PHTY605 - Advanced Physiotherapy Practice 3: Vestibular Rehabilitation

Year

Credit points

Campus offering

Prerequisites

HLSC632 Holistic Rehabilitation and Restoration 2 AND PHTY613 Optimising Interprofessional Collaborative Practice for Physiotherapists

Teaching organisation

Unit rationale, description and aim

The ability to comprehensively assess and manage a range of vestibular disorders is an essential aspect of clinical practice for physiotherapists. Advanced knowledge and skills will enhance clinical reasoning and inform assessment and management strategies specific to a range of peripheral and central vestibular disorders. This unit aims to enable students to further develop and apply to their practice, advanced knowledge and skills associated with vestibular assessment, diagnosis, and collaborative person-centred application of evidence-based techniques required to optimally manage people with vestibular disorders.

Learning outcomes

To successfully complete this unit you will be able to demonstrate you have achieved the learning outcomes (LO) detailed in the below table.

Each outcome is informed by a number of graduate capabilities (GC) to ensure your work in this, and every unit, is part of a larger goal of graduating from ACU with the attributes of insight, empathy, imagination and impact.

Explore the graduate capabilities.

On successful completion of this unit, students should be able to:

LO1 - Integrate, apply and critically discuss advanced knowledge of functional anatomy and physiology of the peripheral and central vestibular systems as a basis for undertaking an assessment of people with peripheral and/or central vestibular disorders (GA3, GA4, GA5)

LO2 - Integrate, apply and discuss advanced knowledge and skills to undertake specific and prioritised assessment to inform management of people with peripheral and/or central vestibular disorders to address client-led needs and goals aimed at maximizing outcomes and participation (GA3, GA4, GA5, GA7, GA8)

LO3 - Demonstrate an advanced ability to develop, apply, critically review, justify and communicate an evidenced-based treatment program to promote optimal outcomes for people with peripheral and/or central vestibular disorders. This includes demonstrating an advanced ability to communicate assessment findings and evidence-based management to clients and other members of the multidisciplinary team including medical specialists and other health professionals (audiologists, speech pathologists, psychologists) (GA3 GA4, GA5, GA7, GA8, GA9);

LO4 - Reflect on the application of knowledge and skills in the assessment and provision of optimal vestibular rehabilitation for people with peripheral and/or central vestibular disorders, as well as their personal and professional growth as an advocate for their clients and as an emerging leader within their discipline. (GA1, GA3, GA4, GA5, GA7, GA8)

Graduate attributes

GA1 - demonstrate respect for the dignity of each individual and for human diversity 

GA3 - apply ethical perspectives in informed decision making

GA4 - think critically and reflectively 

GA5 - demonstrate values, knowledge, skills and attitudes appropriate to the discipline and/or profession 

GA7 - work both autonomously and collaboratively 

GA8 - locate, organise, analyse, synthesise and evaluate information 

GA9 - demonstrate effective communication in oral and written English language and visual media 

Content

Topics will include: 

Overview of the vestibular system including:

• Anatomy and physiology of the peripheral and central components of the vestibular system
• The functional organisation of the vestibular system and its critical role in maintaining stable gaze, balance and higher cerebral functions
• The relationship of vestibular system anatomy and physiology to clinical signs and subjective symptoms in people with vestibular system dysfunction
• Physical assessment techniques / protocols that assist in the differential diagnosis of vestibular system dysfunction including assessment of the oculomotor system and the vestibular ocular reflex
• Neurophysiology of vestibular system compensation and its relationship to recovery from vestibular system dysfunction
• Current theoretical principles and clinical practice guidelines that underpin evidence-based vestibular rehabilitation strategies including the clinical reasoning related to titration of exercise interventions

Unilateral Vestibular Hypofunction (UVH)

• Differential diagnosis and management of common clinical presentations of UVH including:

o  Vestibular neuritis / labrynthitis

o  Vestibular schwannoma / acoustic neuroma

o  Meniere’s Disease

• Investigative procedures / audiology tests relevant to the management of UVH
• Evidence-based vestibular rehabilitation protocols for people with UVH

Benign Paroxysmal Poisitional Vertigo (BPPV)

• Application of the principles of semicircular canal physiology to differentiate the affected canal (posterior, horizontal and / or anterior canal) and the type of BPPV (canalithiasis or cupulolithiasis)
• Contemporary clinical practice guidelines to inform the assessment and appropriate management of BPPV variants
• The importance of recognising and identifying red flags and BPPV mimics in the context of physiotherapists in Australia working as first contact clinicians

The role of the Audiologist for people with dizziness

• Functional anatomy and physiology of normal hearing
• Assessment of conductive and sensorineural hearing loss hearing and the clinical interpretation of audiograms
• The role of vestibulo-audiology assessment in the differential diagnosis of central and / or peripheral vestibular dysfunction including the role of videonystagmography (VNG), vestibular-evoked myogenic potentials (VEMPs), calorics and rotary chair assessments
• Understanding when a person with dizziness should be referred for a hearing assessment and / or audiovestibular testing

Ageing and the vestibular system

• The causes and impact of impairments in the vestibular system in the older adult including the clinical implications of vestibular system dysfunction and falls
• The importance of including assessment of the vestibular system in the comprehensive assessment of the older adult who is at risk of falls, has fallen or is deconditioned
• Clinical integration of evidence-based vestibular rehabilitation strategies into the holistic physiotherapy management of older adults across the continuum of care

Central vestibular dysfunction

• Functional anatomy and physiology of central components of the vestibular system
• Common central pathologies that result in vestibular signs and symptoms
• Vascular lesions (Posterior Inferior Cerebellar Artery (PICA) / Anterior Inferior Cerebellar Artery (AICA)
• Diffuse lesions (Traumatic brain injury (TBI) and concussion)
• Progressive neurological diseases such as Multiple sclerosis (MS) and Parkinson’s Disease (PD)
• Vestibular migraines
• The role of medical specialists in the assessment and management of people presenting with vestibular dysfunction and / or dizziness, particularly the specialities of neurology and ear nose and throat (ENT)
• Current theoretical principles and clinical reasoning underpinning vestibular rehabilitation strategies for people with central vestibular dysfunction, including the the clinical reasoning related to titration of exercise interventions

Acute vestibular syndrome (AVS) in the emergency department

• Clinical assessment and differential diagnosis of people presenting with sudden onset of dizziness including differentiating peripheral vestibular neuritis from an acute stroke
• HINTS protocol and variants (Head Impluse, Nystagmus, Test of Skew)
• Positional testing for BPPV in the Emergency Department,
• Imaging of Acute Vestibular Syndrome
• Clinical utility of the video Head Impulse test in the emergency department / acute hospital setting
• Clinical reasoning underpinning the vestibular physiotherapy management of people with acute onset dizziness in the emergency department or the acute hospital setting
• The expanding role of the advanced vestibular physiotherapist in the Emergency Department and acute hospital setting

Learning and teaching strategy and rationale

This unit is offered as multi-mode and online delivery for specific on and offshore cohorts. Both modes aim to facilitate learner centred activities and workplace learning. Learning and teaching strategies within this Masters level unit are based on a blend of constructivism, social constructivism, and experiential learning. These strategies focus on active participation and developing a community of inquiry. Purposefully designed content and activities that are the same or similar for all participants regardless of the mode of delivery have been identified. This has led to the development of purposefully designed learning activities that are transferable and work well across both delivery mediums whilst maintaining the flexibility to create and deliver mode specific activities focusing on inquiry-based learning principles aimed at encouraging critical thinking, application of knowledge and skills, evidence for practice, collaborative peer learning, and critical self-reflection. Examples of these learning activities include observation of expert clinicians, opportunities to practice observation and interpretation of specific vestibular assessments, opportunities for peer and expert clinician feedback on student performance of specific clinical vestibular assessment and management techniques, and case-based peer group discussions, facilitated by an expert clinician.

In addition, students participate in individual and small group activities based on analysis of current practice, to assimilate application of advanced knowledge and facilitate translation of learning into practice. Engagement in extended dialogue is encouraged to guide change to a more interprofessional, person-centred practice. Unit activities can include, but are not limited to: guided readings, synchronous on-line tutorials, work-based activities with reflection, use of a reflective journal during experiential learning, skill development, and mentoring to enhance practice.

Activities undertaken in both modes are aimed to facilitate acquisition of advanced knowledge and skills in collaborative and assessment and intervention planning strategies. Post workshop workplace activities are supported through a clinical visit and/or use of information and communication technologies. 

Assessment strategy and rationale

PHTY605 assessments have been purposefully designed to replicate authentic clinical practice. Significantly, the unit’s assessments have also been designed from an “Assessment for Learning” approach in order to not only provide evidence for judgement of learning, but also to reinforce, facilitate and support learning and application of learning. The assessment tools have been designed to provide for a broad range of tasks aligned to andragogic principles of adult learning, facilitating choice and self-direction for the post graduate student. The design enables timely judgement to ensure students have appropriate knowledge and skills prior to the workplace application segment of the unit. In addition, the range of assessment activities at the end of the unit encourage application of evidence to practice and embed clinical reasoning, problem solving and implementation of advanced knowledge and skills.  

The first assessment task provides students with the opportunity to demonstrate advanced and critical analysis of a case study and to identify and apply optimal evidence-based interventions. The focus of the final two assessment items, is to reflect on personal and collaborative practice, and communicate reflections, evidence-based reasoning and decision making, to management and peers. In the second assessment task students will present a complex case highlighting the clinical reasoning and evidence-base underpinning their management of this case. Assessment task 3 enables students to demonstrate the application of advanced skills in the delivery on an evidence-based intervention with a client, their clinical reasoning and clinical decision making.  

 In addition to assessing enhanced clinical skills, a major focus of the final two assessment items, is the ability to reflect on personal and collaborative practice, and communicate reflections, evidence-based reasoning and decision making, to management and peers. These assessments incorporate the advanced level of professional knowledge and skills, enhanced critical analysis and professional presentation modes developed throughout the post graduate program. Scheduling of assessments will be equitable for both modes of delivery. Assessment tasks may be delivered and assessed locally with moderation according to University Policies and Procedures. All assessments will be submitted electronically. 

Overview of assessments

Representative texts and references

Bhattacharyya, N., Gubbels, S., et al. (2017). Clinical practice guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery, 56(3S), S1–S47 DOI: 10.1177/019 10.1177/0194599816689667

Bronstein, A., & Lempert, T. (2017). Dizziness: A practical approach to diagnosis and management (2nd ed.). Cambridge University Press, Cambridge UK. ISBN 978-1-316-75646-1 Cambridge Core.

Hall, C.D., Herdman, S., et al. (2016). Vestibular rehabilitation for peripheral vestibular hypofunction: An evidence-based clinical practice guideline. Journal of Neurological Physical Therapy, 40, 124-154. DOI: 10.1097/NPT.0000000000000120

Herdman, S.J., Clendaniel, R., & Steele, R. (2014). Vestibular rehabilitation. Philadelphia: Philadelphia: F. A. Davis Company.

Kim, J.S, & Zee, D.S. (2014). Benign Paroxysmal Positional Vertigo. New England Journal of Medicine, 370, 1138-47. DOI:10.1056/NEJMcp1309481

Lundy-Ekman, L. (2013). Neuroscience: Fundamentals for rehabilitation. St. Louis, Mo: Elsevier Health Sciences.

Strupp, M., Dlugaiczyk, J., Ertl-Wagner, B.B., Rujescu, D., Westhofen, M., Dieterich, M. (2020). Vestibular disorders—diagnosis, new classification and treatment. Deutsches Arztebl att International, 117, 300–10. DOI: 10.3238/arztebl.2020.0300

Whitney, S.L., Alghadir, A.H., & Anwer, S. (2016). Recent evidence about the effectiveness of vestibular rehabilitation. Current Treatment Options in Neurolology, 18, 13. DOI 0.1007/s11940-016-0395-4