Helping People with Vestibular Disorders
Tech Topic | Hearing Review September 2014
By Wendy Crumley-Welsh, MS
Continuing education is the secret to helping patients with vestibular disorders.
It has been said that Michelangelo wrote “I am still learning” on the edge of a drawing in 1562 at the age of 87—proof that learning never stops, even for one of the greatest masters of all time. The same is true for audiologists, especially when it comes to balance assessment and the vestibular system.
Vestibular disorders can occur frequently and strike people of any age. They occur for many reasons, including aging, concussions, head and ear trauma, disease, stroke, cardiovascular problems, stress, and tension—to name just a few. According to the Vestibular Disorders Association (VEDA), Portland, Ore, a recent epidemiological study estimates that up to 35% of US adults aged 40 or older have experienced some form of vestibular disorder, and that 4% report a chronic problem with balance. Additionally, approximately 2.4 million Americans suffer from dizziness.
With so many people exhibiting a vestibular disorder, audiologists need information, training, and education to develop the competence necessary to help these patients.
Long Journey to Proper Diagnosis
It can be difficult for people with a vestibular disorder to obtain a proper diagnosis. Human balance is controlled by the complex integration of three sensory systems: the visual, the vestibular, and the somatosensory. No one specialty addresses all three systems. Therefore, it can be challenging to determine what the problem is and from what organ it originates. By the time a patient reaches an audiologist, they may have spent years visiting multiple specialists trying to understand the cause of their symptoms.
Getting a Proper Diagnosis
“A vestibular disorder is very difficult to diagnose,” says Cynthia Ryan, MBA, executive director of VEDA. “Dizziness is a common symptom for many diseases, and doctors look to rule out the life-threatening conditions first. When they discover that the dizziness or imbalance is not caused by a life-threatening condition, they treat the symptoms of dizziness without correcting what’s actually causing it.”
Without a proper diagnosis, patients are left with what can become a debilitating condition that affects every aspect of their lives. “Many of our members tell us that they feel they have an invisible chronic illness,” says Ryan. “Their symptoms and condition are not always acknowledged, leaving them to deal with the devastating consequences on their own.”
VEDA (www.vestibular.org) is working to change that. Their goal is to reduce diagnosis times and prediagnosis doctor visits—while improving treatment effectiveness. Newer initiatives include advocating for better training and education in vestibular disorders among the medical profession.
“Part of what we are trying to do is to really encourage education institutions to look at the training they provide,” says Ryan. “Our activities in this area include a ‘Champion of Vestibular Medicine Award’ to increase awareness of vestibular disorders in medical schools by recognizing the outstanding contributions of medical professionals to the vestibular community. We are also working on vestibular triage protocols to help primary care practitioners recognize vestibular symptoms and refer their patients to the appropriate specialist for appropriate diagnosis and treatment.”
Lack of Adequate Training
Lack of training in vestibular disorders among healthcare personnel may partly explain why it can be difficult to obtain a proper diagnosis.
Many ENTs and GPs receive very little vestibular training in their professional education and during their residencies.
This is also true for audiologists. While balance disorders and the vestibular system are part of the basic audiology education, the current audiology curriculum in many graduate schools does not necessarily focus on vestibular assessment clinical practices. Therefore, there is a need for more awareness of vestibular disorders and how to assess and diagnose them.
“Vestibular testing used to be an elective part of the curriculum,” says Kamran Barin, PhD, assistant professor emeritus in the Department of Otolaryngology-Head and Neck Surgery and Department of Speech and Hearing Science at Ohio State University, an educational speaker on balance disorders. “So some audiologists graduated without receiving a full set of courses in vestibular disorders, or perhaps it was a general introduction. Fortunately, this is changing. Nevertheless, like anything else, understanding the physiology of a disorder is important in effective assessment, diagnosis, and treatment. Education provides the necessary foundation.”
New Diagnostic Tools
There are a number of diagnostic tests and tools available today to assess the patient with a vestibular disorder, with some more useful than others. The goal of assessing the patient with vestibular symptoms is to determine if the disorder is unilateral or bilateral, as well as what end organ is contributing to the disorder, and the severity of the disorder.
In the past, the caloric test and the passive whole-body rotation tests have been complementary. These tests assisted in the diagnosis of peripheral disorders and determined if the disorder is unilateral or bilateral. While still used today, many of these tests are time-consuming, require special equipment, can cause adverse side effects for the patient, and may not be suitable for all patients, such as children, the elderly, or bed-ridden patients.
However, there are more diagnostically useful tests, including the established tests such as videonystagmography (VNG), cVEMP (cervical vestibular evoked myogenic potential), and OVEMP (ocular vestibular evoked myogenic potential), as well as newer testing methods and systems, including the video head impulse test (vHIT). Equipment such as the ICS Impulse®—a vHIT system—assesses the vestibulo-ocular reflex for all six semicircular canals and provides precise objective data based on real-life stimuli quickly and without unpleasant side effects for the patient.
To help patients with a vestibular disorder, the audiologist must be familiar with the full battery of tests available to assess the vestibular system. They also must know how to conduct the tests, make precise measurements, and understand the results so they can discuss them with the medical team.
It can be challenging to stay abreast of developments in this area as innovative methods and technologies in vestibular assessment become available. Therefore, continuing education plays an even greater role in helping both new and experienced audiologists stay up to date.
Vestibular Learning Opportunities
There are several options available for audiologists to increase their knowledge about the vestibular system and disorders, as well as diagnostic tools and testing. These include continuing education courses offered by universities, associations and institutes, and equipment manufacturers.
Continuing the legacy established by ICS®, GN Otometrics and Audiology Systems have been key players in this area. Working in close collaboration with industry experts, such as Dr Barin, Jorge Kattah, MD, and Kristen Janky, PhD, the companies have created learning opportunities that help clinicians increase their knowledge of vestibular assessment and maximize the use of hearing and balance instrumentation.
Since 2001, Otometrics’ course, led by Dr Barin, has been a leading vestibular educational opportunity for audiologists and other hearing care professionals looking for both theoretical and practical knowledge. To date, he has taught over 2,000 audiologists, physicians, physical therapists, and technicians who perform and interpret balance disorder testing. The Barin VNG/ENG and vHIT course is a 3-day information-intensive course designed to provide practical information necessary to make the VNG/ENG and vHIT testing an effective part of the diagnostic process.
“In this course, we strive to cover the fundamentals of vestibular testing and bring all the participants up to date on the latest findings, theory, and clinical best practices,” says Dr Barin. “More importantly, we give participants the practical knowledge—so they can return to their clinics with a better understanding of VNG/ENG and vHIT and to successfully implement their own workflow for their patients and clients.
“Audiologists receive continuing education credit for their attendance, while physicians come to the course purely to learn about new diagnostic information,” says Dr Barin. “Many attend every 2 to 3 years to get updated on new developments. We tweak the course content every year to ensure that the course provides the newest and most relevant information.
“The vestibular area is changing very rapidly,” he adds. “The course has to be relevant to those who are new to the area, as well as those who have experience in vestibular assessment and testing.”
Outlook for Improved Balance Assessment
Each year, researchers are learning more about the intricacies of the vestibular system and how it works. Until recently, it has not been possible to assess many of the vestibular end organs. Now it is possible with new and improved diagnostic tools.
“Our knowledge of the vestibular system today can be compared to where we were with audiology 30 years ago,” says Dr Barin. “But we have come a long way in the last 10 years or so. These are exciting times for vestibular assessment—and with new technologies such as the ICS Impulse® vHIT system, we can begin to catch up and make balance assessment as easy and accessible as auditory assessment is today.”
Also important, the vestibular system and its disorders has become a mandatory part of the audiology curriculum at many universities in recent years. “Over time, the graduates of this area will build up their knowledge and experience and transfer that knowledge to the existing pool of audiologists,” says Dr Barin. “This is actually taking place now to some degree and is important; however, there is still a need for audiologists and other clinicians to maintain their level of expertise in this rapidly changing field. Courses, including the ones GN Otometrics and Audiology Systems provide, can help audiologists stay up to date with the latest information on how to use new testing methods.”