Clinical Kit 97 - 4/11/2015 - Vestibular Course Learning Experience

As part of the 2015 Vestibular Program we offered a $1000.00 scholarship to rural and remote physiotherapists wanting to attend the Melbourne Basic 5 day course. One of the successful recipients was Jono Prowse from NT. Here is a pic of the happy camper with his man sized cheque and his account of Day 1.

My learning experience started day 1. Brief introductions and we hit the ground running, delving straight into the anatomy and physiology of the vestibular organs. My experience in the area was limited to observing and assisting colleagues with the Epley, or as I now know it the Canalith repositioning maneuver, and listening to inservices which never seemed long enough to get around what is clearly a complex system.

Although I had done some pre-reading in the hope to not get left behind early in the piece, I found the first lectures difficult. The most challenging aspect being not just the general anatomy but the orientation of it all and in particular that of the semi-circular canals and the Otolith organs. This being imperative later on in understanding the purpose of strategic positioning for both assessment and treatment of various conditions as well as the principle of excitation and inhibition. I also found the neuro-anatomy difficult as I do not consider this to be one of my strong points as a clinician.

An early important understanding was that of differentiating between different causes for dizziness. It was interesting to learn how various types of dizziness including central and peripheral disorders can present quite similarly to the untrained examiner. This being an important aspect in my role within the Emergency Departement at RDH in determining whether or not an individual requires further investigation or is potentially treatable. It was reassuring though to note that with most central causes the Vestibular assessment will demonstrate clear signs and symptoms that would indicate a non-vestibular cause for pathology.

The physiology aspect of the mornings lectures seemed to make more sense. I felt there was only a brief explanation on specific disorders involving the peripheral system such as Neuritis or Menieres, however I had made myself aware of most of these prior to the course and case examples were used well with each condition. I found it particularly useful looking at differential diagnosis tables that looked at tempo and symptom characteristics in aiding clinical reasoning. And most of which could be either ruled out or narrowed down from a thorough subjective assessment. And this was something that really hit home for me. Its easy to jump straight into performing an oculomotor exam or assessing someones dynamic gait but in reality the most important aspect has to be obtaining an accurate history and if done effectively the objective assessment should simply be confirming hypothesis. Probably something I should think more about in general practice.

We then moved on to the clinical examination. This involved identifying some commonly used objective assessment tools, which were unfamiliar to me in the context of vestibular assessment. These being the VAS, Disability scale, Acitivity Specific Confidence Scale and the Vestibular Rehabilitation Benefits Questionaire. It was interesting to see how widely these were used amongst the faculty and puts in perspective the impact that these problems can have on quality of life.

From here we looked at the oculomotor exam. This put earlier anatomy and pathophysiology to the test but was interesting in its practical application. Prior to attending the course I was familiar with some of the exam techniques but wasn’t clear on the diagnostic significance of all tests. A colleague had completed an inservice for our department on the HINTS paper, which was briefly touched on later in the course. This paper looked at the sensitivity and specificity of aspects of the oculomotor exam in determining central versus peripheral pathology. I had therefore practiced a few of these techniques but was completely limited to the conclusion of this is/isn’t a peripheral vestibular problem. It was interesting to learn about the concept of a unilateral vestibular hypofunction and how this could be quite easily assessed and treated with vestibular rehab. This whole concept was new but I found it quite simple in broadly classifying a variety of conditions into one in order to focus treatment. It was good to practically apply the concepts of VOR and excitation/inhibition using Ewalds Laws and certainly placed more relevance on the range of tests.

These concepts were then put to practice with our first practicum. It was really beneficial to have these opportunities to practice techniques such as these throughout the course. The way things were set up with regards to practical sessions and competences meant there was no getting left behind. Unfortunately we didn’t get a chance to play with the infrared or frenzel lenses, having never seen or used these before. However we observed others using them and it appeared much easier in observing nystagmus and appeared as though they would be very handy in the clinical setting.

This lead into the final session for the day being the oculomotor videos. Observing nystagmus was something I was very unfamiliar with prior to attending the course. I was completely unaware of the diagnostic capabilities of observing directional nystagmus. It made absolute sense on the back of the earlier presentations with regards to excitation and the various planes of movement, however that all involved accurately seeing the nystagmus and noting its direction. Initially this was challenging and I’ll be the first to admit I was one of those people yelling the incorrect answers out. However with some tips in regards to where on the eyes to look in order to see linear or torsional eye movements and some practice, it started to come good. The presenter also used case studies throughout to make it practical and set the scene for what we were seeing in the videos. It was again a good opportunity to practice clinical reasoning and establish what might be required for treatment – gaze stabilization, balance and gait retraining! By the end of this session I felt confident in identifying what was required and was putting into practice already some of the concepts of vestibular assessment that a day previous I had near no knowledge of.

All in all, it was a very challenging first day but that was inevitable. The pace was good and there was plenty of opportunity provided to practically apply the learned principals and ensure a thorough understanding.

Jono Prowse

Love to hear your thoughts and experiences.

Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education


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