Vestibular Rehabilitation

There has been much discussion over the past several years regarding the Audiologists role in Vestibular Rehabilitation. The ASHA position statement starting on page 156 of my book suggests that Audiologists should be doing Canalith Repositioning, but should “serve as a member of a multi-disciplinary managing patients with balance disorders or dizziness.” The Academy of Audiology recently issued a position statement on diagnosis and treatment of vestibular disorders. It states “Audiologists .. participate as full members of the balance treatment team.” Clearly, both organizations recognize that there are patients that require the expertise and training of other allied health professionals. But where do you draw the line? Which patients can be handled by Audiology alone? Which need to be referred, and to whom?
There is general agreement that canalith repositioning is in the scope of practice for Audiologists. Of course, other professionals including PT, Primary Care and even Chiropractors have been doing repositioning. My personal opinion is that it doesn’t really matter which professional is doing it as long as they are trained and experienced. From a purely philosophical viewpoint, one could argue that repositioning is not physical therapy, but rather a mechanical repair of a pure vestibular disorder. Canalith repositioning really has nothing to do with spinal manipulation or muscular re-education, so how does it fall within the scope of practice of a Chiropractor and/or a Physical therapist? Just a thought!

There are really two groups of patients that are candidates for vestibular rehabilitation: 1. Those with stable vestibular dysfunction, but no other contributory problems affecting their balance and mobility, and 2. Those with stable vestibular dysfunction, in addition to other contributory factors. Those in group one can be handled by Audiology alone. These patients tend to be younger, better able to understand and follow instructions, and are less likely to fall and injure themselves during therapy exercises. We typically send these patients home with an exercise program, and follow up with them at 4 and 8 weeks. Most do just fine.

The second group tends to be older, and in need of more hands on guidance. Often there are other issues such as weakness, joint instability, visual deficits, etc. We refer these patients to Physical Therapy, and our experience has been that the PT often adds components to the therapy that we would have been unable to address. A good PT is invaluable in managing elderly patients with multi-factorial balance problems.

Occupational Therapists can also be helpful in helping these patients function more safely in their home environment. We leave it to the PT to make the referral or recommendation for OT if it is indicated.

Keep in mind that balance and movement are complicated activities that are learned. If you have noticed pre-toddler children, most have no trouble staying upright as long as they have something to hold on to. They have sufficient leg strength to support their body early in life, but they have yet to learn to maintain their balance and shift their weight appropriately. They eventually figure out by trial and error (falling) how far and how fast they can lean without falling.

Walking is a complex coordinated task of controlled forward falling. The ability to walk is also learned and requires constant practice and feedback. After a vestibular injury, walking is a very conscious activity. The goal of therapy is to make walking and moving an unconscious activity through the process of repetition and motor learning. Consider the case of baseball players. After the winter season relaxing, they don’t go back to work on opening day. They go to spring training where they take thousands of swings, throws etc. It is the process of repetition and motor learning that allows them to get their timing back, or develop “an eye for the ball.”

The current state of health care in America is one of reaction to, rather than prevention of illness. Patients seem to expect that all complaints can be treated with a pill. I have had many people ask, “Isn’t there something you can give me for this dizziness?” Many are discouraged when I tell them that they are going to have to work a little to improve their balance and reduce their symptoms. As expected, compliance is a bit of an issue. I find that it is well worth the time to explain to the patient how and why therapy works, and how vestibular suppressants inhibit recovery from vestibular injuries. Fortunately, recovery from vestibular injuries is pretty predictable, so I can tell the patient with a good degree of confidence what they are going to experience. This goes a long way in getting the patient to follow your advice.