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.
So how can we bridge this gap in understanding? Increasingly in Aural Rehabilitation we are encouraged to gather an understanding of not only the specific scenarios in which the patient experiences hearing difficulty, but also how these difficulties make them feel. The caring skills each of us inherently possesses as a human being, and in particular as a healthcare professional, can be utilised along with some basic non-professional counselling skills. In doing so, we move from a clinician-centred model of care to a patient-centred model.
Currently, the majority of counselling involved in vestibular rehabilitation is informational; that is, the dispensing of information on the diagnosis, the prognosis, and the rehabilitation process. Whilst every effort is generally made to gain an understanding of the physical movements or scenarios that exacerbate the patient’s dizziness, little attention is paid to the emotional content of the patient history. Indeed such emotional content is actively avoided and regarded as a barrier to obtaining the useful information required to make an accurate clinical diagnosis.
Perhaps this is what I am missing, then. As clinicians, we must make an effort to understand the change in self-concept that has occurred since the onset of the balance deficit. We already know that the chances of a patient adhering to a given treatment plan are more than doubled if patient-centred counselling is employed (Zolnierek & Di Matteo, 2009). Demonstrating an understanding of the individual emotions involved may help encourage the patient to change their behaviours further, to move away from reliance upon vestibular sedatives or avoidance strategies, in order to progress with exercise-based rehabilitation.
Dealing with emotional content and changes in self-concept requires counselling skills that are not routinely taught to Audiologists or Physical Therapists working in this field. However, this does not mean that these skills cannot be acquired, and indeed all that is really required is that the clinician acknowledges the humanity of the situation. Dizziness is a distressing sensation because it is a sensation of the head, and patients logically assume that the problem therefore originates in their brain. It is easy to understand the anxiety and worry that might stem from this.
Recent years have seen a move from a one-size-fits-all approach to vestibular rehabilitation towards more individualized exercise programmes, and this has increased the efficacy of such therapy. However, I think it is critical to remember that the difficulties facing these patients are not just physical, but emotional too, and we must attend to these needs equally if we are to truly rehabilitate the patient, and allow them to feel that they have been restored to a useful life.
Herdman S.J., Hall C.D. & Delaune W. 2012. Variables associated with outcome in patients with unilateral vestibular hypofunction. Neurorehabil Neural Repair, 26(2): 151-62.
Hillier S.L. & McDonnell M. 2011. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev, 2:CD005397
Honrubia V., Bell T.S., Harris M.R., Baloh R.W. & Fisher L.M. 1996. Quantitative evaluation of dizziness characteristics and impact on quality of life. Am J Otol, 17(4): 595-602
Yardley L. 1994. Prediction of handicap and emotional distress in patients with recurrent vertigo: symptoms, coping strategies, control beliefs and reciprocal causation. Soc Sci Med, 39(4): 573-81
Yardley L. & Luxon L. 1994. Treating dizziness with vestibular rehabilitation. BMJ, 308(6939): 1252-3
Zolnierek K.B. & Di Matteo M.R. 2009. Physician communication and patient adherence to treatment: a meta-analysis. Med Care, 47: 826–834