Simon Howe, Clinical Scientist (Audiology), BSc (Hons), MSc
Manchester Royal Infirmary
Rehabilitate (v): To restore to good health or useful life
As an Audiologist working for the National Health Service in the UK, it is my job to rehabilitate both patients with hearing loss and those with vestibular deficits. Whilst full recovery from vestibular deficits is likely, up to 2/3rds can become chronic, disabling conditions (Yardley & Luxon, 1994). As General Practitioners (GPs) tend only to refer those cases of dizziness persisting for months for a specialist opinion, the majority of patients seen in our Vestibular Rehabilitation Clinic at the Manchester Royal Infirmary have developed chronic dizziness, present for many months or years.
Many patients experiencing an acquired loss of vestibular function will recover fully without the need for any therapeutic intervention. So what causes some patients’ vestibular deficit to become a chronic balance problem? Firstly, the long-term prescription of vestibular sedatives by GPs is commonplace, and inhibits the natural process of recovery, and secondly, the natural behaviour for motion-provoked or situation-specific dizziness is to avoid the movements or environments which elicit the symptoms, again hampering recovery. Often these avoidance strategies can result in almost phobic thoughts related to these triggers of the dizziness.
Exercise-based vestibular rehabilitation is the primary therapeutic approach for such patients, focusing on promoting central compensation for the acquired vestibular deficit. The application and benefits of vestibular rehabilitation are well documented (Hillier & McDonnell, 2011). However the more I work with patients with chronic balance problems, the more I find myself increasingly perplexed by their unpredictable prognosis. Three things strike me as unexplained:
- Some patients struggle to make any meaningful progress with vestibular rehabilitation, despite apparently adhering to their exercise programme.
- The time taken for patients to recover seems to be completely independent of the degree of vestibular deficit.
- Attendance at rehabilitation appointments and adherence to exercise programmes is inconsistent, even if the patient’s difficulties would appear to act as sufficient motivation.
Reassuringly, it appears I am not alone in seeing this variability (Herdman et al, 2012), therefore there are clearly other factors at play which are influencing recovery. But there is a piece missing from the puzzle; something still unaccounted for in all the research thus far.
The Missing Piece
Chronic balance disorders can be functionally limiting conditions because of our reliance on balance to fulfil the most basic of personal, household, and occupational responsibilities. Difficulties in performing these tasks can increase dependence on family and friends, and can place strain on relationships. Where such a support network is not readily available, the resulting social isolation can have profound emotional effects. Reduced activity levels can also lead to an increased incidence of co-morbid conditions which can in turn exacerbate the psychological impact. Some chronic balance disorders can also be unpredictable in the frequency and severity of their presentation and this can further increase emotional stress.
So here is the paradox, the missing piece: this inter-relationship between dizziness and emotion is well recognised and documented (Yardley, 1994), and yet there is a very poor correlation between patient and clinician ratings of dizziness severity (Honrubia et al, 1996).
In many ways this poor correlation is not unlike the mismatch we might see in Aural Rehabilitation between the hearing difficulties the clinician might predict from a patient’s audiogram and their self-perceived disability. In fact hearing loss and loss of vestibular function are not dissimilar. Difficulties are often specific to certain activities or situations and can therefore cause a change in self-concept; the functional capabilities of the patient have changed and this can have a profound effect on their feeling of self-worth.
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