Audiologists have historically taken the lead role as the provider for vestibular evaluation. Since this blog is written primarily for an Audiology audience, we will focus on what the Audiologist can and should do. There are critical aspects of evaluation and management of the dizzy patient that are not/may not be within our scope of practice and training, and require the input of other professionals.
The overwhelming majority of vestibular disorders do not benefit from medication or surgery. Not unlike dealing with sensorineural hearing loss, Audiologists are placed as the health care professional dedicated and uniquely trained to deal with non-medically treated ear disorders. Audiologists, with sufficient experience and training, may take the lead position as clinic director (not medical director). The lead clinician in a comprehensive balance clinic should be familiar with all known causes of dizziness, be capable of recognizing a medical emergency when it walks in the door and have protocols to manage these, be proficient in taking a thorough history, performing screening and electrophysiologic examinations of the Vestibular/Ocular Reflex, performing Canalith Repositioning for all variations of BPPV, and be able to design customized therapy programs for patients with vestibular disorders.
All of this is within the Audiology scope of practice per ASHA and AAA.
Certain labyrinthine disorders such as Meniere’s Disease, Superior Canal Dehiscence and Perilymph Fistula are best managed by an Otolaryngologist, Neuro-Otologist or Otologist. These physicians are trained in the medical/surgical management of ear disorders.
Neurologists are trained in the diagnosis and treatment of diseases and disorders of the brain, spinal column, nerves and muscles. Conditions such as Migraine, Multiple Sclerosis, and cerebellar degeneration, stroke or mass lesion leading to ataxia are best managed by a Neurologist. Neurologists also perform electromyography and nerve conduction velocity examinations, and evaluate patients for conditions such as peripheral neuropathy and muscle weakness.
Physical Therapists have traditionally taken the lead the lead role in providing rehabilitation services to patients with vestibular or non-vestibular balance disorders.
Several causes of dysequilibrium and gait disorders, such as peripheral neuropathy and musculoskeletal injuries, fall squarely in the realm of physical therapy. Audiologists, despite additional training in vestibular rehabilitation, are generally not prepared to evaluate and treat these conditions.
The rising costs of health care and the dramatic recent reductions in reimbursement have made it essential that services be provided in the most cost effective manner. The judicious use of support personnel can allow the professional to practice more efficiently, and increase the number of patients seen in a given time period. The obvious concern over use of support personnel is whether they are qualified to provide tasks assigned by the professional. Both the American Academy of Audiology (AAA) and the American Physical Therapy Association (APTA) have issued statements regarding minimal qualifications and supervision requirements for support personnel in the fields of Audiology and Physical Therapy.
Primary Care Physicians (PCP)
Although the primary care physician may not be a balance team member in the traditional sense, it is important to recognize the contribution of well educated referring physicians. Not only will a PCP educated in the management of vestibular disorders be more likely to refer a patient to the clinic, there is a higher likelihood that the patient will be an appropriate referral and that needed medical history information will be provided. Many causes of dizziness, such as orthostatic hypotension and cardiac arythmia, can be managed by the attending Primary Care Physician or Cardiologist.