PT (physical therapy), PVD (peripheral vestibular disorder), VR (vestibular rehabilitation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dunlap P.M.
        • Khoja S.S.
        • Whitney S.L.
        • Freburger J.K.
        Assessment of health care utilization for dizziness in ambulatory care settings in the United States.
        Otol Neurotol. 2019; 40: e918-e924
        • Bösner S.
        • Schwarm S.
        • Grevenrath P.
        • et al.
        Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review.
        BMC Fam Pract. 2018; 19: 33
        • Sun G.H.
        • Cain-Nielsen A.
        • Moloci N.M.
        Who’s managing otolaryngologic conditions in the United States?.
        Otolaryngol Head Neck Surg. 2017; 157: 416-418
        • O’Loughlin J.L.
        • Robitaille Y.
        • Boivin J.F.
        • Suissa S.
        Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly.
        Am J Epidemiol. 1993; 137: 342-354
        • Pluijm S.M.F.
        • Smit J.H.
        • Tromp E.A.M.
        • et al.
        A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study.
        Osteoporos Int. 2006; 17: 417-425
        • Lin H.W.
        • Bhattacharyya N.
        Impact of dizziness and obesity on the prevalence of falls and fall-related injuries.
        Laryngoscope. 2014; 124: 2797-2801
        • Agrawal Y.
        • Carey J.P.
        • Della Santina C.C.
        • Schubert M.C.
        • Minor L.B.
        Disorders of balance and vestibular function in US adults: data from the National Health and Nutrition Examination Survey, 2001-2004.
        Arch Intern Med. 2009; 169: 938-944
        • Oghalai J.S.
        • Manolidis S.
        • Barth J.L.
        • Stewart M.G.
        • Jenkins H.A.
        Unrecognized benign paroxysmal positional vertigo in elderly patients.
        Otolaryngol Head Neck Surg. 2000; 122: 630-634
        • Ciorba A.
        • Bianchini C.
        • Scanelli G.
        • Pala M.
        • Zurlo A.
        • Aimoni C.
        The impact of dizziness on quality-of-life in the elderly.
        Eur Arch Otorhinolaryngol. 2017; 274: 1245-1250
        • Neuhauser H.K.
        • Radtke A.
        • von Brevern M.
        • Lezius F.
        • Feldmann M.
        • Lempert T.
        Burden of dizziness and vertigo in the community.
        Arch Intern Med. 2008; 168: 2118-2124
        • Neuhauser H.K.
        • von Brevern M.
        • Radtke A.
        • et al.
        Epidemiology of vestibular vertigo: a neurotologic survey of the general population.
        Neurology. 2005; 65: 898-904
        • Corrales C.E.
        • Bhattacharyya N.
        Dizziness and death: An imbalance in mortality.
        Laryngoscope. 2016; 126: 2134-2136
        • Rodriguez A.I.
        • Zupancic S.
        • Song M.M.
        • Cordero J.
        • Nguyen T.Q.
        • Seifert C.
        Importance of an interprofessional team approach in achieving improved management of the dizzy patient.
        J Am Acad Audiol. 2017; 28: 177-186
        • Tokle G.
        • Mørkved S.
        • Bråthen G.
        • et al.
        Efficacy of vestibular rehabilitation following acute vestibular neuritis: A randomized controlled trial.
        Otol Neurotol. 2020; 41: 78-85
        • Hall C.D.
        • Herdman S.J.
        • Whitney S.L.
        • et al.
        Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline: from the American Physical Therapy Association Neurology Section.
        J Neurol Phys Ther. 2016; 40: 124-155
        • Bhattacharyya N.
        • Gubbels S.P.
        • Schwartz S.R.
        • et al.
        Clinical practice guideline: benign paroxysmal positional vertigo (update).
        Otolaryngol Head Neck Surg. 2017; 156: S1-S47
        • Jumani K.
        • Powell J.
        Benign paroxysmal positional vertigo: management and its impact on falls.
        Ann Otol Rhinol Laryngol. 2017; 126: 602-605
        • Ganança F.F.
        • Gazzola J.M.
        • Ganança C.F.
        • Caovilla H.H.
        • Ganança M.M.
        • Cruz O.L.M.
        Elderly falls associated with benign paroxysmal positional vertigo.
        Braz J Otorhinolaryngol. 2010; 76: 113-120
        • Gámiz M.J.
        • Lopez-Escamez J.A.
        Health-related quality of life in patients over sixty years old with benign paroxysmal positional vertigo.
        Gerontology. 2004; 50: 82-86
        • Bressi F.
        • Vella P.
        • Casale M.
        • et al.
        Vestibular rehabilitation in benign paroxysmal positional vertigo: Reality or fiction?.
        Int J Immunopathol Pharmacol. 2017; 30: 113-122
        • Mandalà M.
        • Salerni L.
        • Nuti D.
        Benign positional paroxysmal vertigo treatment: a practical update.
        Curr Treat Options Neurol. 2019; 21: 66
        • McDonnell M.N.
        • Hillier S.L.
        Vestibular rehabilitation for unilateral peripheral vestibular dysfunction.
        Cochrane Database Syst Rev. 2015; 1: CD005397
        • Maslovara S.
        • Butkovic-Soldo S.
        • Peric M.
        • Pajic Matic I.
        • Sestak A.
        Effect of vestibular rehabilitation on recovery rate and functioning improvement in patients with chronic unilateral vestibular hypofunction and bilateral vestibular hypofunction.
        NeuroRehabilitation. 2019; 44: 95-102
        • Porciuncula F.
        • Johnson C.C.
        • Glickman L.B.
        The effect of vestibular rehabilitation on adults with bilateral vestibular hypofunction: a systematic review.
        J Vestib Res. 2012; 22: 283-298
        • Arnold S.A.
        • Stewart A.M.
        • Moor H.M.
        • Karl R.C.
        • Reneker J.C.
        The effectiveness of vestibular rehabilitation interventions in treating unilateral peripheral vestibular disorders: A systematic review.
        Physiother Res Int. 2017; 22
        • Grill E.
        • Penger M.
        • Kentala E.
        Health care utilization, prognosis and outcomes of vestibular disease in primary care settings: systematic review.
        J Neurol. 2016; 263: S36-S44
        • Lloyd M.
        • Mackintosh A.
        • Grant C.
        • et al.
        Evidence-based management of patients with vertigo, dizziness, and imbalance at an Australian metropolitan health service: an observational study of clinical practice.
        Physiother Theory Pract. 2018 Oct 17; ([Epub ahead of print])
        • Grill E.
        • Strupp M.
        • Müller M.
        • Jahn K.
        Health services utilization of patients with vertigo in primary care: a retrospective cohort study.
        J Neurol. 2014; 261: 1492-1498
        • Roberts D.S.
        • Lin H.W.
        • Bhattacharyya N.
        Health care practice patterns for balance disorders in the elderly.
        Laryngoscope. 2013; 123: 2539-2543
        • Centers for Disease Control and Prevention National Center for Health Statistics
        Ambulatory health care data. Centers for Disease Control and Prevention.
        (Available at:)
        Date accessed: October 16, 2019
        • National Center for Health Statistics
        2012 NAMCS micro-data file documentation. Centers for Disease Control and Prevention National Center for Health Statistics.
        (Available at:)
        • Centers for Disease Control and Prevention
        The Ambulatory Care Drug Database System. Ambulatory health care data.
        (Available at:)
        • Dunlap P.M.
        • Khoja S.S.
        • Whitney S.L.
        • Freburger J.K.
        Assessment of physician adherence to guidelines for the diagnosis and treatment of benign paroxysmal positional vertigo in ambulatory care settings.
        JAMA Otolaryngol Head Neck Surg. 2018; 144: 845-846
        • Melo R.S.
        • Lemos A.
        • Paiva G.S.
        • et al.
        Vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with sensorineural hearing loss: a systematic review.
        Int J Pediatr Otorhinolaryngol. 2019; 127: 109650
        • von Brevern M.
        • Radtke A.
        • Lezius F.
        • et al.
        Epidemiology of benign paroxysmal positional vertigo: a population based study.
        J Neurol Neurosurg Psychiatry. 2007; 78: 710-715
        • Iglebekk W.
        • Tjell C.
        • Borenstein P.
        Pain and other symptoms in patients with chronic benign paroxysmal positional vertigo (BPPV).
        Scand J Pain. 2013; 4: 233-240
        • Moon S.Y.
        • Kim J.S.
        • Kim B.K.
        • et al.
        Clinical characteristics of benign paroxysmal positional vertigo in Korea: a multicenter study.
        J Korean Med Sci. 2006; 21: 539-543
        • Prokopakis E.P.
        • Chimona T.
        • Tsagournisakis M.
        • et al.
        Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure.
        Laryngoscope. 2005; 115: 1667-1671
        • Epley J.M.
        The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo.
        Otolaryngol Head Neck Surg. 1992; 107: 399-404
        • Lempert T.
        • Tiel-Wilck K.
        A positional maneuver for treatment of horizontal-canal benign positional vertigo.
        Laryngoscope. 1996; 106: 476-478
        • Sim E.
        • Tan D.
        • Hill K.
        Poor treatment outcomes following repositioning maneuvers in younger and older adults with benign paroxysmal positional vertigo: a systematic review and meta-analysis.
        J Am Med Dir Assoc. 2019; 20: 224.e1-224.e23
        • Chang W.-C.
        • Yang Y.-R.
        • Hsu L.-C.
        • Chern C.-M.
        • Wang R.-Y.
        Balance improvement in patients with benign paroxysmal positional vertigo.
        Clin Rehabil. 2008; 22: 338-347
        • Hu A.
        • Sardesai M.G.
        • Meyer T.K.
        A need for otolaryngology education among primary care providers.
        Med Educ Online. 2012; 17: 17350
        • Harvey M.
        • Bowe S.N.
        • Laury A.M.
        Clinical practice guidelines: whose practice are we guiding?.
        Otolaryngol Head Neck Surg. 2016; 155: 373-375
        • Geser R.
        • Straumann D.
        Referral and final diagnoses of patients assessed in an academic vertigo center.
        Front Neurol. 2012; 3: 169
        • Michel L.
        • Laurent T.
        • Alain T.
        Rehabilitation of dynamic visual acuity in patients with unilateral vestibular hypofunction: earlier is better.
        Eur Arch Otorhinolaryngol. 2020; 277: 103-113