Vestibular Rehab and Telehealth Part 1: To the Clinician

First, let’s pretend there isn’t a world-wide pandemic currently turning our world upside down and changing the healthcare system as we know it. If I were to put the words “Telehealth” and “Vestibular Therapy” in the same sentence, your first thought would most likely be “that couldn’t possibly work and provide quality care!” Aside from talking just about vestibular therapy, I think many physical therapists would think the same thing applied to telehealth physical therapy in general. However, COVID-19 has us all thinking and feeling a little differently these days, and let me say… I wish I saw the light sooner!

We’re now living in times where we have shelter-in-place or stay-at-home orders that are keeping a large amount of our patients in their homes. Many PT clinics and additional healthcare settings remain open, leaving all of us scrambling to keep up with the constant rule changes for Medicare/Insurance Companies, figuring out how to best serve our patients, and monitor changes in our practice acts. Not to mention we’re now navigating the increased stress of stepping-up health precautions in the clinic, worrying about getting yourself or your family sick, managing caseloads with massive amounts of cancelations, and now learning how to perform telehealth visits! Yikes!

At first, I was not a fan of the idea of learning how to perform telehealth visits, but now I must admit that I’m really liking it since I’ve been getting the hang of it! Here’s why…

Before completely dismissing the idea, let me make some things clear:

• Telehealth is not appropriate for everybody. You must use your clinical judgement!
• Telehealth will not be able to replace getting your hands on a patient.
• Telehealth is still a little bit like the wild west… There’s a lot that needs to be done to clearly outline its role and rules in the healthcare industry across our country, especially in physical therapy. You need to do your own research into your state’s practice act as well as advocate for the expanded use of telehealth.
• And finally, yes, it is possible to perform a vestibular evaluation via telehealth

Consider these things in terms of a vestibular telehealth visit:

Telehealth may be a way to manage a patient’s anxiety

• Anxiety can be a large contributing factor to a vestibular patient’s symptoms. Imagine how much more relaxed they could be sitting in their own home, without getting into a car to drive to an office, and then arrive to feel rushed to fill out the millions of pages of paperwork (which could be difficult for them due to symptoms). Also, another way we typically decrease anxiety is through educating the patient about their symptoms, the vestibular system, and how we're going to be able to help them. Through telehealth, you can still provide the patient with visual and verbal education which is extremely important to set the patient up for the greatest amount of success with their plan of care. 

Subjective history alone gives you a ton of information

• A huge chunk of your vestibular evaluation is subjective history! Usually, if you allow a patient to talk long enough, they’ll give you a lot of useful clues as to what might be their problem. Also, a majority of people with vestibular dysfunction just need to be listened to and reassured that what they’re feeling isn’t all in their head to start feeling a little better.

We don’t need to perform every test under the sun

• Does it feel great to perform every bedside test imaginable to back up our evaluation conclusions? Heck Yes! Do we absolutely need to perform every bedside test imaginable to start formulating exercises for the patient to help reduce symptoms? Definitely not. Sometimes, the patient won’t even be able to tolerate a ton of testing at the initial evaluation, and we already find ourselves prioritizing only the tests we feel we really need to do.

“But what if I miss something because I’m not using my Infrared Goggles?”

• Yes, some signs of peripheral dysfunction can be missed if only being viewed or tested in room light. It is reassuring to us to see nystagmus intensify when we remove fixation, or when we are able to perform tests such as a hyperventilation or Valsalva testing on rare occasion when appropriate. But will the presence of a central sign or a positive peripheral test with fixation removed in goggles affect what you do for the rest of your evaluation that day and/or the treatment plan moving forward? Will it stop you from getting the patient started with a few home exercises based on your other eval findings and the patient’s reported symptoms? My guess would be “No”. There have been almost no occasions where I’ve immediately referred a patient back to their neurologist/ENT/OTO or even to the ER based on my findings from a vestibular evaluation in an outpatient physical therapy setting. When I recently moved from Maryland to South Carolina, there was a span of about 4 months where I had to practice without infrared goggles. Although I prefer using them over not using them, I learned that I could rely on my knowledge of testing and treatment skills to confidently treat patients without worrying about missing something.

But… Goggles!

• Yes, goggles are amazing. So amazing, in fact, that I wrote a blog about their importance not too long ago! (IVOG Blog Entry) But many clinicians have been able to practice and help patients without them for many years. In times like these, many people can’t leave their homes… but don’t they still need help? Imagine if your sweet grandmother called because she gets dizzy in bed, and she knows you help dizzy people. Couldn’t you talk to a family member there with her to FaceTime with you so you can walk them through testing and treatment on her bed while you watch her nystagmus?

I’m not going to go into the nitty-gritty of how to perform a vestibular telehealth visit. That’s going to differ from clinician to clinician. My hope is that this blog entry will help vestibular clinicians feel more comfortable with the idea of telehealth, and to see the potential in front of us to help more vestibular patients. Aside from the pandemic, there are SO MANY patients in areas without access to comprehensive resources for vestibular diagnosis and treatment. Others may lack transportation or the mobility to be able to attend a session in the clinic. Consider how much easier a BPPV follow up visit could be if performed over telehealth!

If you’re one of the many currently furloughed from work, start to consider how you could replicate tests you perform in the clinic over a virtual visit. Think outside the box! There are already a few brave pioneers who are forging a path ahead for us and letting us in on their accumulated knowledge. Take Kathleen Stross, PT, MS, CHC for example. Here is a fantastic video she put together that she sends out to her vestibular telehealth patients before their first visit.

In January 2019 at the APTA Combined Sections Meeting, Linda D’Silva, PT, PhD, NCS, Sarah Gallagher, PT, DPT, NCS, Alan Chong W. Lee, PT, PhD, DPT, CWS,GCS, Sara Oxborough, PT, and Karen Skop, PT, DPT, MS gave a fantastic presentation on “Telehealth and Vestibular Rehabilitation” where they shared their insights and experience on performing telehealth with patients. (See a summary here)

Abbie Ross, PT, DPT, NCS also presented a poster at CSM on “The Use of Telerehabilitation in the Treatment of Post-Concussion Syndrome: A Case Study”. Back in 2018, she opened one of the first completely virtual physical therapy (telehealth) practices in the nation and has provided care through live videoconferencing ever since. I should mention here that I had the pleasure of meeting Abbie at CSM back in 2019, and now I couldn’t be more excited to be joining her and Balancing Act Rehabilitation on a flexible part-time basis treating patients from South Carolina, Maryland, and Virginia.

Here are some great resources for you if you’re interested in learning more about telehealth:

• APTA Telehealth Resources: http://www.apta.org/Telehealth/
• APTA’s top 10 ‘To Do” list for Telehealth: http://www.apta.org/Blogs/PTTransforms/2020/3/27/TelehealthAdvice/
• A discussion on the use of telehealth in vestibular rehabilitation with Sarah Gallagher PT, DPT, NCS and Sara Oxborough PT: https://podcasts.neuropt.org/vrsig/telehealth-in-vestibular-rehabilitation/
• Vestibular Rehab Special Interest Group Newsletter with Telehealth Presentation Summary and resources: http://www.neuropt.org/docs/default-source/vsig-newsletters/spring-summer-2019.pdf?sfvrsn=f5695343_0
• https://www.balancingactrehab.com/
• Practice Acts by State: http://www.apta.org/Licensure/StatePracticeActs/