Investigations into a physiotherapy-led vestibular rehabilitation model of care

People with dizziness commonly seek medical solutions through primary contact medical practitioners and Ear Nose and Throat (ENT) outpatient services. Physiotherapists trained in vestibular rehabilitation may independently and safely assess and manage these people. This thesis presents a programme of research undertaken to investigate a standalone physiotherapy-led vestibular rehabilitation service and its management of people with dizziness screened from the wait lists of ENT outpatient services. A systematic review and two clinical studies support the main service investigation.

The published systematic review, Study 1, synthesised vestibular diagnostic proportions reported by the specialties of ENT/Otology, Neurology, Emergency, General Practice and Physiotherapy, enabling comparison with the findings of the clinical studies in this programme of research. A 2020 update found increased awareness for setting-specific differences in diagnostic proportions and for benign paroxysmal positional vertigo (BPPV) diagnostic procedures; however, awareness of correct BPPV management was still deficient.

The Study 2 pilot demonstrated the feasibility of the model of care and informed the extension of the trial into a major study. Sixty-seven participants from an ENT wait list included a 44:23 female to male ratio, a mean age of 55.2 years (SD 17.57) and a diagnostic profile of common diagnoses including BPPV (22%), unilateral vestibular hypofunction (40%), vestibular migraine (10%) and cervicogenic dizziness (6%). Service outcomes included a mean wait of 382.6 days (SD 246.3) with 31(46%) participants receiving one occasion of service. Nine percent of people assessed were returned to ENT for consultant review and no adverse events were recorded. Patient management led to the resolution of BPPV and unilateral vestibular hypofunction clinical signs and significant improvements in the Dizziness Handicap Inventory (34.9/100 to 11.1/100, p< 0.001) and the Activities-specific Balance Confidence scale (78.3/100 to 87.9/100, p= 0.009).

Study 3, an interrater reliability trial between a vestibular audiologist and physiotherapist for diagnostic accuracy and referrals for vestibular rehabilitation included 22 people (82% female) with dizziness from ENT wait lists with a mean age of 54.9 years (SD 19.44). Clinician diagnoses compared closely for the common forms of vestibular dysfunction: BPPV 100% agreement (Kappa 1.0), unilateral vestibular hypofunction 77.3% (Kappa 0.54), vestibular migraine 95.5% (Kappa 0.78), and cervicogenic dizziness 86.4% (Kappa 0.65). Percentage agreement for referral to vestibular rehabilitation was 95.5% (Kappa 0.89).

Study 4 investigated a cohort of 301 people with dizziness (191 (63%) females) from ENT wait lists averaging 55.5 years (SD 17.23) in age and with a diagnostic profile of BPPV (20%), unilateral vestibular hypofunction (36%), vestibular migraine (15%) and cervicogenic dizziness (8%). Wait times reduced significantly from 390.2 days (SD 243.5) in 2013 to 93.0 days (SD 219.4) (p= 0.004) in 2017, and occasions of service and duration of treatment were skewed positively towards medians of one. Consumer engagement using visual analogue scales showed consistently high median levels of satisfaction for wait time (9.3/10 cm) and service quality (10/10 cm). Clinical effectiveness of the model of care was demonstrated through its treatment of BPPV leading to resolution in 48 out of 50 people (p< 0.001) and its treatment of unilateral vestibular hypofunction leading to compensation in 47 out of 54 people presenting with uncompensated DVA (p< 0.001). Whole cohort Dizziness Handicap Inventory scores improved from 38.1/100 (SD 22.1) to 24.6/100 (SD 21.6) (p< 0.001) and Activities-specific Balance Confidence scale scores from 73.2/100 (SD 21.89) to 81.0/100 (SD 18.94) (p< 0.001).

Investigating the burden of dizziness, initial assessment utility scores calculated from the Assessment of Quality-of-Life 8 Dimensions questionnaire averaged 0.58 (SE 0.01), representing a 30% reduction in quality of life compared with published normal population scores. Treatment saw a significant improvement in the utility by 0.08 (95% CI 0.06, 0.10) (p< 0.001). Using the Work Productivity and Activity Impairment (Dizziness) questionnaire, absenteeism in 2013 participants amounted to potential annualised lost wages of AUD $16380 per person: reducing to AUD $4185 by 2017. Presenteeism by people with dizziness at a mean of 30%, represented a considerable potential cost in lost productivity to employers in 2013 at AUD $20998, reducing with wait reduction by 2017 to AUD $5308. Cost consequences analysis using decision tree modelling of two models of care, physiotherapy-led and ENT-led, showed dominance in cost by the physiotherapy-led model.

In conclusion, the physiotherapy-led vestibular rehabilitation model of care was shown to be one of high value care; being clinically, service, and cost effective, and safe and satisfactory for people with dizziness referred to an ENT waitlist. Research into the burden of dizziness considering quality of life, absenteeism and presenteeism indicated considerable consequences for people with dizziness and found the physiotherapy-led model improved this burden significantly. In the Australian public hospital setting, independent, primary contact, physiotherapy-led vestibular rehabilitation services provide a safe, effective, efficient and cost-effective pathway for people with dizziness referred to ENT.