Background
During my undergraduate career, I was very interested in sports performance and sports rehabilitation. I pursued this through work as a personal trainer and as a research assistant in the Sports Medicine Research Lab. I have always found myself drawn to Orthopedics and thought this would be my primary interest when entering the UNC DPT program. However, as we progressed through our curriculum, I began to find myself fascinated with Neuromuscular concepts like improving balance and preventing falls. When we began to study Vestibular Rehabilitation, I realized that this was an area of interest for me. This interest was further reinforced when I was given the opportunity to work in an Outpatient Neuro setting for my third clinical rotation. I saw many patients that were referred for vestibular dysfunction and had the opportunity to refine my clinical skills with this population. I realized that I thoroughly enjoyed working with these patients and wanted to become more confident in my ability to treat them. I saw this Capstone project as an opportunity for me to explore an area of interest more thoroughly and create a product that could help these patients in the future.
Statement of Need
According to the National Institutes of Health (NIH) patients’ complaints of dizziness and vertigo can account for nearly 9 million doctor visits per year with vestibular disorders being responsible for nearly 85% of these symptoms.1 The symptoms of peripheral and central vestibular dysfunction can overlap, and typically can consist of vertigo, nausea, vomiting, intolerance to head motion, nystagmus, unsteady gait, and postural instability.2 Additionally, one of the consequences of having a vestibular disorder is that the symptoms frequently cause people to adopt a sedentary lifestyle in order to avoid bringing on, or worsening, dizziness and imbalance that occurs with movement.3 As a result, decreased muscle strength and flexibility, increased joint stiffness, and reduced stamina can occur from this lifestyle.4 It is crucial to address these vestibular impairments in order for our patients to return to prior levels of function.
To begin vestibular rehabilitation, a comprehensive evaluation and assessment should be performed to determine the patient’s deficits and then an individualized plan of care should be established.5 However, vestibular rehabilitation is a niche sector of physical therapy, and many therapists are not as confident in their clinical skills of assessing and treating this patient population.
Current vestibular rehabilitation consists of an exercise-based approach that typically includes a combination of 4 different exercise components to address the impairments and functional limitations identified during evaluation: exercises to promote gaze stability, exercises to habituate symptoms, exercises to improve balance and gait, and walking for endurance.6 As a patient progresses through therapy, they are often provided with a customized exercise program to perform at home in order to increase self-management of symptoms and progress their rehab. This is necessary for patient autonomy in their rehabilitation and management of chronic symptoms. Therefore, I wanted to create vestibular rehabilitation home exercise materials that clinicians can easily access and distribute to their patients with vestibular dysfunction.
Purpose
The purpose of this project was in part to get a better understanding of the current literature regarding vestibular rehabilitation and commonly prescribed home exercise programming. I wanted to challenge my understanding of how we assess patients and then select proper exercises to address vestibular deficits. In addition to this, a secondary purpose of this project was to create a high-quality set of materials that clinicians can then utilize for vestibular rehabilitation in a home exercise program. By creating a core set of materials for common home exercises, clinicians will have an easily accessible document that they can use at their judgement to further a plan of care for their patients. This should benefit clinicians and patients as it aims to improve home exercise adherence and self-management of symptoms.
Products
The main product of this Capstone project is the Vestibular Rehabilitation Home Exercise Program hand out to be used and distributed by clinicians as they deem appropriate. Additional products include an Evidence Table that assesses the current literature surrounding vestibular rehabilitation, a Capstone Narrative summarizing and interpreting the literature review.
Capstone Vestibular Rehabilitation HEP
Capstone Evidence Table Morris
Evaluation
I would ultimately like to receive feedback from patients about the effectiveness of my materials. This information will be difficult to acquire because it will take some time to administer these materials out to the patients that need them. However, I am looking forward to keeping in contact with any clinicians that decide to use my materials. Currently, my Capstone materials have been distributed to local clinicians that treat vestibular dysfunction and they have been asked to respond to a short Qualtrics survey assessing the quality of the materials.
Self-Reflection
I set various personal learning goals at the beginning of this project. This included having a better understanding of the current best practices for treating various vestibular disorders, effectively communicating and collaborating with clinicians to receive feedback on my progress, and ultimately being able to provide patients with high-quality education that allows them to have autonomy in their rehabilitation through a home exercise program.
I believe that my Capstone site and final products are evidence of me achieving the goals that I had set. I was able to thoroughly assess current evidence regarding treatment of vestibular dysfunction and compile the findings into an evidence table with a supplemental narrative to synthesize the research. I was then able to take this information and apply it to clinical practice through the form of patient education materials while receiving feedback from local clinicians. This project was able to challenge me in many ways while also allowing me to pursue an area of interest. Many individuals struggle with vestibular dysfunction, however there are not many physical therapists that are comfortable addressing these disorders. I believe that this project allowed me to add important professional skills to my toolbox and I am confident that it will make me a better clinician in the future.
Acknowledgements
To Vicki Mercer, PT, PhD, thank you so much for providing guidance and support as my faculty advisor throughout the course of this project. Your feedback and input were extremely helpful and allowed me to design this project in a way that would benefit future clinicians and patients.
To Ashton Harrington, PT, DPT, thank you so much for agreeing to be a part of my advising committee. Your guidance and support through my early exposure to Vestibular Rehabilitation developed a newfound interest of mine which resulted in this project.
To Kaitlin Luffman, PT, DPT, thank you so much for your time and support. Your knowledge and expertise were much appreciated as I navigated throughout this project. It was reassuring to know that I could always reach out to you for any questions or concerns.
References
- Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane database of systematic reviews. 2011;2:CD005397-CD005397
- Dougherty JM, Carney M, Emmady PD. Vestibular Dysfunction. [Updated 2021 Jul 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558926/
- Shepard NT, Telian SA, Smith-Wheelock M. Habituation and balance retraining therapy. A retrospective review. Neurol Clin. 1990;8:459–475
- Han BI, Song HS, Kim JS. Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7(4):184-196. doi:10.3988/jcn.2011.7.4.184
- Sulway S, Whitney SL. Advances in Vestibular Rehabilitation. Adv Otorhinolaryngol. 2019;82:164-169. doi:10.1159/000490285
- Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION. J Neurol Phys Ther. 2016;40(2):124-155. doi:10.1097/NPT.0000000000000120
2 Responses to “Home Exercise Program Materials for Vestibular Rehabilitation”
Sarah Stewart
Jevon, I appreciate the thoroughness of this project and in my opinion is clinically useful for physical therapists in all settings, as vestibular patients can present in outpatient or inpatient, and can occur in a variety of patient populations. Although vestibular rehab evaluation and intervention can become very complex and detailed, most likely requiring continuing education to master these skills, physical therapists should be proficient in identifying and treating vestibular impairments, or at least know where to find additional information on the subject. Your HEP handout is detailed, easy to understand, and includes images that are extremely helpful to ensure clinicians and patients replicate the exact exercises you describe. I appreciate your effort on this excellent project and will definitely use your HEP as a reference for the future!
hruss4
Hey Jevon,
This capstone project was really great to look over. As someone who has never treated a patient with vestibular dysfunction on my clinical rotations, I felt like I was your perfect clientele. You are not wrong when you said, many clinicians do no feel comfortable with treating a patient who has a vestibular dysfunction. During one of my clinical rotations, I witnessed purposeful avoidance by clinicians to try to switch their vestibular evaluations. In order to test the effectiveness of your HEP I gave your sheet to my wife after educating her on the purpose of the movements. For someone who has no experience with vestibular rehabilitation, she said the pictures and instructions were really easy to use! I have no doubt your product will be effective in assisting both clinicians who have experience with treating vestibular deficits and those who do not. I found your wording to be both patient and clinician friendly. From your review of the literature, I appreciated how you outlined the impact of vestibular dysfunction to quality of life and daily function. The risk of developing a sedentary behavior following vestibular dysfunction is so impactful. You have inspired me to look back at my vestibular rehabilitation notes during this rotation. Thank you for sharing both your knowledge and passion for the field of vestibular rehabilitation with me!