Course Review - Vestibular Rehab

At Jetset Rehab Education, we like to do reviews on our own Con Ed courses that we take to maintain our PT license.  Remember, we are Rehab Specialists as well and often take classes in areas we want to improve.

• In fact, the instructors that we use to teach our classes are always instructors for us first.  I decided to do a photo journal but then decided to do a running email chain with the three of us discussing our experience with this class:
  
  Vestibular and Balance Rehabilitation, unlocking the mysteries of dizziness.
  In my clinic there are 3 of us who have taken this class:
  1) Robin Pottukalam
  2) Gabrielle Comrie
  3) Me!  Randal Glaser
  Here is our discussion: 

Date: 10/26/2015 09:03AM
Subject: Wendy Wood Vestibular Class email blog post

Hey guys!
Thanks for being a part of this email blog post.
For our readers, I took a weekend course on vestubular rehab with a few of my co-workers.  The instructor was the amazing Dr. Wendy Wood.
My first question for us is:

-  What have you changed clinically as a direct result of this class?

On Tuesday, October 27, 2015, <robin.j.pottukalam*********> wrote:

Since I participated in this course, I have mostly changed my patient education strategies. Within the first hour in the course, I could tell that the instructor, Wendy Wood, was very experienced and well-rounded. She helped me to understand the emotional components that play a significant role in the patient's clinical picture and overall response to rehabilitation. I found it particularly interesting that many patients experience anxiety over their vertigo because their family and friends don't believe that they have dizziness. Since dizziness is not visible, it is hard for family/friends to understand the patient's condition, which makes the patient feel isolated. After learning this I try to approach my patients with a sense of understanding and letting them know that what they feel is real and there are options to help. That has really improved my patient interaction with this challenging population. Another clinical pearl in regards to patient education was the variety of home exercises and strategies that Wendy Wood taught us, which really helped the patient to feel in-control and empowered to improve their condition. Overall, my treatment approach is more specific and engaging after Wendy Wood's course.

Robin Pottukalam

Subject: Re: Wendy Wood Vestibular Class email blog post
From: Randal Glaser

For me the major thing was to not ignore dizziness In our patients.  It is the main reason why people fall and in our elderly population, falls are fatal.  I think a lot of PTs feel that treating dizziness or doing the Dix Hallpike test to screen for BPPV is too complicated.  I used to feel this way.  I also have started screening for BPPV with any patient who reports vertigo like symptoms.

On Wednesday, October 28, 2015, <robin.j.pottukalam******* wrote:

That's a good idea, Randal. Its such a simple screen that provides valuable information regardless of whether its positive or negative. I will start screening as well, I believe thats good practice.

 

Robin

On Oct 28, 2015, at 10:05 AM, randal glaser wrote:
 

I was also able to get some great ideas for balance retraining.  For example, I have a patient with a TBI with dysfunction in the cerebellar region.  Dr. Wood was able to report on her many years of experience and scientific data to make the case that of the three components of dizziness (vestibular, somatosensory, and vision) the focus should be on somatosensory.

The main point is that we can do better!  Balance retraining is more than single leg stance.  

Clinically, we all have the tools to figure out what balance component to focus on to get the most meaningful result for our patients.

Gabi? 

- Randal

On Wednesday, October 28, 2015, Gabrielle Comrie wrote:

Hey guys,

 

Great input so far and I would have to agree with all of you. I agree with Randal on the ideas for balance retraining! 

 

For me, clinically I feel like I have a much better grasp on al of the systems that could possibly be contributing to subjective dizziness. For example, any disconnect between the vestibular system, somatosensory system, or visual system could give patients deficits. Knowing exactly what to look for in terms of subjective complaints, then moving into objective signs will lead you right into the treatment that is appropriate. Dizziness can be a daunting issue for the PT and the patient, but being concise with the examination will definitely take out some of the confusion. 

 

The main take home I got from this course is dizziness is VERY treatable and as PT's we all have the tools to treat this patients successfully, even when it comes to vertigo. 

 

Unfortunately I have not had a balance patient since completion of the course, but am looking forward to putting my freshly refined skills to work! 

Sincerely,

Gabrielle

On Wed, Oct 28, 2015 at 12:48 PM, randal glaser wrote:

What are some examples of exam findings that would lead you guys to treat the visual aspect of balance?  Also, what exercise would be an example of treatment?

On Nov 2, 2015, at 8:07 AM, robin.j.pottukalamwrote:
 

Good morning!

I am a big fan of the m-CTSIB test to assess for visual dependency in balance. Before the course, I always opted for single leg balance testing with eyes closed. What I found was that the test was too advanced for certain populations, and it made it difficult to guage how far along the balance continuum that the patient landed. With the m-CTSIB, we provide a series of challenges that gradually increases in difficulty as the four portions are completed. As we know, the final portion of the m-CTSIB consists of eyes closed/foam surface/feet together, which greatly diminishes visual input for balance. Based on this, we have more options for treatment. We can modify the surfaces (compliant vs. non-compliant), the BOS (feet together or tandem), or the visual stimulus (eyes closed or head/trunk rotations). My "go-to" first day exercise is standing with feet together and eyes closed, possibly adding ankle sways - this seems to help the patient grasp the intention of treatment. The m-CTSIB ends up being a great re-assessment tool in which the patient can usually see a difference after practicing these exercises.
 

Robin

On Tuesday, November 3, 2015, Gabrielle Comrie wrote:

For me, I always seems to be pressed for time so I'll usually do a quick VOR screen and test to see if dizziness or imbalance is reproduced with series of screens including eyes open/closed with head movements and with narrow base of support. If the patient shows deficits with focusing on an object with head turns or have difficulty with eye tracking (jumping eye movements can be observed during the exam) then I will usually treat the visual aspect of balance. So far this approach has reared good outcomes with patients that have this deficit. 

Sincerely,

Gabrielle

On Wed, Nov. 4th, 2015 at 12:48 PM, randal glaser wrote:

Great answers.  After taking this class I have found myself usung the Dix-Hallpike test more frequently and yesterday it brought me some success.  As Dr. Wood says, it only takes a minute and is worth the time if you have a positive result.  If someone mentions that they are dizzy, I am screening for BPPV with that test.  I have already found one particular patient to have BPPV with this screening tool and I was seeing them for neck pain!  After 3 Epley manouvers, her dizziness was treated and she was able to fix what had been bothering her for over 6 months!  

On a side note, Dr. Woods tips on doing the Dix-Hallpike test on the elderly population and those with a thoracic kyphosis were valuable here.

I am also always thinking that for some patients, a fall can eventually be fatal.  There is that stat that mentions that 50% of elderly patients who break their hip in a fall will not make it home and die within 6 months.  This always runs through my head when I hear that balance is impaired or they have fallen.

Last question:

- describe this class to a fellow PT who wants to take it and mention the pros and cons.  (Be honest) your "friend" needs to know if he/she should take this class!

Randal

On Nov 16, 2015, at 1:55 PM, Robin wrote:
 

Pros:

- Well-rounded and experienced instructor

- Patient-friendly educational materials in the handbook (printer friendly)

- Great insights about functional tests and how to document well

Cons:

- Discussion about technology may not be relevant for most clinics due to costs

- Not all tests/maneuvers practiced in lab portion - ie Semont, BBQ roll

Overall, I highly recommend it as a foundational course. I will be looking into an intermediate course to learn more about special tests

Robin

On Nov 16, 2015, at 7:55 PM, Gabrielle Comrie wrote:

Pros:

- the instructor really knew her stuff. Her extensive background in the field really made me value her expert opinion and knowledge.

- appropriate amount of lab time the first day of the course.

- variety of options for exercise progression for dizzy patients.

Cons:

- the second day was really lecture heavy which made me lose focus. Would have benefitted from more lab time the second day to break up the sitting.

Overall, I agree with Robin. Great class for an introduction or refresher in how to treat this patient population. 

Sincerely,

Gabrielle