Finding a provider of Vestibular Rehabilitation Therapy (VRT)

Timothy C. Hain, MD, Professor of Neurology, Otolaryngology, and Physical Therapy/Human Movement Science, Northwestern University Medical School, Chicago IL, USA.

Page last modified: July 4, 2009

Introduction

Vestibualar rehabilitation treatment (VRT) is an unregulated medical discipline, and there is a "wild wild west" situation. There are lots of options for providers as well as many pitfalls.

Groups that offer VRT include

• Physician based practices specializing in dizziness and balance
  • Otolaryngologists (usually Otologists)
  • OtoNeurologists (such as the author's practice, Chicago Dizziness and Hearing)
• Rehabilitation hospitals that offer a full array of specialized therapy (such as the Rehabilitation Institute of Chicago)
• Stand-alone Physical therapy practices specializing in dizziness (for example, Lifestyle Physical Therapy in Chicago).
• Stand-alone Audiology practices that treat dizziness as well as hearing problems (for example, Hearing Health in Naperville)
• Chiropractic practices that specialize in dizziness (for example, 21st century health in OakLawn)

So which one to choose ? Sorting this out can be complex.

If you think you might need vestibualar rehabilitation therapy (VRT), there are several methods of identifying a suitable person:

• Call your doctor and ask for a referral. Whether or not this works depends on your doctor's connections.
• Check with the VEDA (vestibular disorders association) as they maintain a list of people who suggest that they have expertise in this.
  • Note that this list has NO quality control - - it is just people who say that they know something. Still, it is a good place to start.
  • Do some screening using the suggestions below.
• Do some research online, or with your phone-book, develop a list, and screen the list using the suggestions below.

Qualifications of Individuals claiming expertise in vestibular rehabilitation (VRT)

In recent years, at least in Chicago, Illinois, we have seen a gigantic upswing in individuals claiming expertise in the treatment of vertigo. Nearly every week, we get another circular, generally from a physical therapy practice, indicating a willingness to provide exercises to patients in an attempt to improve their balance. These circulars rarely indicate their source of expertise. Wild wild west again --

Lets take a careful look -- the common training situation for the groups that commonly offer VRT, counting only training post college, are as follows:

We will focus here on the differences between the non-physician and physician groups who claim expertise in VRT..

Generally speaking, none of the groups listed above get more than "basic" training in VRT in their professional school. Some get no training at all. VRT is a "hands on" activity - -and not something that you can learn solely out of a book. Thus, to be good at VRT, a degree is not enough, and everyone needs to get training.

There are two areas of knowledge needed for safe and effective VRT --

• 1). Medical knowledge - for diagnosis and proper direction of treatment of diseases that impact balance. We have had patients who were being treated for positional vertigo, but who were later discovered to have life-threatening brain tumors. We have encountered patients with very low blood pressure, being treated for inner ear disorders. This is totally inappropriate. Medical knowledge is required for safety as well as to direct treatment.
• 2). Procedural knowledge - -methods of improving balance using exercise paradigms.
  

Detailed medical knowledge is mainly the province of physicians, who also have roughly 7 years more medical training than the other groups. None of the groups above are provided with detailed procedural knowledge at present, in their core professional education.

If one considers the dizziness/and balance training opportunities available this is limited to several possibilities:

• Participation in a 1-3 day course on vestibular rehabilitation (very common and reasonable) -- The author of this page, Dr. Hain often teaches in courses like this. These courses provide both medical and procedural knowledge, although in a very compressed format. We think that non-physicians who take these courses should repeat them once/year, to refresh their medical knowledge about these conditions. We think that physicians who take these courses should refresh themselves on the procedural portions once/5 years.
• Undergoing Ph.D. training for four years, in a suitable field (this is extremely uncommon, but there are a few individuals like this in the country).
• Visiting someone who does this for 1-2 days (common, but not as good as the first two options). This process provides bare essentials of procedural knowledge. Because the experience is a "hit or miss" one, the person doing this does not come away with a comprehensive knowledge of relevant medicine or procedures.
• Working in a practice with someone who does this for a few months (very uncommon, but very good way to get training). This process provides both medical and procedural knowledge.

So to summarize, most individuals who offer VRT, base this on a small amount of basic training given to them during their core education, and 1-3 days of post-graduate education. The providers who do VRT, have diverse amounts of education and understanding of the medical situation, and also varying abilities to troubleshoot problems.

How to determine the qualifications of a VRT provider

We think that the ideal VRT combination is a team including a suitably trained physician (preferably an otologist or neurologist) and a physical therapist. Note that these questions reflect Dr. Hain's biases, and are certainly personal opinions.

• Do you use video-frenzel goggles in your practice ? This is the most important question.
  • Practioners who don't use video-frenzel goggles, should not be treating vertigo. One cannot make an accurate diagnosis of BPPV without these goggles.
• Is there a physician close by when patients are treated for dizziness ? This is the second most important question.
• An integrated practice with both a physician and non-physician is preferable to practices that separate diagnosis from treatment.
• What kind of training and experience have you had in VRT ? If there is no answer, or no training, be wary.
  • We think that the following groups are reasonable treaters. Practicaly, one has to balance accessibility with expertise. For this reason, we would rank order their desirability roughly like this:
    • Physical therapist (with additional training) working with a physician
    • Physician who does VRT (Otolarynologist, Neurologist, and a few other specialties). Should have experience in doing this - -at least 10 patients/year. Here, you may actually be getting an experienced technician with physician oversight. Such a person (often an audiologist) should have had at least 1 month of supervised experience, and physician at hand to take over if need be.
    • Physical therapist working separately from physician. (should have taken at least one multi-day course, preferably yearly courses)
    • Audiologist (with additional training, at least one multi-day course)
    • Chiropractor with considerable additional training, and who does not "snap" necks, or schedule more than a total of 4 appointments.
• If the practice does not include a physician, ask them "is diagnostic testing done in your practice ?" If the answer is yes, what kind is done ? If the answer includes some of the following, be wary.
  • Vestibular diagnostic testing being done by persons have relatively little medical training as compared to physicians, is a common feature of fraudulent vestibular testing. We suggest avoiding autonomous audiology or PT practices that routinely perform "VAT or VORTEQ" vestibular testing, computerized or non-computerized posture platform testing, and "VEMP" testing. While these testing procedures can be useful in diagnosis, they are just a small subset of the procedures need to diagnose patients. Most PT practices are ill equiped to perform or interpret these tests, and also that they are unable to perform or obtain the full array of inner ear tests (i.e. hearing testing, MRI scans, and others), needed to complete the job.
• How frequently and how long are patient's seen in your VRT practice ? If the answer is twice/week for several months, be wary.
  • The most common disorder -- BPPV, takes only 2-4 visits to treat.
  • A practice that typically treats all patients for many months, is probably using ineffective methods (or has very complex patients).

There are some that disagree.

We favor the team approach, and in fact, our practice in Chicago Dizziness and Hearing includes three provider groups - -physicians, audiologists, and physical therapists that work together. A team including complimentary groups of providers can provide better and safer care and lines of communication are tighter (i.e. care is faster) when the providers are under the same roof.

Although we strongly favor the team approach, not everyone agrees. In fact, the team approach to patient care has been and is still under vigorous attack from the practice organization for physical therapists, the APTA -- Here, we quote a statement from the American Physical Therapy Association concerning "physician owned physical therapy services", written in 2003.

"Physical therapists (PTs) in private practice across the country are finding themselves confronted with one of the most serious threats they've ever faced. POPTS steal away their patients and virtually eliminate their ability to attract new clients. In many cases it cripples PTs' ability to carry on autonomously." (for full text,see this link to the APTA)

The audiology professional organization, ASHA, is pursuing a similar agenda. Here we quote from their 2009 goal statement:

"Autonomy for audiologists. Promote audiologists' autonomy through direct patient access and comprehensive coverage of audiology services under Medicare"

What "direct patient access" means, is that audiologists could bill medicare for services to patients who have not been referred by a physician.To us, this seems to be about money for audiologists rather than improving patient care.

Our position is that teamwork is far better than autonomous function, and that there is an intrinsic conflict between autonomy and best patient care. We think that patient care comes first, and that these professional organizations are overly aggressive.

Our suggestions for the future

We would like to see VRT provided in a more standard way, by persons who can pass a test that establishes them to be safe and knowledable. Their knowledge should combine relevant medical knowledge as well as procedural knowledge.

• Certification procedure for treaters (with any background)
  • Required CME (continuing medical education) relevant to vestibular rehabilitation for all groups. This should be a "hands on" course, and not an "online" course, as it requires procedural training.
    
    • Yearly 3 day course for non-physicians, to refresh medical specialty knowledge (see testing suggestions below)
    • Periodic (every 5 years) course for physicians, to refresh procedural knowledge
  • Written testing procedure required for certification for both groups. The written test should be written and administered by a multispecialty group other than the course providers.
    • Procedural knowledge - procedures to treat
      • BPPV (all variants)
      • Unilateral vestibular loss
      • Bilateral vestibular loss
    • A substantial knowledge of all conditions that are associated with dizziness and imbalance
      • Medical -- for example, blood pressure disorders, diabetes, and cardiac disorders
      • Neurological - -cerebellar disorders, brainstem disorders, hydrocephalus, Migraine, etc
      • Otological -- vestibular disorders such as vestibular neuritis, tumors such as acoustic neuroma
      • Medications that impact balance and can cause dizziness (all ear and centrally acting drugs)
  • Reimbursement levels linked to certification.