Friday, August 7, 2015

Reflections & thoughts on “Vestibular Rehabilitation: A Competency-Based Course”. Blogpost by Tracey Wagner, DPT, OCS, FAAOMPT

My PT background is in outpatient orthopedics with an emphasis on movement re-education and like many rehab clinicians, I possess a natural wonder of the vestibular system. I marvel at the capacity of the human movement system with it’s ability to produce poetic motion - the trapeze artist flying through the air upside down never losing orientation of their partner’s outstretched arms, the flyboarder performing back flips and landing on pillars of water, or the prima ballerina spinning endless fouetté turns en pointe.  And not to be out done by such levels of dynamic brilliance, the mundane can also be marveled - the balance, coordination and strength needed to get up off the floor is a valid sign for longevity. Now that is important!  My appreciation of this “wonder” led me to registering for this 6-day advanced competency-based course in 2014 with Susan J. Herdman, PT, PhD, FAPTA sponsored by the Department of Rehabilitation Medicine, Emory University School of Medicine. 

Thoughts on the 6-day competency-based course format

This 6-day course required prior knowledge and experience of vestibular disorders. The multi-disciplinary instructors come from all over the country and are all experts in vestibular evaluation and rehabilitation providing an enriched environment for learning. I found them not only responsive to questions in class but also with follow up emails after the course was over.

There was a good balance between group lectures and demonstrations that took place in the large lecture hall and break down groups for practicums led by different instructors in smaller conference rooms. Case study presentations were a constant all week - those and video presentations really helped improve my differential diagnostic skills. Competencies were performed in the evenings and we completed a video and written exam at the end of the week.

Much like other clinical presentations, there are often multiple facets that make up each vestibular case, so honing skills and clinical reasoning to assist in identifying and understanding such nuances is a sign of an improving skill set.  At the end of this 6-day course I now have a deeper understanding of managing this particular patient population and am able to connect the dots better with respect to the clinical reasoning behind specific presentations. Although I have a long way to go to fill in the gaps of my knowledge related to neuroscience, this course definitely helped me gain more clarity in examining, evaluating and treating vestibular disorders.

Summary of my “aha” moments and clinical pearls

1.  I was fascinated to learn that the size of a dime covers the contents of each labyrinth containing the semi circular canals (SCCs), the utricle and saccule as well as the cochlea.

2.  In order to experience vertigo (the sensation of movement when there is no movement) – you have to have a “rapid onset of asymmetrical neural activity”, otherwise central compensation has time to kick in as the system can adapt to slow changes over time.

3.  Identifying the less common presentation of horizontal BPPV canalithiasis (5% of BPPV cases).

While performing the Roll Test on a patient whose subjective examination pointed toward BPPV, the patient demonstrated clear geotropic nystagmus on the left side greater than the right that attenuated while in the test position. Being able to identify the direction and interpret the nystagmus correctly allowed me to diagnose the patient with left horizontal canal BPPV canalithiasis and treat him successfully with the BBQ roll.

4.  Effectively progressing gaze stabilization (VOR adaptation) training.

For patients with unilateral vestibular loss (UVL) due to vestibular neuritis gaze stabilization training using treatment variables such as duration, frequency, speed, background motion, distance and more challenging bases of support can help promote vestibular compensation. This patient population generally has a favorable prognosis due to central compensation.

5.  Recognizing the characteristic wide-based, slow and ataxic gait, complaints of oscillopsia and dizziness, increased postural instability in the dark with the patient with bilateral vestibular loss (BVL).

Though this condition has several etiologies exposure to ototoxic medication is the most common cause and generally the prognosis is not as good as UVL but through substitution tactics patients can make surprising gains in balance though they will always have difficulty walking in the dark.

6.  Recognizing that vertigo or dizziness related to Migraine headaches can occur with or without a headache.  Treating the Migraine headache is the primary intervention so appropriate referral or follow up with the MD is essential.

7.  Understanding Alexander’s Law is one component that has improved my understanding of peripheral versus central nervous system presentations.

Peripheral presentations - follow Alexander’s Law and nystagmus is mixed plane – horizontal & torsional
Central presentations – nystagmus can be pure torsional, pure vertical or direction changing with change in direction of gaze

8.   Dizziness associated with concussion or head trauma has several possible etiologies that can be central and/or peripheral in nature and the symptoms are usually the result of a combination of issues. If vertigo due to BPPV is present it is not part of the concussion rather because the otoconia have been displaced from otolithic membrane due to the actual head trauma.

9.  Recognizing the need to have video goggles to assist with the accuracy of the diagnosis of the type of BPPV including the identification of the involved canal. This tool assists in evaluating nystagmus beyond the acute phase where compensation with fixation is present (no goggles) but may still be present when fixation is removed (goggles on with darkened visual field). Ultimately this helps guide the appropriate and most effective treatment.

Other diagnoses discussed during the course included Meniere’s disease, motion sensitivity, cervicogenic dizziness, chronic subjective dizziness, dizziness related to psychological diagnoses, central nervous system pathologies, orthostatic hypotension and other more rare presentations such as perilymph fistulas.

Below is the website for Vestibular Disorders Association (VEDA) which I have found informative as a clinician and for patients as well as a link for the aVOR app a fun-learning tool.

aVOR app:

I appreciate Dr. Herdman’s passion and extensive work in the area of vestibular disorders and for the clinicians and physicians who have contributed to the literature and textbook and who come together to provide this intensive and rewarding experience. For now I continue to pour over my notes and the text, discuss cases with my colleagues and physicians and at some point I will hopefully complete the advanced course.

Reference:  Herdman Susan, J. Vestibular Rehabilitation 3rd edition. Philadelphia, PA: F.A. Davis Company;2007.

Blogpost by Tracey Wagner, DPT, OCS, FAAOMPT

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