Author: Ashlyn Warren, SPT
Primary Advisor: Karen McCulloch PT, PhD, MS, FAPTA, FACSM, NCS(E)
Committee Members: Vicki Mercer, PT, PhD, Jeremy Bradford, PT, DPT, OCS, and Blair Bergquist, PT, DPT
Background:
Going into my second clinical rotation, I had little experience with evaluating and treating patients with vestibular disorders. Throughout my clinical rotation, I saw many patients who presented with a primary complaint of “dizziness” or “imbalance.” I quickly realized the breadth of pathologies and mechanisms that can contribute to these symptoms and found it fascinating. I also came to realize how much these symptoms affect our patient’s quality of life, making everyday tasks such as driving and walking difficult. Throughout my rotation, the importance of physical therapy in treating these patients and allowing them to experience greater quality of life became clear. With the help of my clinical instructors, I was able to develop my clinical skills and passion for working with patients with vestibular disorders. My instructors played a crucial role in developing my critical thinking skills when working with these patients and coming up with creative interventions catered to the patient’s individual needs. This clinical experience inspired me to complete my capstone project on learning more about the evaluation and treatment of patients who present with dizziness and imbalance.
Statement of Need:
Many clinicians do not feel comfortable diagnosing and treating vestibular disorders and differentiating the multitude of pathologies and mechanisms that contribute to complaints of dizziness and imbalance. This is an essential skill as dizziness is commonly experienced in older adults and the presence of dizziness is associated with falls and decreased quality of life. Furthermore, the experience of dizziness is prevalent across practice settings and patient populations. By conducting a thorough examination of the dizzy patient, we can appropriately treat vestibular disorders and identify serious neurological conditions that warrant referral to a neurologist for further testing.
Although we learn about vestibular dysfunction in our PHYT 784 course, one thing I recognized while on my clinical rotations and in speaking to fellow classmates was the breadth of information learned in such a short period of time. Many of us are visual learners and access to video resources can help supplement the information in lectures. Therefore, one of my main focuses of this capstone was to improve access to video resources that can be referred to post-graduation by embedding videos from F.A. Davis into the lecture materials for the PHYT 784 course. The other overarching goal of this project was to incorporate a case study on multisensory integration impairments in older adults. This case study is necessary as many older adults present with non-specific dizziness and imbalance it can be hard to pinpoint a specific cause of their complaints. This case study looks at an evidence-based approach to evaluating and treating an older adult patient with impairments in multisensory integration.
Purpose:
The purpose of this capstone project was two-fold: to present a case study focused on multisensory dizziness in older adults to supplement the content taught in PHYT 784 and to improve access to video resources and information for students to refer to during clinicals and future clinical practice. The materials will help supplement the vestibular lectures, which are taught over two days during the PHYT 784 course at UNC.
Products:
My products for this capstone project consist of the following:
(1) Multisensory integration impairment case study which will be used to supplement the information in the vestibular lectures for PHYT 784.
Multisensory Older Adult Case Study
(2) Incorporation of Herdman videos from the F.A. Davis textbook demonstrating clinical skills for vestibular evaluation and treatment.
https://docs.google.com/presentation/d/1rlEfUEsSTJwbJYyJbiG1J8q–gmCe11X00bDEs5EctM/edit?usp=sharing
(3) An updated resource guide with valuable links to more information on vestibular rehabilitation.
Updated_Videoclips for vestibular class
Self-Reflection:
Overall, I learned so much from this capstone project and feel that the process has been beneficial to my growth and preparation for becoming a clinician. I have honed my skills of incorporating clinical experiences and literature review to ensure that my treatment plan is sound and backed by current evidence. I have also gained so much from utilizing feedback from my committee and primary advisor to improve project materials. This experience of asking for feedback from more experienced clinicians has been invaluable and will translate well in seeking out mentors to improve future clinical practice. This project has also helped me develop my skills of creating materials aimed at educating peers and colleagues. It is my hope that these materials will supplement the vestibular lectures in PHYT 784 and help future cohorts improve their clinical competency with treating vestibular disorders and identifying multisensory integration impairments in older adults. Lastly, this project has broadened my knowledge and understanding of vestibular disorders. I am interested in working in neurology after graduation and believe this project has been integral in furthering my clinical skills when working with patients who complain of dizziness and imbalance, a common complaint in this setting.
Evaluation:
To evaluate my project, I utilized frequent self-assessment and revision in addition to integrating the valuable inputs provided by my primary advisor and committee members. Through reflection and feedback, I was able to make several rounds of revisions in order to develop the final product.
I have also developed this quick 5-question evaluation tool that will help to give me insight into how useful these materials are for clinical practice and what could be improved. If you could take a few minutes to review the PowerPoints and evaluate the effectiveness of materials it would be much appreciated! The link can be found below:
https://forms.gle/9XmGUUJmcc9G24ieA
Acknowledgements:
Dr. Karen McCulloch PT, PhD, MS, FAPTA, FACSM, NCS(E): Thank you for the time and effort you have dedicated to serving as my primary advisor on this project. I have learned so much from you through my education at UNC and have appreciated your mentorship throughout the development of my capstone. Your clinical and educational experiences have been invaluable to the development of materials for this project and my preparation as a future PT!
Dr. Vicki Mercer, PT, PhD: Thank you for taking the time to serve as one of my committee members on this capstone project. Your contributions to my education and feedback on this project have been crucial in the development of my capstone and clinical skills. I greatly appreciate the effort you put into helping focus my efforts on this project, thoroughly reviewing the materials, and providing feedback to refine the final capstone deliverables!
Dr. Jeremy Bradford, PT, DPT, OCS: Thank you for donating your time to serve as a committee member on this capstone project and serving as such a valuable clinical instructor. I have learned so much from your clinical expertise and ability to treat such a wide variety of patient populations in physical therapy. Your contributions to this project and to my clinical knowledge have been paramount to my success and preparation for practice!
Dr. Blair Bergquist, PT, DPT: Thank you for taking time out of your busy schedule to serve as a committee member on this capstone project and inspiring my passion for treating vestibular and neurological disorders. The clinical experiences, input, and resources you have provided in the development of this capstone have been so valuable. You have helped to shape the image of how I would like to practice as a physical therapist and I admire you and Jeremy’s dedication to serving as such excellent clinical instructors!
References Utilized in Case Study:
- Herdman PT PhD FAPTA SJ, Clendaniel PT PhD R. Vestibular Rehabilitation (Contemporary Perspectives in Rehabilitation). 4th ed. F.A. Davis Company; 2014:544.
- Therapeutic Research Center. Potentially Harmful Drugs in the Elderly: Beers List and More. PHARMACIST’S LETTER / PRESCRIBER’S LETTER. 2007.
- APTA geriatrics. Outcome Measure Toolkit for Geriatric Fall/Balance Assessment. APTA Geriatrics. https://aptageriatrics.org/sig/balance-falls-special-interest-group-bakup/bfsig-outcome-toolkit/. Published 2020. Accessed April 21, 2023.
- Lawson J, Bamiou D-E, Cohen HS, Newton J. Positional vertigo in a falls service. Age and Ageing. 2008;37(5):585-588. doi:10.1093/ageing/afn151
- Lawson J, Bamiou D-E, Cohen HS, Newton J. Positional vertigo in a falls service. Age and Ageing. 2008;37(5):585-588. doi:10.1093/ageing/afn151
- Sampaio RAC, Sampaio PYS, Castaño LAA, et al. Cutoff values for appendicular skeletal muscle mass and strength in relation to fear of falling among Brazilian older adults: cross-sectional study. Sao Paulo Med J. 2017;135(5):434-443. doi:10.1590/1516-3180.2017.0049030517
- Dynamic gait index. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/dynamic-gait-index. Accessed April 1, 2023.
- Berg balance scale. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/berg-balance-scale. Published 2020. Accessed April 1, 2023.
- Activities-specific balance confidence scale. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/activities-specific-balance-confidence-scale. Accessed April 1, 2023.
- Wang Y-C, Sindhu B, Lehman L, Li X, Yen S-C, Kapellusch J. Rasch analysis of the activities-specific balance confidence scale in older adults seeking outpatient rehabilitation services. Journal of Orthopaedic & Sports Physical Therapy. 2018;48(7):574-583. doi:10.2519/jospt.2018.8023
- Lusardi MM, Fritz S, Middleton A, et al. Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Posttest Probability. J Geriatr Phys Ther. 2017;40(1):1-36. doi:10.1519/JPT.0000000000000099
- Wingert JR, Corle CE, Saccone DF, Lee J, Rote AE. Effects of a community-based Tai Chi program on balance, functional outcomes, and sensorimotor function in older adults. Physical & Occupational Therapy In Geriatrics. 2020;38(2):129-150. doi:10.1080/02703181.2019.1709600
- Xiao C-M. Effects of Long-Term Tai Chi Ball Practice on Balance Performance in Older Adults. J Am Geriatr Soc. 2014;62(5):984-985. doi:10.1111/jgs.12805
- Voukelatos A, Merom D, Rissel C, Sherrington C, Watson W, Waller K. The effect of walking on falls in older people: the “Easy Steps to Health” randomized controlled trial study protocol. BMC Public Health. 2011;11:888. doi:10.1186/1471-2458-11-888
- American Heart Association. 12 week beginners walking program. livgov.com. https://www.livgov.com/hr/benefits/Documents/12-Week-Beginners-Walking-Program.pdf. Accessed April 21, 2023.
- Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC. Vitamin D treatment for the prevention of falls in older adults: Systematic review and meta-analysis. Journal of the American Geriatrics Society. 2010;58(7):1299-1310. doi:10.1111/j.1532-5415.2010.02949.x
- Zhang S, Xu W, Zhu Y, Tian E, Kong W. Impaired multisensory integration predisposes the elderly people to fall: A systematic review. Frontiers in Neuroscience. 2020;14. doi:10.3389/fnins.2020.00411
- Mahoney JR, Cotton K, Verghese J. Multisensory integration predicts balance and falls in older adults. The Journals of Gerontology: Series A. 2018;74(9):1429-1435. doi:10.1093/gerona/gly245
- Allison LK, Kiemel T, Jeka JJ. Sensory-challenge balance exercises improve multisensory reweighting in fall-prone older adults. Journal of Neurologic Physical Therapy. 2018;42(2):84-93. doi:10.1097/npt.0000000000000214
- Hu M-h., Woollacott MH. Multisensory training of standing balance in older adults: I. Postural stability and one-leg stance balance. Journal of Gerontology. 1994;49(2). doi:10.1093/geronj/49.2.m52
- Wagner AR, Akinsola O, Chaudhari AM, Bigelow KE, Merfeld DM. Measuring vestibular contributions to age-related balance impairment: A Review. Frontiers in Neurology. 2021;12. doi:10.3389/fneur.2021.635305
- Hall CD, Heusel-Gillig L, Tusa RJ, Herdman SJ. Efficacy of gaze stability exercises in older adults with dizziness. Journal of Neurologic Physical Therapy. 2010;34(2):64-69. doi:10.1097/npt.0b013e3181dde6d8
5 Responses to “Vestibular Videos and Multisensory Integration Impairment Case Study”
Courtney Snyder
Ashlyn, Stellar job on this project! I really enjoyed reading through your thorough case study and looking over the videos you compiled. I am also particularly interested in vestibular rehabilitation and find these resources to be very useful. I’m glad that you were able to accumulate new videos for students and even clinicians to be able to reference. I definitely plan to review this content when I work with the vestibular population in the future! So proud of you!
Hasmik
Ashlyn, congratulations on completing your capstone project! These resources you have put together are amazing and so helpful. I know so many students (including myself) will benefit from what you have put together!
Ashley Hodge
Hey Ashlyn,
Amazing job on your project and a HUGE congratulations on completing and submitting your capstone! Your presentation was concise yet thorough. It provided us with relevant background information regarding the patients PLOF and baseline outcome measure performance. Additionally, it discussed various effective interventions that can not only be prescribed for complex patients with multi-sensory integration impairments but also for patients that are simply just experiencing balance impairments and lack confidence. I know your project will serve as a useful and relevant additional resource for future students that can help facilitate their knowledge and increase their confidence in treating patients of this population. Overall, Great Job Ashlyn (Lyn)!! I am proud of you!!
Vicki Mercer
Hi Ashlyn,
Thank you for providing these materials for PHYT 784! Your case study is an especially helpful addition to the course. Could you explain a little more about how the diagnosis of multisensory integration impairment was made in this case? What are the theoretical explanations for why this impairment develops (in the absence of neurological injury or any other salient event)? Although it seems clear that this patient had difficulties with use of sensory inputs for balance, she also seemed to have significant LE weakness that likely contributed to her balance problems. Why the emphasis on sensory versus motor contributions to balance in the diagnosis?
hearrow
This is a great project area, Ashlyn! I wish we had more time devoted to vestibular topics in our curriculum, but there is just so much to learn. These resource guides and videos are a great guide, even just to point people in the right direction for more in depth information. I know I will refer back to them if I’m treating vestibular patients! Vestibular videos always make me laugh, so those were fun to watch, and the updated links for the neuro curriculum will be especially helpful for 2nd year students in the future!!