Diagnosis and Management of Balance Vestibular Disorder

September 2016

Belinda C. Sinks, AuD, CCC-A

The Facts

Balance and vestibular disorders are major health concerns. According to the National Institute on Deafness and Other Communication Disorders (NIDCD, 2015), it was estimated that 40% of the population, at some point in their lifetime, will experience some form of balance or vestibular disorder. Balance/vestibular problems know no age boundaries. Although we are more likely to have problems with balance as we age, with a prevalence of sensory impairment at 70 years and older, balance/vestibular disorders also occur in children. Literature suggests that 2/3 of children with acquired deafness will have vestibular deficits (NIDCD, 1995). Balance dysfunction is also suspected after cochlear implantation due to otitis media and other viral pathologies, migraine, and Benign positional vertigo (BPV) of childhood.

Dizziness affects our quality of life and sense of independence, and it doubles the risk of falling. Falls are the number one cause of trauma, hospital admissions, and fractures in older adults, with more than 1.6 million reporting to hospital emergency departments each year (National Institute on Aging, 2013).

The psychological impact of the fear of falling should not be underestimated. The fear of injury or embarrassment takes a toll and can be debilitating. The patient becomes more at risk for depression and anxiety and can become less mobile, experience a decrease in muscle strength and coordination, and become socially reclusive.

The patient with a balance/vestibular disorder gets funneled through a variety of diagnostic and treatment referrals. Over the span of 10 years—when looking at the diagnostic code of "Dizziness and Giddiness" (Centers for Disease Control and Prevention/National Center for Health Statistics, 2016)—1,653,000 patients were first seen in primary care settings; 355,000 were seen in surgical specialty offices; 394,000 were seen in medical specialty offices; 208,000 were seen in hospital outpatient departments; and 853,000 were seen in hospital emergency departments. Most of the emergency room patients who had been evaluated were instructed to follow up with their primary care physician/internist. A large percentage of patients were referred on to medical specialty offices from primary care settings. Thus, a string of referrals can be tracked from one professional to the next.

It is not uncommon for the patient with dizziness to see up to four physicians for their complaints and to have visited the hospital emergency department at least once for their symptoms. In our experience, some patients' histories go back many years without a clear diagnosis. This trend lends support to the idea of interprofessional education and interprofessional collaborative practice (IPE/IPP; American Speech-Hearing-Language Association [ASHA], 2016).

The relationship of the team members revolves around each member sharing their expertise in a respectful and positive way. Each member has a critical role in the common health care goal of the patient and a responsibility to help the patient achieve optimal outcomes. That is especially true with the often-complex case of the patient who is experiencing a balance/vestibular disorder.

Managing Balance/Vestibular Disorders in Patients: An Overview

The most effective way to manage dizziness in patients is with a multidisciplinary team or an IPE/IPP-based approach. Balance/vestibular disorders can be complex and difficult to diagnose, as they can have multiple causes that often cannot be isolated to a single source. Because of the brain's adaptive responses, the resulting impairments from a specific cause can vary considerably from one patient to the next. In addition, these multiple causes may arise from different sensory systems. These multisystem problems may require expertise from more than one medical specialist for appropriate management. Having a working relationship with a group of providers is most effective in the care of this population. However, it is not necessary for IPE/IPP team members to be part of the same group or site. Often, the patient who is experiencing dizziness will initially seek consultation with various health professionals, including those in primary care, otolaryngology, neurology, or emergency medicine. Point of entry may lead to consultation with additional health care team members specializing in cardiology, audiology, and physical therapy.

The World Health Organization (WHO) recognizes that IPE/IPP is critical to achieving the three goals of the Institute for Healthcare Improvement: (a) improve the patient's experience (quality and satisfaction), (b) improve health, and (c) reduce the per capita cost of health care. Using the experience and expertise of different professionals—while each maintains their own identity within the team—shows respect for each team member and works toward a common goal of providing the best team-based patient care (WHO, 2010).

Our Experience

The model at Washington University School of Medicine's Dizziness and Balance Center consists of an interprofessional collaborative team that includes a medical director (who happens to be a neuro-otologist), two audiologists, a physical therapist (PT), and a patient service representative. Although each patient's experience may differ because of their unique needs, Washington University School of Medicine Balance Center Flow Chart [PDF] shows a good example of the typical flow within the center. The text that follows outlines the duties of the major members of the team. In addition, a well-developed and reciprocal working relationship with neuro-ophthalmology, neurology, neurosurgery, cardiology, and psychiatry is advantageous. Please refer to Figure 1 [PDF] at the end of this article.

The patient representative receives the orders via electronic task from our centralized scheduling group. She reviews the orders for required information such as referral signature, testing required, diagnosis code, and insurance. She also makes sure that a patient packet was sent to the patient. The packet contains a welcome letter, instructions to be followed prior to testing, a questionnaire, a medical release form, an insurance form, and a map. She will forward the referral to the audiologists if testing protocol information is incomplete or if the referral source seeks assistance. In this event, the audiologist will call the referral source for clarification. Although the referring physician checks off which tests they would like completed, the audiologist can add tests as appropriate. Sometimes, these alterations in testing protocol are sometimes done when the notes arrive and after discussion with the outside referring physician. At other times, the decision is made spontaneously during the appointment due to how the testing unfolds and whether the primary question has been answered.

Meanwhile, the patient representative pre-certifies the appointment through the patient's insurance carrier and notes the information in the patient's electronic record. Two days prior to the patient's appointment, the patient representative calls the patient to remind them of the appointment, to verify that the patient understands the directions and has filled out the questionnaire, to inform them of insurance coverage, and to answer any questions. Sometimes, the insurance process requires multiple phone calls.

The audiologist is responsible for all diagnostic testing in the lab. This includes computerized dynamic posturography, video-oculography (VOG), rotational chair (RC), video head impulse testing (vHIT), and cervical and ocular vestibular evoked myogenic potentials (cVEMP/oVEMP). The audiologist often triages the patient's records, as the referral sources request assistance in decision making regarding which tests to order. The evaluation process involves a complete history, a diagnostic evaluation, a comprehensive report that includes the result of each individual test, an executive summary bringing the whole picture together, and recommendations. This report is then forwarded to the medical director (neuro-otologist) electronically for review, after which time the audiologist faxes it to the outside referring physician.

The medical director, who is a neuro-otologist within our group, acts as a liaison between the center and the outside referring physician. He is available for patient consultation before or after testing in our center, if desired. Some referring physicians, depending on their level of comfort with this type of patient, prefer that their patients follow up with the medical director or another neuro-otologist within our center after testing. The medical director also reviews all raw testing and the reports generated by the audiologist before everything is sent to the outside referral sources. In addition, the medical director is available if the referring physician would like a phone consultation regarding their patient.

The PT is responsible for managing rehabilitation for the patient diagnosed with balance/vestibular disorder. The PT (a) reviews the medical and diagnostic information and (b) performs any additional functional (objective) evaluations of the patient as well as any subjective measures (paper-and-pencil questionnaires) in order to fully understand the patient's primary and secondary problems due to their balance/vestibular disorder. The PT then designs an exercise-based program to reduce these symptoms. Compensation and recovery is different for each patient, and the PT monitors the progress of the patient and communicates their assessment to the balance center physician.

Case Examples

The following cases represent common examples of providers from multiple specialties working together by sharing information. This type of medical model will likely provide the best care for the patient.

Case 1: 28-Year-Old Female
A 28-year-old female nursing student presented to the Dizziness and Balance Center with a complaint of intermittent "waves" of imbalance. She was referred by her otolaryngologist for VOG testing. The records from her physician revealed a normal exam and normal comprehensive audiometry. The VOG results were normal, with the exception of random saccade testing. Random saccades revealed an internuclear ophthalmoplegia (INO). An INO is a disorder of adduction and affects conjugate lateral gaze. In other words, if you were to look to the right, your right eye would move as it should but your left eye would lag behind. Results were written as per our protocol; however, the medical director was alerted. A courtesy call was made to the referring physician to expedite the management of this patient. She was then scheduled for an MRI and neurological consult. The patient was diagnosed with multiple sclerosis and is being treated and followed through neurology.

Case 2: 58-Year-Old Male
A 58-year-old male was referred for symptoms of dizziness and imbalance for the past several months. He was referred by his otolaryngologist. He reported symptoms of vertigo during rapid head movements and imbalance when ambulating, often veering to the right. He was referred for VOG testing. Bithermal caloric results revealed a 62% right-reduced response with a total eye speed of 73 degrees per second (º/s). At our facility, a difference of 30% or greater is considered a significant difference. This means that one ear—in this case, the right—is significantly weaker than the other. There was a 3º/s leftward beating spontaneous nystagmus with vision denied that increased to 6º/s with gaze left. This means that when the patient was in the dark and looking straight ahead, he had a nystagmus, or "beating" eye movement to the left; this is the same movement that happens when you are turning to the left or if your brain thinks you are turning to the left. This movement was exacerbated when he looked to the left. Results were also positive for a 7º/s leftward beating post-headshake nystagmus. After shaking the patient's head back and forth for 20 s, the spontaneous nystagmus increased. This leftward beating is happening because the left labyrinth is being stimulated more than the right (due to the weakness on the right), and the brain thinks that the patient is turning to the left. All other subtests were within normal limits. This suggested significant asymmetry in the peripheral labyrinthine input, with the right side being weaker than the left. The audiologist decided to add an RC study to further investigate the peripheral asymmetry and evaluate for central compensation. Vestibulo-ocular reflex (VOR) gain revealed decreased low-frequency gain with phase lead and asymmetry with the clockwise (rightward) rotations being weaker than the counterclockwise (leftward) rotations. This confirmed the weakness on the right side. This time the patient was actually in motion during the VOR testing. Step velocity time constants were also reduced. These results suggested uncompensated peripheral vestibular dysfunction of the lateral canal, with the right side being weaker than the left. It also explained why the patient often veered to the right when he was walking. It was recommended that the patient be referred for vestibular rehabilitation to assist in central compensation. The diagnostic information was made available to the PT in order to streamline her evaluation to the most pertinent tasks. The PT created the goals based on the functional evaluation of the patient and in collaboration with the patient. After 6 weeks of therapy, the patient was reevaluated, revealing that all therapy goals were successfully met (the patient's symptoms had significantly decreased), and he was discharged from therapy. A report was sent to the center physician.

Conclusion

Evidence supports the fact that, when applied appropriately, the IPE/IPP model will improve patient outcomes. For this reason, the WHO and the Health Resources & Services Administration (which is part of the U.S. Department of Health and Human Services) have initiated this collaborative approach to improve interdisciplinary health care. Improving the quality of patient care while optimizing patient outcomes in an evidence-based system requires teamwork. Building a network of productive interprofessional collaborative professionals expedites efficient care, lowers costs, and increases patient satisfaction for diagnosis and treatment of balance/vestibular disorders.

About the Author

Belinda C. Sinks, AuD, CCC-A, is a clinical and research audiologist in the Department of Otolaryngology–Head and Neck Surgery at Washington University School of Medicine (WUSM) in St. Louis, Missouri. She currently maintains a clinical practice and conducts research at the Dizziness and Balance Center within the department, and she also is a lecturer for the Program in Audiology and Communication Sciences at WUSM. Sinks' clinical and research interests focus on the areas of vestibular function and evaluation, balance prostheses, vHIT, cVEMP, oVEMP, and evaluation of the dynamic subjective visual vertical.

References

American Speech-Hearing-Language Association. (2016). Interprofessional education/interprofessional practice (IPE/IPP). Retrieved from www.asha.org/Practice/Interprofessional-Education-Practice/

Centers for Disease Control and Prevention/National Center for Health Statistics. (2016). Annual number and percent distribution of ambulatory care visits by setting type according to diagnosis group: United States, 2009–2010. Retrieved from http://www.cdc.gov/nchs/data/ahcd/combined_tables/2009-2010_combined_web_table01.pdf [PDF]

National Institute on Aging. (2013). Falls and older adults. Retrieved from http://nihseniorhealth.gov/falls/aboutfalls/01.html

National Institute on Deafness and Other Communication Disorders. (1995). National strategic plan: Balance and balance disorders (NIH Pub. No. 96-3217). Bethesda, MD: Author.

National Institute on Deafness and Other Communication Disorders. (2015). Balance problems. Retrieved from https://www.nidcd.nih.gov/health/balance-disorders#4

World Health Organization. (2010). Framework for Action on Interprofessional Education and Collaborative Practice. Retrieved from http://www.who.int/hrh/resources/framework_action/en/ [PDF]