Vestibular —
Training activity: 8

Details

Develop a holistic and individualised vestibular rehabilitation programme for routine patients

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Principles of patient-centred care
• Components of a detailed rehabilitation interview
• Functional evaluation of postural stability, gait and gaze stability
• Patient safety
• Comorbidities, limitations and restrictions
• Level of exercises
• Written information
• National and international guidance, consensus and best practice
• Patient-centred education and information counselling
• Cultural and social attitudes to healthcare
• Goal setting
• Scope of practice
• Onward referrals and sign-posting

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • What constitutes developing a holistic and individualised vestibular rehabilitation programme for routine patients?
  • Have you discussed expectations for individualisation, goal setting, and shared decision-making with your training officer?
• What is your prior experience of this activity?
  • Have you previously developed exercise-based vestibular rehabilitation programmes?
  • What do you already know about the principles of rehabilitation, setting appropriate goals, and using shared decision-making?
  • What specific challenges related to assessing functional impact, ensuring patient buy-in/compliance, or tailoring exercises to a patient’s home environment might you face. How might you plan to handle them?
  • What is the scope of your own practice for developing routine rehabilitation? When will you need to seek advice (e.g., if specialist physiotherapy is required), and from whom?
  • How do you feel about designing rehabilitation programmes?
• What do you anticipate you will learn from the experience?
  • What specific skills in applying shared decision-making principles or selecting appropriate exercise-based rehabilitation components do you want to develop, drawing upon previous experiences?
  • What specific insights into outcome measures and transdisciplinary working (e.g., falls team) do you hope to gain?
• What additional considerations do you need to make?
  • Have you reviewed any actions identified from your previous reflections on management planning or rehabilitation?
  • Do you need to review specific rehabilitation exercises, outcome measures, or resources to support patient adherence before starting?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate while designing the rehabilitation programme? Are you encountering situations such as:
    • The patient revealing significant environmental or physical constraints (e.g., specific phobias, living situation) that make the proposed exercises unsafe or impossible?
    • The patient having complex functional limitations (e.g., significant visual impairment, severe fatigue) that drastically limit the standard exercise selection?
    • The patient showing resistance to the principle of exercise-based rehabilitation?
    • How is this experience comparing with previous experiences of similar activities?
• How do you react to the unexpected development?
  • How is the unexpected development being resolved as you progress during the activity? Are you successfully managing the situation yourself (e.g., adapting exercises in real-time), or do you need support (e.g., from a physiotherapist or falls team specialist)?
  • What are you learning in this moment as a result of the unexpected development? For example, are you gaining proficiency in adapting exercises based on patient feedback regarding environmental constraints, improving the holistic nature of the plan?
  • How is this impacting your actions?
    • Are you responding to the situation appropriately (e.g., prioritising safety and feasibility)? Are you adapting or changing your approach to exercise selection immediately?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately ensuring the rehabilitation programme remains individualised based on the patient’s specific functional limitations?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in ensuring patient compliance? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
  • How are you working within your scope of practice? E.g. Are you successfully developing a rehabilitation programme that is individualised based on the patient’s specific functional limitations and safety considerations? Are you ensuring the exercise regime aligns with your professional training and local rehabilitation guidelines?
  • What are you learning as a result of the unexpected development? E.g. Are you gaining proficiency in adapting exercises based on patient feedback regarding environmental or physical constraints, improving the holistic nature of the plan? Are you learning better strategies for motivating patients to engage with the programme and overcome potential compliance barriers?

On action

• What happened?
  • Begin by summarising the key steps you took in developing the holistic and individualised vestibular rehabilitation programme for a routine patient.
  • Consider specific factors, decisions, or interactions that felt important during the design process, such as integrating assessment results or ensuring patient goals were met. How did you feel during the development of the programme?
  • Include any ‘reflect-in-action’ moments, where you had to adjust your initial ideas or approach based on unexpected patient needs or limitations discovered during the planning discussion.
• How has this experience contributed to your developing practice?
  • What learning can you take from designing this specific rehabilitation programme?
  • What strengths did you demonstrate in developing a holistic and individualised plan? What skills or knowledge gaps were evident (e.g., related to assessment integration, exercise selection, individualisation)?
  • How did this experience compare against previous engagements with similar activities? Were any previous identified actions for development achieved? Has your practice improved?
  • Identify any challenges you experienced (e.g., balancing needs with exercises, resource availability, patient factors, time constraints) and how you reacted to these. Did these challenges affect your ability to deal with the situation? Were you able to overcome them?
  • Was there anything significant about this activity, such as needing to seek advice or clarification on exercise selection or programme structure, or considering if you were working within your scope of practice?
• What will you take from this experience moving forward?
  • Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you received.
  • What will you do differently next time you develop a rehabilitation programme?
  • Has anything changed in terms of what you would do if you were faced with a similar situation again?
  • Do you need to practise any aspect of developing rehabilitation programmes further? E.g.
    • Review the evidence base for specific exercise progressions (e.g., VOR adaptation vs. habituation) to improve your rationale for exercise selection.
    • Practise incorporating goals developed through shared decision-making more explicitly into the documented rehabilitation plan structure.
    • Develop a standardised tool or template to ensure the holistic plan systematically addresses physical, psychological, and functional aspects.
    • Seek advice on identifying potential barriers to adherence (e.g., motivation, environment) during the initial planning phase to pre-emptively address them.

Beyond action

• Have you revisited the experiences?
• • Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (developing a vestibular rehabilitation programme)?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to incorporating holistic management approaches, setting achievable and measurable goals (shared decision-making), selecting appropriate exercises, or documenting the programme clearly?
  • Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
  • Have you engaged in professional storytelling or discussed your experiences of programme design with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the evidence base for specific exercises, the principles of shared decision-making, or transdisciplinary working?
• How have these experiences impacted upon current practice?
• • Considering your cumulative experiences and reflections on this activity, how will the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module? Your improved planning skills are crucial for general Case-Based Discussions (CBDs) where management plans are discussed.
  • How has your practice related to developing a holistic and individualised vestibular rehabilitation programme developed and evolved over time across multiple instances of undertaking this training activity? Can you identify specific examples of improvement or increased confidence in tailoring exercise difficulty to patient baseline, integrating psychosocial considerations, or articulating the rationale for the plan?
  • Based on your experiences, how has your ability to recognise when something related to rehabilitation programme development is beyond your scope of practice improved? Do you have a clearer understanding of when and from whom (e.g., supervisor, specialist physiotherapist, psychological services) you need to seek advice or clarification regarding patients with severe co-morbidities requiring complex evaluation, patients with severe balance dysfunction, or when psychological barriers prevent engagement?

Relevant learning outcomes

#	Outcome
# 5	Outcome Provide safe and effective vestibular rehabilitation for commonly occurring disorders in patients without significant comorbidities.
# 6	Outcome Evaluate vestibular rehabilitation options for complex cases with comorbidities.