Diagnosis and Management of Balance/Vestibular Disorder: A Team-Based Approach
Belinda C. Sinks,
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
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],
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).
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
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.
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.
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.
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.
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.
Speech-Hearing-Language Association. (2016). Interprofessional
education/interprofessional practice (IPE/IPP). Retrieved from http://www.asha.org/Practice/Interprofessional-Education-Practice/
Centers for Disease Control and Prevention/National Center for Health
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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
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
Washington University School of Medicine Balance Center Flow Chart [PDF]