How to Manage a Dizzy Patient
23rd and 24th October 2012
Programme
Day 1
9.00 - 9.30: Registration
9.30 -10.15: How do we stop feeling dizzy: Adaptation and compensation in the
vestibular disordered patient.
Professor Deepak Prasher
Sudden unilateral loss of vestibular function sets off a series of symptoms which
may include involuntary eye movements, postural instability, nausea and vomiting.
Over time these symptoms spontaneously resolve and the person is able to resume
most of their daily activities. This occurs as there is adaptation of the reflexes that
are mediated by vestibular input; namely vestibulo-ocular reflex (VOR),
vestibulospinal reflex (VSR), vestibulocollic (VCR) and the cervico-ocular (COR)
reflexes. It is the plasticity of the central nervous system which allows the brain to
compensate for the loss of peripheral input and re-balance through adaptive control
such that loss of input is no longer a detriment to postural stability.
The above will be discussed in a context of how patients stop feeling dizzy,
why some patient’s do not compensate and what happens when de-compensation
occurs.
10.15 – 11.00: How to use adaptation, substitution and habituation techniques in
unilateral vestibular dysfunction, bilateral vestibular dysfunction, visual vertigo, and
multifactor etiological cases.
Ms. Nicola Topass
Each patient is an individual, but broadly speaking you are able to characterise
them into categories based on their history, functional complaints and vestibular
diagnostic test results.
Vestibular rehabilitation patients can be characterised into many treatment groups,
but the four most common that will be discussed include: unilateral vestibular
dysfunction (stable versus unstable), bilateral vestibular hypofunction, visual
vertigo, and multifactor etiological cases.
This section will look at which techniques are appropriate for which categories of
patients.
1100-11.30: Coffee break
1130-12.30 How to create an individualized treatment plan
Ms. Nicola Topass
This section will discuss how to individualize a treatment plan to the needs of your
patient and how to customize exercises within the technique category of
adaptation, substitutions and habituation.
The treatment plans should address techniques such as pacing and self-monitoring
to ensure that the therapy program, exercises and level is set appropriately. It also
teaches simplistic counselling techniques which are the corner stone of any
successful vestibular rehabilitation program.
Delegates are made aware of the differences of personal adjustment counselling
versus informational counselling and how these counselling tools can be employed
by an audiologist.
12.30 - 13.30 Lunch
13.30-14.15: How to manage a patient with BPPV
Ms. Karen Lammaing
Benign positional paroxysmal vertigo is one of the most common
peripheral vestibular disorders and is often the most easily treated. BPPV is
caused by movement of detached otoconia that have displaced into the semicircular
canals. Treatment of BPPV involves the manipulation of the patient’s head to
relocate these otoconia into the utricle where they can be reabsorbed. Identification
of the involved canal is typified by specific eye movements when the patient is in
the test position.
It is important that the correct canal and correct side is identified as the treatment
procedure is different for each of the 3 canals.
Treatment for BPPV of the anterior, posterior and horizontal canal will be
discussed and demonstrated. The delegate will have a good understanding on
identifying which canal is involved and how to perform the different treatments.
14.15-15.00: How to optimise your therapy, beyond the use of physical exercises: use of
bibliotherapy, goal setting, and motivation counselling in individualised therapy
For any vestibular rehabilitation program to be successful it is important that the
patient be motivated. A non-motivated patient will never improve no matter how
much time or expertise is employed by the clinician. Therefore it is important to
assess the motivation of the patient, be it via a simple conversation or by formally
completing a motivation questionnaire such as the Multidimensional Health Locus
of Control (MHLC) Scale.
Once a patient is motivated then goals setting can be discussed. It is essential for
the patient to have realistic goals or they set themselves up for failure, this is
another corner stone concept for successful treatment. It is important that the
clinician is able to listen to the patient and formulate appropriate goals with them.
Studies have shown that patients only remember a small amount of what is actually
said in any clinical interaction, and that is based on them having normal hearing.
Thus our patients with balance and often hearing problems would remember even
less. Thus it is important that all information is documented appropriately and that
patients are directed to ‘safe’ internet sites for further reading to understand their
condition.
15.00-15.30 How to assess the value of therapy: use of outcome measures.
Ms. Nicola Topass
The only way to ensure that the service you are providing your patients is
beneficial is to measure that benefit. If you don’t measure it, it does not exist.
There are two types of assessing benefit, namely by subjective assessment and by
objective assessment.
Subjective assessment can take place in the form of questionnaire assessment.
There are several different outcome measurements available for vestibular
rehabilitation from the more general SF 36 Health questionnaire to the more
disease specific such as the Dizziness Handicap Inventory, Vertigo Symptom Scale
and the Vestibular Rehabilitation Benefit Questionnaire (VRBQ).
This section will focus on the VRBQ as it is a questionnaire that provides
psychometrics. It is thus able to identify how much of a change pre-post therapy
would be considered as a significant change due to the intervention offered.
Objective assessment can be in the form of assessing postural sway. An example of
an objective measure of postural sway is the EquiTest system by Neurocom. It
enables the clinician to assess the increase in postural stability, decreased sway and
increased limits of stability as the patient improves with the vestibular
rehabilitation program.
15.30-16.15: How to manage the anxious and depressed patient and employ pacing and
communication strategies. The use of psychological techniques in treating VR patients.
Ms. Jacqui Seaton
Anxiety and depression are closely linked with many chronic conditions, it
is therefore no surprise that patient’s with vestibular disorders often have anxiety
and depression. Stress, anxiety and depression are closely linked and can enhance
dizzy symptoms and thus intern enhance the stress, anxiety and depression.
It is a vicious cycle that can perpetuate itself and end in the patient being
withdrawn from society. If the patient is in this anxiety state their ability to
centrally compensate to their vestibular disorder is vastly diminished and they do
not progress with their program. It is thus important that these patients be
identified early and appropriate intervention is offered.
This section will discuss how to identify these patients and the therapy programs
that are currently offered for patients who have been identified. The therapy may
be in the form of individualised intervention or group therapy depending on the
needs of the patient. Some of the psychological concepts that will be discussed will
include: acceptance and commitment therapy, pacing, defusion, and assertiveness.
16.15-16.45 Coffee
16.45- 17.15: The Vestibular Rehabilitation Process from the Patient’s Point of View
Mr. Gordon Salter
Mr. Salter had vestibular neuronitis in 2010. He sort help and was referred to the
diagnostic Vestibular clinic at the Royal Surrey County hospital at which time he
was diagnosed with peripheral right sided vestibular dysfunction. He was then
referred to the Vestibular rehabilitation clinic in 2011.
He did not spontaneously recover from this episode and it subsequently greatly
affected his quality of life. He started the vestibular rehabilitation program in
September 2011. He has been determined in his therapy outcomes and will inform
us of his journey.
18.00-20.00: Evening break out session and dinner:
Evening break out session to include:
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MCQ on topics of the day to test the basic understanding of topics discussed.
Group breakout sessions on topics for further discussion.
A chance to network with other members of the seminar as well as the lecturers.
Day 2
9.00 – 11.00: How to use bedside tests to identify treatment goals and also use them to
identify progress with therapy plans: Putting the key elements of a vestibular
rehabilitation plan into practice with practical hands on session.
Ms. Nicola Topass
Bedside tests can be used as objective measures to assess uncompensated
vestibular lesions.
Post-head shake nystagmus is able to identify if there is tonic asymmetry at the
level of the vestibular nuclei, hence depicting a centrally uncompensated lesion.
The Fukuda stepping test evaluates the vestibular spinal reflex giving insight into
how the vestibular system affects postural stability.
Dynamic visual acuity is a measure of the VOR, and provides us with information
of how vision with head movement may be affected due to the vestibular deficit.
The Motion Sensitivity Quotient can be employed to quantify the degree of motion
sensitivity the patient is experiencing.
All of these measures would initially identify the uncompensated lesion and how it
affects various reflex systems which are dependent on vestibular input. They
would also change as the patient’s vestibular system compensates, hence
improving as a measure of vestibular rehabilitation.
The Fukuda would give insight for the need for stability exercises; the DVA would
identify the need for Herman VOR exercises, and the MSQ would identify the
need for habituation exercises such as the Cawthorne-Cooksey exercises.
These tests will be demonstrated in a practical session. It will be shown how to use
these tests to identify, implement and modify an exercise program.
11.00-11.15: Coffee break
11.15 – 12.15: Machine based VR practical
Ms. Nicola Topass
Most vestibular rehabilitation is based on clinical assessment of benefit of the VR
therapy. The Machine based VR looks at the use of the Neurocom Balance Master
platform for assessment improvement in postural stability and sway patterns with
the progression of VR exercise therapy programs. It provides an objective measure
of the patient’s improvement, which also serves as a motivational tool. The session
will focus on how to use the principles that were taught in the Individualised VR
practical with the machine based technology.
12.15 – 13.15: Lunch
13.15-15.15: BPPV assessment and management practical
Ms. Karen Lammaing
The techniques for BPPV assessment and management will be demonstrated
practically. Techniques included will be:
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Dix-Hallpike
Side Lying
Roll Test
Modified Epley
Semont
Brandt-Daroff
BBQ roll
Appiani
Cassani
Gans Manoeuvre
Gufoni
15.15-15.30: Coffee break
15.30-16.30: Support groups for successful treatment of vestibular patients
Ms. Natasha Harrington-Benton
Director, Ménière’s Society
Synopsis
“When I was diagnosed with Ménière's I felt completely abandoned. Nobody told me of your
Society and I felt lost…after searching the internet I have found you, and just to know that
someone understands and I am not alone has made a world of difference.” The Meniere’s
Society is the only UK registered charity dedicated solely to supporting people
with dizziness and imbalance from vestibular disorders. The Society offers support
at all stages of a person’s condition. For those who are newly diagnosed and want
help locating a health professional who specialises in vestibular disorders, through
to those in the later stages of the condition or if their symptoms have returned after
a period of remission. Peer support, whether one-to-one, in a group, by telephone
or online, plays an important part in the management of vestibular disorders and is
often a valuable tool. The Ménière’s Society can give support and information and
put people in contact with others facing the same problems. Knowing they are not
alone and others share their concerns can be an enormous help to them in the
management of their symptoms.
Ménière’s Society
The Ménière’s Society is a UK registered charity dedicated to supporting people
with dizziness and balance problems caused by vestibular disorders. The Society
provides information to patients and those who care for them, health professionals
and the general public. Members are from all over the UK, with a small number
overseas.
With over 25 years experience providing information to those affected by
vestibular disorders, the Ménière’s Society helps people source specialists in their
local area, publishes a quarterly magazine, Spin, and factsheets on a variety of
subjects (e.g. driving, surgery and vestibular rehabilitation), as well as providing a
telephone information line during working hours.
For health professionals, the Society offers information and support for their
patients, we are able to supply booklets on vestibular rehabilitation and provide a
list of ENT and vestibular rehabilitation specialists; useful if referring a patient for
further testing and treatment.
The Society maintains an active relationship with interested clinicians and
researchers and, where funds allow, funds vital research into vestibular disorders.
16.30-17.00: VR case studies from a Physiotherapy Perspective
Ms. Michelle Dawson
Michelle is going to present a variety of case studies of patients who have
undergone vestibular rehabilitation with a physiotherapy bias. Michelle is part of
the vestibular rehabilitation MDT and was kindly invited to attend last year’s
excellent study day and would highly recommend this informative study day.
17.00-17.30
VR cases studies from an Audiology Perspective
Ms. Nicola Topass
Nicola is going to present a variety of cases studies of patients who have received
vestibular rehabilitation. It will focus on their therapy program from an
audiological perspective.
17.00-18.00 Evening break out session: MCQ, BPPV Practical questions, or Machine
based VR questions.
Delegates will have the opportunity to choose from either:
1. A multiple choice question and answer session on all the topics that were discussed
during the 2 day seminar.
2. Further session on question and answer session focused on BPPV assessment and
management.
3. Or a further question and answer session on the machine based approach for VR.
Outcomes for 2 day training:
Upon completion of the course, participants should be able to:
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Understand the concepts behind vestibular reflex pathway adaptation and central
compensation
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Identify the canal and side involved with BPPV and treat the patient appropriately
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Know how to classify a patient into treatment categories and how to identify exercise
types based on those categories
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Understand how to develop an individualised vestibular rehabilitation program
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Understand the importance of outcome measures and how they could influence your
therapy program
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Understand how to use bibliotherapy, goal assessment, and motivation in your
vestibular rehabilitation program
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Understand how to employ psychological concepts in your vestibular rehabilitation
program
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Understand the potential benefit of machine based vestibular rehabilitation
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Understand the benefits of support groups
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Understand the patient’s journey through the vestibular rehabilitation process
Details of speakers/lecturers
Professor Deepak Prasher, BSc,
Consultant Clinical Scientist (Audiology)
Email: d.prasher@nhs.net
Professor Prasher has recently moved from University College London (UCL) Ear Institute
where he was Head of the School of Audiology. He is the Chief Examiner for the Hearing
Aid Council, Editor-in-Chief of the International Journal of Noise and Health, on the Board
of Trustees for the National Deaf Children’s Society (NDCS). He has been an advisor to the
European Commission and the World Health Organisation on matters of hearing and
environmental noise issues. His interests are in special tests of hearing and balance.
Ms Karen Lammaing - Deputy Head of Audiology (Adults)
Karen Lammaing is the Deputy Head of Audiology and the clinical lead for Adult services in
the Audiology Department at the Royal Surrey County Hospital.
She was born in Belgium and completed her MSc in Audiology at the University of Ghent
(Belgium). She has worked in the UK since 2003 and has worked in several Audiology
Departments across the country. She joined the Audiology Department at the Royal Surrey
County Hospital in 2010 and completes vestibular evaluations on a daily basis alongside her
duties as Deputy Head.
Ms Nicola Topass - Team Leader (Balance Service)
Nicola Topass qualified as an Audiologist in 2004 and has been working at the Royal Surrey
County Hospital since 2006. She is currently completing the Doctor of Audiology program
with Nova Southeastern University on a part-time basis. She has special interests in
Vestibular assessment and rehabilitation, but also does work with hearing assessment in
Special needs adults, other Physiological Measures, Baha assessments and fittings and adult
hearing assessments and fittings. She was appointed the Team Leader for the AudioVestibular service in 2009 and completes vestibular evaluations on a daily basis.
Ms. Jacqueline Anne Seaton- Chartered Clinical Psychologist
Jacqui joined the Vestibular rehabilitation Team in 2011 and worked closely with the team to
develop psychological interventions appropriate for vestibular rehabilitation patients. She
offers both individual therapy sessions in which she uses a holistic approach to patient
therapy and draws from her many years of experience working with patients who are poorly
motivated and have avoidance behaviours. She also offers educational group therapy which
is part of the basic intervention program offered at the Royal Surrey County Hospital. These
groups focus on the psychological concepts of pacing and communication tactics.
Ms. Natasha Harrington-Benton
Natasha Harrington-Benton is Director at the Ménière’s Society and has held this post for
seven years. Natasha is responsible for the day to day running of the Ménière’s Society. Her
role involves a wide range of activities including fundraising, strategy, publicity, attending
events and liaising with health professionals, researchers and related organisations; as well as
remaining a hands-on member of the office team, responding to enquiries and taking calls on
the Society’s information line.
Natasha has 18 years experience of working in the voluntary and not-for-profit sector and has
previously worked for the Historic Churches Preservation Trust, The Industrial Society and
Authors’ Licensing and Collecting Society.
Ms. Michelle Dawson
Michelle Dawson is a senior Physiotherapist who has worked at the
Royal Surrey County Hospital since 2002. Michelle is a
Musculoskeletal Physiotherapist who has developed skills in
vestibular rehabilitation. Michelle is a member of the special
interest group the ACPIVR (Association of Chartered
Physiotherapists in Vestibular Rehabilitation) and attends regular
update courses.
Mr. Gordon Salter
Mr. Salter is a vestibular rehabilitation patient.