Striking the Right Balance: Vestibular Assessment and Rehabilitation: Pushing the Boundaries in the Field of Audiology

By Sylvie Auger

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Question 1: Can you tell me about where you work and how long you have been performing vestibular testing and management?
I am currently practicing audiology at Audiology Centre West which is the private clinic I opened 21 years ago in Montreal. At the beginning I was the only audiologist here, but over the years I have hired several colleagues, which enabled us to diversify our services from testing toddlers to testing auditory processing, tinnitus and hyperacusis assessments, musicians’ management and assessment and, finally, vestibular evaluation and rehabilitation. I was one of the first audiologists in the province of Quebec to offer, in addition to assessment, the rehabilitation in vestibular disorder.

Question 2: You have been a pioneer in vestibular management in Quebec and across Canada. What made you decide to focus your career on vestibular?
It unfolded naturally. Actually, one of my professors from University kept mentioning that we should do something for this segment of our clientele. I was curious enough to push the boundaries of my practice since these dizzy patients called on my office regularly. I decided that I might as well provide them with the solid help they needed. So after I tackled auditory processing disorder (including the occasional post concussion patient) and got more deeply involved with tinnitus and hyperacusis patients, it became a natural step to jump in to the world of vestibular disorders.

It has been an exciting and rewarding adventure as all the pieces of the puzzle fell into place: what you learn from auditory processing, from hearing science and from tinnitus and hyperacusis is complemented by the understanding of the intricacies of the vestibular system. I feel now that my practice has completed a full circle.

Question 3: How has your vestibular practice changed since you first started?
My vestibular practice has evolved following the developments and new evidence that have surfaced over the years. For example, we can now distinguish between BPPV and a centrally provoked positional vertigo. Still within BPPV management, I used to complete a BBQ roll maneuver when dealing with horizontal canalolithiasis. Now, we can use the Kurtzer hybrid maneuver: much faster, much safer and so much easier for both the patient AND the clinician to complete.

Over time, our understanding of the mechanics and functionality of the vestibular system, became more profound. This, in turn, allowed us to use “custom made” flow charts as we evaluate each patients.

The fact that I was given the opportunity to teach the vestibular assessment and management course at both the Université de Montréal and University of Ottawa to audiology students also allowed me to stay abreast of these developments. Recently, the new tools for assessments came on stream; such as the vHIT, the c-VEMP, the o-VEMP, the Subjective Visual Vertical test etc.

One major step forward in this field is the fact that there are now enough audiologists practicing in the area of vertigo, that we can have a great deal of exchange of precious ideas!

Question 4: Some audiologists who do vestibular testing may be hesitant to perform rehabilitation. What advice would you give them on taking this first step?
What’s holding you back? With vestibular rehabilitation, you can actually make a big difference in a patient’s quality of life. And this, may not be the case when we deal with a regular hearing loss or loss of communication abilities. Vestibular rehabilitation, in essence, means helping the brain to re-adjust and re-calibrate around a vestibular dysfunction . This activity is best performed by an audiologist. It uses the vestibulo-ocular reflex and a home based program with some follow up meetings (that could even be over the phone, over emails...). This is not too time consuming in a busy clinic and we understand the vestibular system better than any other health professional.

If we are dealing with someone who has a balance problem or a centrally provoked disequilibrium which is not solely originating from the peripheral vestibular system, then, obviously, a physiotherapist, and an occupational therapist, and maybe even mental health practitioners should take over (obviously, physicians and diverse specialists could also be involved here).

If, as an audiologist, you don't feel “safe” in taking the first step, just apply a generic therapeutic program to begin with. The information is available to you: in books, in lectures, in workshops on the internet and even on YouTube. Connect with your colleagues and simply make sure that your patient is safe while doing the exercises: vestibulo-ocular reflex can be worked on while sitting. And it may help your elderly patient to be able to continue to live safely at home by reducing the probability of falls.

Doing nothing may actually significantly increase the probability of falls and therefore have a negative impact on your elderly patient’s lifestyle. We, as audiologists, can make a positive difference in our patient’s quality of life.

Question 5: The role and practice of an audiologist seems to differ from province-to-province with regards to vestibular testing. What is the current role of audiology in Quebec and how do you see the profession changing in years to come?
As for vestibular testing in Quebec, it has been an uphill battle in the public sector. We are making progress, often through the use of the electrophysiologic testing: the c-VEMP and the o-VEMP. Moreover, the ENT specialists are against our involvement in vestibular testing and rehabilitation: most likely for political reasons. However, outside of the constraints of the public sector, some ENT specialists are happy to count on our knowledge and expertise, so we can say that in the private sector, the offer of vestibular services keeps growing.

Our profession will definitely take its place in the field of vestibular intervention since there is now a 45 hours course specifically on this topic offered to audiology students at the Université de Montréal. So the new generation of audiologists will feel confident in owning this part of our field of practice and it will be difficult to argue that we, as professionals, do not have the knowledge or the training to intervene in this specific field.

Question 6: There are now more audiology students applying to audiology programs with the hopes of working with vestibular patients. What advice would you give them about working in this specialty?
I would strongly suggest that they first thoroughly know their basics in audiology: hearing and balance problems usually go hand-in-hand (including tinnitus and auditory processing disorders). I would definitely encourage them to embrace this specialty and claim it as our own. We do have a very important role to play in an interdisciplinary team working with patients who are dizzy.

The diagnostic intervention as well as the rehabilitation is extremely gratifying with this type of patient. I have often said that it feels good to solve a person’s problem of dizziness after you perform a repositioning maneuver.

This would be in contrast to seeing them over the years and simply confirming that their hearing loss is progressing and feeling helpless in preventing this deterioration and even more so in solving the problem (we all know that even the best of hearing aids have their limits and do not solve “completely” the issue of a hearing loss).

Question 7: What would you like to see change in our field with regards to vestibular assessment and management?
I would like to see audiologists boldly claim their knowledge and know-how in that specialty: who else amongst the health professionals has spent countless hours studying the ear (where the vestibular system is, by the way)?

We are trained in both diagnostic and rehabilitation: some of us will specialize in cochlear implants, some in tinnitus and hyperacusis, some in pediatrics hearing loss, all of these specialties have developed exponentially over the last twenty years or so. No professional can claim to be the only expert in vestibular assessment and management and neither could we. But we can definitely claim to be the most knowledgeable amongst all other health professionals involved in this specialty and trust that our expertise and our ability to put forward evidence informed practice will support us in walking down this path.

And our patients will greatly benefit from our involvement: they are eagerly waiting for us to jump in!

Be bold! Trust! and Enjoy!