Checks and balance

A pioneering physio-led clinic is offering prompt treatment to people with vestibular and related conditions.  Robert Millett reports

Two physiotherapists are helping patients with vestibular problems to regain a firm footing, by providing a ‘one stop shop’ of expert treatment at an award-winning balance clinic.

For the last two years Nova Mullin and Cathie Morrow, both specialist physiotherapists in vestibular rehabilitation, have been running a unique physio/audiology-led service at Liverpool’s Aintree University Hospital NHS Foundation Trust.

Since 2011 more than 600 people with dizziness and balance problems have attended the clinic and been assessed, diagnosed and managed by the physiotherapy team.

Traditionally, all these referrals would have been managed by ear, nose and throat (ENT) consultants, but the success of the balance clinic is highlighting the value of physio input.

Mrs Mullin says the service allows physiotherapists and audiologists to act together as the initial point of contact for patients. This simplifies the triaging process, reduces waiting times and prevents an unnecessary chain of referrals.

‘Generally assessment of these patients is done by ENT consultants who are most likely to be surgeons,’ says Mrs Mullin.

‘But having worked closely with balance and dizziness patients, and in shared clinics for many years, we became aware that we – as physios – possess the excellent assessment skills our training gives us, and the necessary management skills, to assess and manage many of these patients without a consultant needing to do so.’

A recent audit has revealed that the physio/audiology-led approach is achieving excellent results, with more than 50 per cent of new patients who attend the clinic being assessed, diagnosed, managed and discharged within the space of just one appointment.

The service evaluation has also confirmed that the clinic is successfully managing around 80 per cent of all patients referred to the trust with balance problems and dizziness.

Additionally, the small number of patients who don’t need further assessment by an ENT consultant are seen speedily.

‘This model is highly efficient in terms of time for patients – as they are assessed and treated with a much lower number of hospital visits,’ says Mrs Morrow.

‘And being assessed initially by audiologists also means they can get any associated deafness or tinnitus managed at their first assessment.’

Feedback from a recent patient satisfaction survey has also proved positive and the clinic won the ‘Rethinking the patient care pathway’ category at the national Advancing Healthcare Awards 2012.  

The judges praised the service’s design and said the model had potential as a highly transferable model.

The service differs radically from the one it replaced and what is commonly available elsewhere, and yet in the space of a relatively short time it’s proved its worth.

So what factors have contributed to its rapid success, and how did it come about?

Mrs Mullin explains that development of the service began following a redesign of certain hospital care pathways in 2010.

An audit of referrals to the hospital’s head and neck department had revealed that about 120 new cases of tinnitus and balance/dizziness were being referred each month to the hospital’s consultant audio-vestibular physician.

While reviewing the data Mrs Mullin and Mrs Morrow realised that from 80 to 90 per cent of these cases could potentially be dealt with by an clinic led by allied health professionals.

‘So, within the ENT team of clinicians and managers, we decided to create a “one-stop” clinic where assessment, diagnosis, treatment and therapies could all be delivered simultaneously,’ says Mrs Mullin.

The physios knew that the project would require them to take on an array of additional responsibilities but, with both having many years experience of musculoskeletal clinical assessment service (MCAS) orthopaedic triage, they felt confident in their abilities and pushed ahead.

The ENT consultants supported the idea.

By luck their plans for the service redesign didn’t require new funding or resources

‘The ENT departments were already moving into a fabulous new building, and once the business managers involved saw how keen, motivated and able we were, they incorporated a balance room into the space of the new ENT clinical area,’ says Mrs Mullin.

By April 2011 they had established the physio-led balance clinic and were offering vestibular patients highly comprehensive initial consultations.

Since then people with dizziness and balance problems have been able to receive audiology hearing examinations, balance and neurological examinations and treatment – all on their first appointment.

Appointment system saves patients’ time

The physio-led balance clinic opens twice weekly and can accommodate 10 new patients, as well as three follow-up patients.

Referrals for ENT conditions into the trust are initially paper triaged by the audiology lead clinician.

The majority of patients are then provided with linked appointments slots that allow them to be assessed at their first appointment – initially by a specialist audiologist and then as part of a specialist balance physiotherapy assessment.

The two assessments run consecutively, each lasting 30 minutes. Then, following both assessments, the physiotherapists and audiologists discuss each case.

A combined letter is dictated, recording both the audiology and balance findings, and detailing examination, diagnosis, management and follow-up plans.  

If necessary, rehabilitation or a particular treatment is started immediately and any prescribed equipment, such as hearing aids, is arranged – along with relevant take home advice and leaflets.

The physio/audiology-led system can mean patients are at the clinic for over an hour, but fewer appointments are needed.

Mrs Mullin adds that, overall, patients find the new system much more convenient and, as the audit figures show, it is also proving to be highly efficient.

‘Data collection to date confirms we are efficiently managing approximately 75 per cent of patients without needing to involve the ENT consultants,’ says Mrs Mullin.

‘And all the patients can now start treatment on day one, rather than having to wait for a referral for vestibular rehabilitation within the out patients physiotherapy department.’

Nevertheless, despite its relative independence, the service also relies on the physiotherapy staff maintaining excellent links with the ENT consultants.

The balance clinic is located in the ENT clinical area of the hospital, meaning information can be passed over easily.

‘The consultants are always available if any help is needed, in order to discuss complex patients, or to quickly see the small percentage of patients we refer on,’ says Mrs Morrow.  

‘We can order scans and vestibular function tests from them whenever needed.’ 

Balance problems rife among the over-65s

One person in four in the UK aged over 65 has a balance problem, many of whom become housebound unnecessarily, stopping them from working and reducing social contact, says Mrs Mullin.

‘It can be a very distressing disorder,’ she says. ‘And it dramatically reduces the quality of life for sufferers.’

Patients attending the Aintree balance clinic are typically experiencing vestibular-inner ear causes of poor balance and dizziness.

This includes a large per cent of patients who present with benign paroxysmal positional vertigo (BPPV), which Mrs Mullin says is the most common cause of vertigo.

She explains that BPPV is a disorder arising in the inner ear, caused when the inner ear otoconia crystals dislodge.

This often occurs after a bang to the head, and the condition is more common in older people due to degeneration.

The symptoms of BPPV can include a spinning sensation, nausea and marked anxiety.

Patients attending the clinic with BPPV are offered immediate access to a procedure called the Elpley or canal repositioning manoeuvre (CRM).

The treatment requires the physiotherapist to move a patient’s head, neck and body through a variety of positions that encourage gravity to reposition the displaced crystals in the inner ear.

Mrs Morrow explains that most patients experience some improvement after just one CRM session.

However, she points out, traditionally patients must wait until they had been assessed by an ENT consultant, and then referred to a physio department before they can benefit from this effective form of treatment.

Other conditions seen at the clinic include labyrinthitis, post- concussion, age-related poor balance and migraine vertigo.

Additionally, the service deals with some non-vestibular disorders, such as peripheral neuropathy, Parkinson’s and postural hypotension.

As well as treating the physical symptoms of vestibular conditions the physiotherapists also educate patients about some of the associated psychological side-effects.

‘Almost 70 per cent of those with vestibular disorders have an element of associated anxiety secondary to the vestibular deficit, and we are able to explain this to them at assessment,’ says Mrs Mullin.

The Aintree physios have set up a balance support group, which aims to provide an additional resource for patients – particularly those with long-term problems.

‘The balance support group was mainly set up to give those patients with long-term balance disorders somewhere to get help with long-term exercise and education,’ says Mrs Morrow.

‘It also allows us to be more confident when we discharge some patients slightly earlier, without long-term clinic follow ups, as we’re able to see them and offer advice at the support group.’

The group provides patients with a forum where they can speak to others with similar problems and share tips and self-help advice.

As well as exploring the relationship between anxiety and dizziness,  the group covers topics including relaxation, Tai Chi, medication use and the ageing balance system.

Surprisingly, the average age of patients attending the clinic and the support group is just 57. Mrs Mullin says this highlights the fact that balance and dizziness disorders are not the preserve of older people.

The ratio of female to male patients is almost two to one. Mrs Mullin says this reflects the high number of BPPV patients they see, as this condition – along with migraine vertigo – is far more prevalent in females. It may be that females tend to report their symptoms to their GPs.

Promoting a ‘balance aware’ future

Further innovative ideas are in the pipeline.

‘Our next idea is to get a website set up, specifically for our patients who have often surfed the net and found incorrect information that has made their anxiety worse,’ says Mrs Mullin.

She believes every physio in the UK should have an up-to-date awareness of vestibular rehabilitation because the condition is set to become more prevalent in our rapidly ageing society.

‘Our excellent assessment and exercise education can be used to great effect  in this field, especially as medication and surgery are really of very limited use, and minimal investigations are needed,’ says Mrs Mullin.

‘So physios should be looking at developing similar set ups in their locations, as balance and dizziness disorders affect part of the population, and the incidence is rising.’

Both Mrs Mullin and Mrs Morrow are members of the Association of Chartered Physiotherapists Interested in Vestibular Rehabilitation.

Mrs Mullin plans to present a motion on the importance of vestibular rehabilitation at the CSP’s next Annual Representative Conference. fl

  • A CSP Physio works briefing on vestibular rehabilitation will be issued next month.

Robert Millett

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