Recommended Vestibular Outcome Measures for Use in the Military Population

Recommended Vestibular Outcome Measures for Use in the Military Population

Author: Elizabeth Nixon, SPT

Background:
As a practicing clinician I’m interested in working with individuals with neurological impairments. However, with such a broad patient population I wasn’t entirely sure which direction I should focus my capstone until last summer when I had a clinical rotation at the Durham VA. I was able to work with some amazing veterans and was inspired by what they’ve done for our country. My clinical at Veterans Affairs involved a patient case load with a high number of veterans who had experienced a traumatic brain injury (TBI). Although I was treating the majority of my caseload for musculoskeletal conditions, many patients had concurrent symptoms that could be attributed to their previous TBI. One patient came in to the clinic with a referral for low back pain but was unable to complete the examination because all testing positions (besides short sitting) caused intense vertigo. The physical therapist treating this patient referred the patient to another health care provider because they were unsure how to treat this combination of conditions. Treating patients with both brain injury and dizziness can be challenging so I saw need for more research and education. After talking with Karen McCulloch about her research with active military and veterans who have experience TBIs she mentioned that further research needs to be done to look at how concurrent vestibular symptoms impact treatment for those with TBI. She suggested I work with her on upcoming research which aligned with my interests of gaining some experience with research and learning more about the grant writing process as a whole.

Overview:
Vestibular symptoms that occur concurrently with traumatic brain injury (TBI) are often complex and require individualized and specific rehabilitation treatment plans of care.¹ Some patients present with complex etiologies such as “perilymphatic fistula, bilateral vestibular hypofunction or loss, Meniere disease, or other dizziness complaints” which might require referral to other healthcare professionals.¹ Physical therapists should be aware of a variety of basic outcome measures and assessment techniques to determine best treatment practices for their patients.

Current best evidence suggests that vestibular rehabilitation can be beneficial in reducing symptoms of dizziness in individuals who have experienced a traumatic brain injury (TBI). Although the evidence is varied in terms of which specific interventions are best practice, some that have been shown to be beneficial include: static and dynamic balance activities, canalith repositioning manoeuvres, gaze stabilization exercises, and adaptation exercises. A physical therapist should be certain to address symptoms of dizziness in individuals with TBI in order to help individuals return to their optimal functioning as swiftly as possible.

The variability in types of studies as well as vestibular rehabilitation specifics (such as set exercises, intensity, frequency, and duration) weakens the overall level of evidence. Some research has been done to evaluate the best outcome measures for assessing vestibular symptoms as they relate to physical therapy rehabilitation evaluation and treatment. These outcome measures are an excellent place to start for clinicians and researchers working with patients with concurrent TBI and vestibular symptoms. More research is needed to provide this patient population with evidence based treatment options.

Gathering the Evidence:
My PICO question for our Evidence Based Practice II (EBPII) class was: “In adults (18 to 65 years) with mild TBI, are vestibular rehabilitation exercises effective in improving symptoms of dizziness (no comparison intervention)?” I searched for the latest evidence for this project in the fall and reran my search this semester to look for the most current evidence on the topic and related to specific outcome measures. Creating a critically appraised topic (CAT) helped me narrow down my information to the most relevant and current literature available. It also illustrated how few studies have been done on this topic and why this project could be helpful in gaining grant approval for further research.

The Project:
I met with Kmac to start planning for this project in late fall with the caveat that we were waiting for information about potential grants or funding to be approved before finalizing a more specific area of focus. Unfortunately, I learned that the process requires a lot of patience and collaboration with a variety of individuals and organizations. After not receiving the funding that we hoped to receive Kmac and myself decided to go ahead with a contribution to a new pre-proposal for a future grant application.

The paper summarizes the best outcome measures that can be utilized in research and with military personnel to treat individuals with vestibular symptoms. Currently there is very little research on specific outcome measures and treatment processes for individuals with concurrent TBI and vestibular symptoms. This paper highlights which outcome measures are best used for patients with these impairments (and more specifically individuals in the military) to help guide further research.

Self-Assessment:
I worked closely with Kmac through this entire process as she was my main source of learning and feedback. We communicated via email and in person meetings throughout the third year in order for me to produce by final product.

The process itself was enlightening as to how much time, energy and research goes into even a pre-proposal for a grant. This is a long arduous process that can many times end in not getting a grant due to the large number of individuals submitting work to be approved. I can imagine that this could be a frustrating undertaking for many people who rely on grant money in order to perform research necessary to help clinicians, educators and especially patients.

I completed most of the project independently including the evidence table, CAT and final paper with frequent check-ins with Kmac either in person or online. I wish I was more knowledgeable about the entire research process in general and how I could contribute to it personally. I relied frequently on Kmac’s knowledge and expertise but thankfully she was patient and willing to help me better understand the process.

Overall, I’m much more aware of the entire process and how much work is involved; from gathering initial data, to proposal, to receiving a grant, performing the research and all the steps in between. I hope the small portion I completed for this capstone is beneficial in the proposal process and ends up in completed research that can be used to ultimately improve patient treatment and outcomes. I look forward to finding more ways to be involved in the research process in the future.

Acknowledgements:
I’d especially like to thank Karen McCulloch, PT, PhD, NSC for her willingness to let me work with her and contribute to her grant proposal process. I learned a lot about performing research with the military population as well as the entire process of grant proposals and research funding. I’d also like to thank Caroline Cleveland, SPT and Amy Cecchini, MS, PT, for their willingness to be a part of my committee. Finally, I’d like to thank all my classmates (especially Sarah Morrison) who helped provide me with support throughout the capstone process.

Reference:
1. Weightman M, Leuty L. Vestibular Assessment and Intervention. In: Mild Traumatic Brain Injury Rehabilitation Toolkit. Vol ; :9-44.