Chronic Imbalance

Details

Title

Chronic Imbalance

Type

Stage Two

Module code

HPS238

Requirement

Compulsory

Module objective

By the end of this module Clinical Scientists in HSST, with respect to the diagnosis, presentation and management of the patient presenting with chronic imbalance and falls, will be able to analyse, synthesise, evaluate and apply their knowledge, in order to identify vestibular causes of chronic imbalance, instigate and interpret appropriate investigations and initiate appropriate management within the scope of a Consultant Clinical Scientist.

Knowledge and understanding

By the end of this module Clinical Scientists in HSST will analyse, synthesise, evaluate and apply their expert knowledge required with respect to the: 

• anatomy and physiology of the vestibular system, vestibular pathways, and central vestibular control centres and how these maintain good balance and are influenced by general medical or neurological problems.
• range of peripheral and central vestibular disorders causing chronic imbalance
• appreciation of the physiological impact of vision disorders or neurological disorders in patients with vestibular problems
• pathology of the stabilising sensory systems which gives rise to multisensory imbalance particularly in the elderly.
• pharmacotherapeutic agents and toxic substances which can cause chronic imbalance and can contribute to falls.
• appropriate audio-vestibular and other investigations.
• effect on balance of recurrent and untreated dizziness of peripheral or central origin.
• effects of ageing, neurological disorder and musculo-skeletal disorders on balance.
• different clinical presentations of chronic vestibular imbalance eg bilateral vestibular failure, Ménierè’s disease, central vestibular pathologies.
• the presentation of non-vestibular causes of imbalance, in particular, epilepsy, syncope, vasovagal attacks, ‘blackouts’ and drop attacks.
• the differentiation of vestibular from non-vestibular causes of imbalance.
• psychological effects of chronic imbalance.
• effective rehabilitative strategies for patients with chronic imbalance.effects of ageing, neurological disorder and musculo-skeletal disorders on balance.
• safeguarding of vulnerable adults.

Technical and clinical skills

By the end of this module Clinical Scientists in HSST, with respect to chronic imbalance, will be able to demonstrate a critical understanding of current research and its application to the performance and mastery of the following technical skills:

• a neuro-otological examination within the scope of a Consultant Clinical Scientist including an accurate examination of the eye movements, characterising any nystagmus.
• vestibular tests
  • videonystagmography.
  • postural sway measurements, including Equitest.
  • tests of oculomotor function
  • tests of vestibulo-ocular function e.g. Halmagyi, head shaking, visual dynamic acuity
  • positioning tests including the Dix Hallpike manoeuvre.
  • caloric function testing including air calorics.
  • bedside test battery to identify signs distinguishing central from peripheral causes of chronic imbalance.
  • Vestibular evoked myogenic potentials (VEMPs).
  • Hyperventilation evoked nystagmus
• systems for ensuring the quality assurance of test procedures:
  • use of appropriate internal controls and performance monitoring.
  • external quality assurance.
• validity and reliability of test results and their application:
  • uncertainty of measurement
  • using systems to produce timely, accurate and relevant reports with appropriate interpretative comments
• particle repositioning manoeuvres e.g. Epley, Semont
• instructing the patient in appropriate vestibular rehabilitation e.g. Cawthorne-Cooksey, Brandt-Darroff and visual exercises.

By the end of this module Clinical Scientists in HSST will be expected to critically reflect and apply in practice a range of clinical and communication skills to advise and communicate effectively with patients, their families, carers and other healthcare professionals and will:

• take an accurate history of balance impairment in order to determine pathology, causation, associated difficulties and extent of disability.
• assess whether musculoskeletal, visual and other medical conditions are restricting rehabilitation.
• select and interpret appropriate audiovestibular and other investigations
• select and request appropriate imaging, when indicated, to investigate chronic imbalance and act appropriately on findings
• assess vestibular/balance disability accurately and make appropriate physiotherapy referral.
• devise and implement a programme of vestibular rehabilitation tailored to the individual, monitoring and reappraising management in line with progress working with the multi-disciplinary teamreflect on the challenges of applying research to practice in relation to
• judge contribution of psychological factors in chronic balance disorders
• within scope of practice suggest to the GP or prescribing doctor alterations in medications suspected of having an adverse impact on balance.
• recognise non vestibular causes of chronic imbalance and request specialist medical opinion as appropriate
• recognise hyperventilation or over-breathing and its impact on balance
• reflect on the challenges of applying research to practice in relation to these areas of practice and suggest improvements, building on a critique of available evidence.

Attitudes and behaviours

By the end of this module Clinical Scientists in HSST, with respect to chronic imbalance, will be expected to evaluate their own response to both normal and complex situations demonstrating the professional attributes and insights required of a Consultant Clinical Scientist working within the limits of professional competence referring as appropriate to senior staff and will:

• work effectively within the multi-disciplinary team.
• recognise the impact of chronic imbalance on employment and activities of daily living.
• recognise the impact and psychological effects of chronic imbalance on the patient and family or carers.
• maintain patient confidentiality at all times.
• be committed to and support continuous improvement of therapeutic services, with particular reference to auditing practice, evidence based practice, innovative, new and improved technologies.