Emergency Department Vestibular Rehabilitation Therapy (ED-VeRT)

After spending the last 9 weeks in acute care physical therapy I found this recent research article interesting. Dizziness accounts for nearly 2 million emergency department (ED) visits per year, yet care often centers on ruling out catastrophic pathology rather than improving patient function or disability. While outpatient vestibular rehabilitation has a strong evidence base, its role in the acute ED setting remains unclear. This study by Kim et al. (2025) sought to answer a foundational question:
Can physical therapists safely, feasibly, and effectively evaluate and manage dizziness in the ED using a standardized algorithm, and does this impact patient-centered outcomes?

Study Goal

The primary goal of this nonrandomized pilot clinical trial was to examine the feasibility of delivering ED-based vestibular rehabilitation therapy (ED-VeRT) and to generate preliminary estimates of longitudinal patient-reported outcomes over 3 months. The authors intentionally framed this as groundwork for a future fully powered randomized controlled trial, rather than a definitive efficacy study.

Methods Overview

Design and Setting

• Prospective, nonrandomized clinical trial

• Single urban academic ED (Chicago, IL)

• Enrollment: November 2021 – February 2023

• Follow-up: 1 week, 1 month, 2 months, 3 months (primary endpoint)

Patients were allocated to ED-VeRT vs usual care at physician discretion, meaning groups were not randomized or blinded.

Inclusion and Exclusion Criteria (High-Yield)

Included

• Age ≥18 years

• Chief complaint of dizziness or vertigo

• No obvious non–balance-related medical cause (e.g., sepsis, arrhythmia)

• Able to complete follow-up surveys in English

Excluded

• Severe neurologic deficits requiring stroke activation

• Clear alternative medical explanation for dizziness-central issues

• Inability to participate in follow-up

This resulted in 125 enrolled patients, with 84% retained for longitudinal analysis, an important feasibility win.

The ED-VeRT algorithm (Figure 1): how PTs evaluated and progressed exams

Figure 1 is the clinical heart of this study. It outlines a protocolized, stepwise diagnostic classification algorithm adapted from the TiTrATE/Newman-Toker framework and designed specifically for ED use.

Step 1: Rule out central pathology

• PTs first screened for central neurologic deficits

• Concerning findings prompted immediate referral back to the medical team for neurologic workup

• This reinforces that ED-VeRT complements, not replaces, medical decision-making

Step 2: Classify dizziness by timing and triggers

Patients were categorized as having:

• Triggered (episodic) dizziness, or

• Spontaneous (continuous) dizziness

This branching dictated the exam pathway.

Step 3A: Triggered dizziness → positional testing

• Dix-Hallpike and/or supine roll test performed

• Findings led to:

  • BPPV diagnosis (if canal-specific nystagmus present), or

  • Triggered undifferentiated dizziness (if testing was negative or atypical)

Step 3B: Spontaneous dizziness → HINTS+ exam

• Head impulse, nystagmus, test of skew plus hearing

• Reassuring findings supported:

  • Unilateral peripheral hypofunction, or

  • Spontaneous undifferentiated dizziness

• Concerning findings triggered medical escalation

Universal components

Regardless of classification, all patients received:

• Balance screening

• Fall prevention education

• Expected symptom trajectory counseling

• Referral to outpatient vestibular PT

This standardized structure is a major contribution of the study.

Diagnostic classifications: what dizziness looked like in the ED

Among ED-VeRT patients (n = 63), classifications were:

• BPPV: 37.1%

  • Mostly posterior canal

  • All received canalith repositioning

• Triggered undifferentiated dizziness: 22.6%

• Spontaneous undifferentiated dizziness: 22.6%

• Unilateral peripheral hypofunction: 14.5%

• Other: 3%

Notably, nearly half of patients fell into undifferentiated categories, reflecting the diagnostic uncertainty common in acute dizziness presentations.

Interventions by dizziness classification

• BPPV: Canalith repositioning maneuvers (Epley, Gufoni)

• Unilateral peripheral hypofunction: Education, medical discussion (e.g., steroids), outpatient vestibular PT referral

• Undifferentiated dizziness: Safety education, reassurance, referral to neurology and vestibular PT

This mirrors real-world ED constraints while still delivering meaningful PT input.

Outcome measures: what they represent

Primary outcome

Dizziness Handicap Inventory (DHI)

• 0–100 scale

• Captures functional, emotional, and physical impact of dizziness

• MCID ≈ 18 points

Secondary outcome

Vestibular Activities Avoidance Inventory–9 (VAAI-9)

• Measures fear avoidance and activity restriction related to dizziness

Additional outcomes

• Sedating medication use

• Numeric Rating Scale (dizziness severity)

• Falls and healthcare utilization

These measures emphasize function and lived experience, not just diagnosis.

Results: what actually changed over time

Main outcome (DHI)

At 3 months:

• ED-VeRT vs usual care difference: −1.68 points

• 95% CI: −11.30 to 7.90

• Not statistically or clinically significant

Over the full 3 months:

• Greater reductions in ED-VeRT, but time × group interaction not significant (i.e. both groups improved, and they improved at the same rate.)

Functional and symptom-based outcomes

• VAAI-9: Small, non-significant reductions favoring ED-VeRT

• Sedating medication use:

  • Higher at 1 week in ED-VeRT

  • Lower at 3 months (6% vs 11%), but not significant

• Numeric rating scale & GROC: Similar between groups

Discussion: what this study adds to the field

This study makes several important contributions:

1. PTs can safely and consistently classify dizziness in the ED

   • Minimal between-physician variability

   • High adherence to the algorithm

2. ED-based vestibular PT is feasible

   • High enrollment and retention

   • Delivered without increasing ED length of stay

   • Associated with less imaging and more discharges home

3. Patient-centered outcomes matter

   • This study shifts the conversation from “Did we miss a stroke?” to
     “Did we reduce dizziness-related disability?”

4. PT outcomes were comparable to usual care

   • Despite higher baseline disability in the ED-VeRT group

   • Suggests PTs can provide at least equivalent downstream outcomes when properly integrated

Importantly, this trial supports the idea that when designated and trained, PTs can meaningfully contribute to ED dizziness care without compromising safety or outcomes.

Key limitations

• Nonrandomized design → baseline group differences

• Underpowered for efficacy

• Single-site study

• Majority of evaluations performed by one PT (generalizability)

These limitations appropriately temper conclusions but do not negate feasibility findings.

Parting Words

This study does not prove that ED-based vestibular PT is superior to usual care, but it convincingly shows that it is feasible, safe, and clinically meaningful. Perhaps more importantly, it positions physical therapists as diagnostic thinkers capable of contributing early in acute care settings.

References

1. Kim HS, Schauer JM, Kan AK, et al. Emergency Department Vestibular Rehabilitation Therapy for Dizziness and Vertigo: A Nonrandomized Clinical Trial. JAMA Netw Open. 2025;8(2):e2459567. Published 2025 Feb 3. doi:10.1001/jamanetworkopen.2024.59567

Disclaimer

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.