the challenges of managing vestibular disorders: a qualitative study of clinicians’ experiences...

The challenges of managing vestibular disorders:a qualitative study of clinicians’ experiences associatedwith low referral rates for vestibular rehabilitation

S. H. Polensek,1,2 R. J. Tusa,2 C. E. Sterk3

Introduction

Vestibular impairment (VI) is frequently under-

diagnosed (1–4), although it may be the underlying

cause of symptoms in as many as 45 percentage of

people complaining of dizziness (5–7). Undiagnosed

and untreated dizziness significantly negatively

impacts quality of life and is quite common particu-

larly in the elderly (8). Untreated vestibulopathy can

lead to significant morbidity and mortality, as vestib-

ular loss significantly increases fall risk (9,10). We

previously reported that patients complaining of diz-

ziness were not routinely screened for VI based on

available recommended practices (4), which likely

contributed to under-diagnosis and subsequent low

referrals for vestibular rehabilitation.

Physical therapy is the cornerstone of treatment

for many symptoms of vestibular loss and benign

paroxysmal positional vertigo (BPPV) (11–17). The

various movement-based treatments used to treat VI

may be referred to as vestibular rehabilitation and

may involve physical therapy for canalith reposition-

ing for BPPV, teaching co-ordination of eye and

head movements, improving balance and walking

skills and teaching methods to ‘desensitise’ the ves-

tibular system. In addition, vestibular rehabilitation

may include providing education about VI, how to

reduce risk of falling as well as coping mechanisms

to use the body’s other senses to compensate for the

VI. Vestibular rehabilitation has been shown to effec-

tively reduce symptoms of dizziness in patients with

longstanding vestibular loss by 85% (13). BPPV goes

1Rehabilitation Research and

Development, Atlanta VA

Medical Center, Decatur, GA,

USA2Neurology, Emory University,

Atlanta, GA, USA3Rollins School of Public Health,

Emory University, Atlanta, GA,

USA

Correspondence to:

Sharon Hartman Polensek,

1670 Clairmont Road, Room

GA109A, Decatur, GA 30033-

4004, USA

Tel.: + 1 404 321 6111, ext.

3140

Fax: + 1 404 728 4837

Email: [email protected]

Disclosures

The authors report no conflicts

of interest.

SUMMARY

Aims: To explore clinicians’ perspectives influencing the under-diagnosis and man-

agement of patients with vestibular impairment (VI). Methods: Data were col-

lected using open-ended, semi-structured interviews with 18 clinical providers from

primary care, neurology, otolaryngology and audiology affiliated with the Veterans

Administration Medical Center in Atlanta, Georgia, from January to September

2007. Topics discussed included healthcare experiences for dizzy patients with pos-

sible VI, and perceived barriers and facilitators for clinical practice according to

published guidelines. The constant comparison method was used for qualitative

content analysis. Results: Clinicians rarely, if ever, diagnosed VI themselves or

were aware of vestibular rehabilitation as the appropriate treatment for vestibular

disorders. They infrequently performed bedside tests for positional nystagmus or

vestibular hypofunction to identify VI and almost never performed canalith reposi-

tioning. Not uncommonly, they ordered a wide variety of diagnostic tests, such as

neuroimaging, cardiac studies and audiograms, prior to make referral to a special-

ist, if they made referral at all. Perceived barriers to identifying VI in patients and

giving treatment consistent with published recommendations commonly included

lack of knowledge and training, perceived time constraints in clinic and difficulties

with dizzy patients giving vague descriptions of their symptoms. Conclusions: Per-

ceptions of lacking knowledge in caring for patients with possible VI were experi-

enced by clinicians both in primary and specialty care. Clinicians were frequently

unaware of the concept of vestibular rehabilitation. Many wanted to learn more to

improve healthcare delivery for their patients. Education appears necessary not only

for enhancing patient therapeutic benefit, but also for minimising costs for unnec-

essary physician hours and diagnostic tests.

What’s known• Physical therapy is the primary treatment for

symptoms of vestibular loss and BPPV.

• Most clinical providers do not routinely screen

patients for vestibular impairment, leading to

under-diagnosis and low rates of referral for

vestibular rehabilitation.

• Untreated vestibular impairment significantly

increases fall risk and negatively impacts quality

of life.

• Vestibular impairment may be the underlying

cause of symptoms for up to 45% of people with

dizziness complaints.

What’s newFindings from this study of clinicians’ attitudes and

perspectives influencing under-diagnosis of

vestibular impairment indicate that:

• Clinicians frequently are not even aware of the

concept of vestibular rehabilitation.

• Commonly perceived barriers to identify and treat

vestibular impairment in patients consistently

included lack of knowledge and training,

perceived time constraints in clinic and difficulties

with dizzy patients giving vague descriptions of

their symptoms.

OR IG INAL PAPER

ª 2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 1604–16121604 doi: 10.1111/j.1742-1241.2009.02104.x

into remission 80–97% of the time with canalith

repositioning (12,15,18,19). Central nervous system

and vestibular plasticity underlie the rationale for

vestibular rehabilitation with complex sensorimotor

integrations within the many different pathways

within the brain. Neurophysiological mechanisms for

compensation after loss of vestibular function

include adjustment of gain of the vestibulo-ocular

reflex, use of other sensory inputs and motor

responses, and changes in the movement strategy

which occur (20).

Guidelines for diagnosis and treatment for VI may

seem straightforward, yet referral rates for vestibular

rehabilitation are low and patients sustain undue

delays in diagnosis and treatment. Several recom-

mendations provide guidance on the approach and

care of patients with VI (17,21–23). Common to

most of these recommendations is the need to obtain

a patient’s history of the dizziness describing the

duration, frequency and exacerbating factors. The

need to evaluate for nystagmus, cranial nerve abnor-

malities and vestibulopathy with head thrust and

Dix-Hallpike manoeuvres, and the advisement to

perform canalith repositioning and ⁄ or refer to a

physical therapist for vestibular rehabilitation are rec-

ommended.

The diagnosis of VI is very frequently missed

(1,2,4), and BPPV, the most common cause of ver-

tigo, is under-diagnosed (2) despite the fact that the

gold standard test for diagnosis, the Dix-Hallpike

manoeuvre (24,25) is easily performed during a rou-

tine office visit without the need of diagnostic equip-

ment. Similarly, vestibular loss may be identified

with no specialised equipment with a head thrust test

with 30–84% sensitivity and 82–100% specificity

depending upon the experience of the clinician (26).

Significant and unnecessary delays in treatment of

BPPV have been documented by our group (27) and

others (3). Studies have found that clinicians fre-

quently do not routinely screen for vestibular nerve

hypofunction (4), treatment is frequently unnecessar-

ily delayed (3,28) and diagnostic tests may be

obtained unnecessarily (1,27). Under-diagnosis of VI

may also contribute to why the average patient with

vestibular neuropathy is symptomatic for more than

a year before starting rehabilitation (28).

While these studies describe what providers do,

they do not reveal clinical providers’ perceptions of

challenges they confront when managing patients

with possible VI, which could underlie some of these

shortcomings in clinical practice. The aim of this

study was to use qualitative methods to examine cli-

nicians’ experiences, attitudes and perceptions

towards evaluating and managing patients complain-

ing of dizziness with possible VI. Subjects’ opinions

were also explored to elucidate providers’ perceived

barriers to implementing previously published prac-

tice recommendations. Reported practice behaviour

was compared with current recommendations to

identify ways to improve care through new

approaches or improved adherence to recommended

approaches.

Methods

SubjectsSubjects were randomly selected from clinical provid-

ers identified in a previous study by our group the

prior year (4), which studied clinical practice meth-

ods used by providers to screen for VI. To be

included in this study, all subjects had to be cur-

rently practicing clinicians within the Atlanta Veter-

ans Administration Medical Center or in an affiliated

clinic. Using convenience sampling technique, pro-

viders were contacted, whereby the study and inter-

view process were explained and their participation

was requested. If they agreed to participate, written

consent was obtained and a mutually acceptable time

to conduct the interview was scheduled. Subjects

were aged between 31 and 65 years, with the group

comprising five clinicians in primary care, two emer-

gency medicine physicians, four neurologists, three

otolaryngologists and four audiologists. The number

of years the clinicians had clinically practiced ranged

from 3 to 33 years. Additional information about the

subjects is provided in Table 1. Study approval was

obtained from the committees of Institutional

Review Board of Emory University, and Research

and Development at the Atlanta Veterans Adminis-

tration Medical Center.

Table 1 Characteristics of the interviewees providing

healthcare to dizzy patients

Characteristics n

Gender

Male 13

Female 5

Medical specialty

Primary care 5

Neurology 4

Audiology 4

Otolaryngology 3

Emergency medicine 2

Resident level physicians

Total 6

Primary Care 2

Neurology 2

Otolaryngology 2

Physicians with any prior residency training in otoneurology 4

Challenges of vestibular disorders 1605

ª 2009 Blackwell Publishing Ltd Int J Clin Pract, November 2009, 63, 11, 1604–1612

Data collection and analysisA qualitative research design was used to obtain

in-depth information about provider perceptions of

appropriate identification and management practices

for patients with possible VI as well as barriers per-

ceived in implementing previously published practice

recommendations. Data were collected using open-

ended, semi-structured one-on-one telephone inter-

views with clinical providers using an interview guide

containing open-ended questions to facilitate subjects

freely expressing their own experiences, opinions and

attitudes. Interview topics discussed included care

experiences for dizzy patients with possible VI, how

and why clinical practice was conducted, advice

offered, their perception of patients with VI and per-

ceived barriers and facilitators for clinical practice

according to published guidelines. The interviewer

also asked about new ways to improve treatment of

patients with VI or probed for how clinical practice

barriers could be addressed or overcome.

All interviews were audiotaped with the aid of a

digital voice recorder and subsequently transcribed

into text-formatted documents to facilitate compre-

hensive thematic data analysis. Interview analysis

employed grounded theory methodology (29), in that

each interview was analysed prior to conducting sub-

sequent interviews. Concepts and ideas from analysis

of earlier interviews were brought to later interviews

for comment and clarification, and as each additional

interview was analysed, data were compared from pre-

vious interviews in a cumulative process allowing for

development of a more valid understanding of the

subject’s perspective. Recurring themes discovered in

the interviews were compared and coded, and then

organised to compare content until a coherent con-

ceptual framework was developed.

Results

The clinical providers’ descriptions of their experiences,

opinions and attitudes regarding providing healthcare

for patients with possible VI formed four broad catego-

ries: clinical encounters with dizzy patients with possi-

ble VI, experience caring for patients with possible VI,

barriers to provide care according to published guide-

lines and suggestions for improvement. Representative

quotations from the interviews are provided.

Clinical encounters with dizzy patientswith possible vestibular impairment

Evaluation methods at the bedsideThe providers described their experiences in obtain-

ing clinical histories in patients complaining of dizzi-

ness, with several citing the importance of obtaining

a good description of the symptoms as illustrated by

the following quote: ‘The first thing I will try to do

when it comes to the initial history is find out what

they are calling dizziness and to actually characterise

the symptom. Many times dizziness is unstableness

or a linear feeling or a spinning sensation. It can

even be passing out or light-headedness so I try to

hone in on exactly what the patient is talking about

when he says dizziness’.

Several providers stressed the importance of

obtaining historical information about the temporal

nature of the dizziness or information about associ-

ated factors. This is illustrated in this quote: ‘I’d

obtain history about duration of symptoms, fre-

quency, whether they were constant or intermittent,

how long they lasted at a time, or if there were any

factors or positions that provoked the symptoms. I

would want to know if there was any preceding

trauma, any prior history of vertigo, any history of

antibiotics use, or any history of alcoholism’.

Informants described few bedside evaluation meth-

ods except looking for nystagmus or occasionally

performing a Dix-Hallpike manoeuvre. Providers

described honing in on various parts of the neuro-

logical examination, but communicated that they did

not know as many bedside tests for elucidating VI:

‘Nystagmus would be something I would look for. I

would look in the ear itself to see if there’s anything

there. If I thought it was benign positional vertigo,

there’s the Dix-Hallpike maneuver…I think, but I

would have to check that, since I have not performed

that test in a few years. In general I would be looking

for other cranial nerve abnormalities or other neuro-

logic deficits, but I’m not familiar with any other bed-

side tests for looking for vestibular impairment. I

know you can dim the lights and that’s a way to bring

out the nystagmus, I think. I have no recollection of

being taught how to do head thrust’.

Other clinicians examine the ears, nose and throat

in an effort to uncover Eustachian tube dysfunction

which could be underlying the dizziness as illustrated

by the following quotation: ‘I would start looking at

their ears and throat and feel around. I’d look at the

membranes to see if they were retracted, bubbles

behind them or whatever’.

Clinicians who had received training in residency

from an otoneurologist described different examina-

tion methods when confronting the patient with possi-

ble VI as illustrated by a quote from one neurologist:

‘I’d look at their tympanic membranes, I’d do a com-

plete cranial nerve examination, and I’d look at vestib-

ular-ocular reflexes with a head thrust maneuver. I

might do a Fukuda stepping test, and then I’d evaluate

1606 Challenges of vestibular disorders


their gait both routine and tandem. I’d do a Dix-

Hallpike maneuver and then I’d test their hearing’.

Diagnostic testsEvaluation frequently employed ordering a wide vari-

ety of diagnostic tests when assessing a dizzy patient

with possible VI.

‘I’d likely order an EKG1, non-contrast CT2, occa-

sionally a Holter monitor, the rest are referrals.’

‘I order my basic stuff: CBC3, urinalysis, and

maybe also a blood screen. If something a little bit

more complex is involved, then maybe I’d need a

head CT, then I might order an MRI4.’

Others described ordering fewer tests in favour of

making referral to a vestibular specialist as illustrated

in the following quote of one clinician: ‘I refer

patients to vestibular experts but I don’t usually

order any specific vestibular testing myself’.

TreatmentsMost clinicians were not aware of vestibular rehabili-

tation for vestibular nerve hypofunction unless they

had spent time in training with an otoneurologist.

Although several were familiar with canalith reposi-

tioning for BPPV, providers described less experience

actually performing the manoeuvres themselves or

having a good understanding of the indications for

the treatment.

‘I have done canalith repositioning, but I don’t

feel comfortable that I’m necessarily doing it very

well, and I usually have to pull out a little diagram

to make sure I’m doing it right.’

When asked what treatments they employed to

treat dizziness, providers cited medication or expec-

tant management, even with management of BPPV.

‘If I can elicit symptoms with a Dix-Hallpike

maneuver then I may give them a trial course of

meclizine; that’s usually if the patient is throwing

up. I might say that this will probably get better

over time, or to make sure you change positions

slowly.’

‘At times I’ve used valium. I think that medicine

is given to be able to give something. It is somewhat

helpful; most of treatment is a matter of waiting,

especially in benign positional vertigo; you wait until

it runs it course.’

Referring practicesSeveral providers were aware of a subspecialty clinic

where patients could be seen by a physician for ves-

tibular disorders, although many were not aware that

physical therapists treated patients with VI. Providers

discussed that they did not always refer dizzy

patients in the same way, depending upon whether

or not the patient could be potentially better evalu-

ated by either an otolaryngologist or a neurologist,

for example.

‘I do make a distinction to refer to neurology or

ENT based on if you have neurological symptoms

accompanying it, speech difficulties, or if you have

problems with vision, say double vision, I would

refer to a neurologist versus if you have just dizziness

with some nystagmus, I would just refer to ENT

dizzy clinic. I have never referred one for physical

therapy.’

Others explained that they would either try expec-

tant management or medication such as meclizine

first, and only if symptoms persisted would they refer

to a specialist. Another physician expressed that con-

cern specialists were underutilised:

‘Most of the time I’ve made a diagnosis and I

don’t think physical therapy treats that, and I think

probably not enough of them get referred for vestib-

ular testing and to a subspecialist.’

Experience caring for patients with possiblevestibular impairment

Comfort level in making diagnosis and treatingSome clinicians complained of having a lack of con-

fidence in the evaluation of a patient with possible

VI, although others described being comfortable

treating these patients knowing they could potentially

refer to a vestibular specialist in the facility if neces-

sary. One clinician voiced discomfort when evaluat-

ing dizzy patients in the following way:

‘Actually I don’t feel comfortable usually seeing

the (dizzy) patients. One of the things that always

bothers me is that I do not maybe trust my bedside

exam as much as I would like. For instance, blocking

fixation is always an issue because I don’t use goggles

or other things to do that. I don’t have Frenzel lenses

to look at the patients.’

Several clinicians felt uncomfortable evaluating

patients with possible VI because of the perception

that the differential diagnosis was ‘vast’. Others

described discomfort in approaching patients

with possible VI because of perceived ambiguity

arriving at a diagnosis as reflected in the following

quotation:

‘I don’t think I ever felt perfectly comfortable,

mostly because I never had in my head a clear algo-

rithm for the differential – ways to differentiate

between the possibilities on the differential –

whether it’s the physical exam, laboratory or imag-

ing. And then treatment. At this point I would

1EKG = electrocardiogram.2CT = computed tomographical scan.3CBC = complete blood count.4MRI = magnetic resonance imaging.



dislike managing these patients because I don’t feel

comfortable.’

Ways clinicians learned about vestibulardisordersA variety of experiences was shared by clinicians as

to how they had learned about vestibular disorders

and dizzy patients in general. Some recalled memo-

ries in their training more vividly than others. Others

cited books, articles, personal experience, being

taught on the job, or learning it all with ‘trial and

fire’. Several recounted that they received very little

memorable formal training in the area:

‘I think that I did some reading and I think prob-

ably many years ago I went to a course or two with

the academy on how the vestibular system works. I

learned very little in training.’

‘I can vividly remember an attending showing me

that maneuver. I was a primary care internal medi-

cine resident at the time. But that was the one time

and clearly it didn’t stick with me.’

Knowledge of published recommendationsin approaching dizzy patientsSome clinicians were familiar with landmark publica-

tions regarding caring for patients with different ves-

tibular disorders, although most participants

reported minimal knowledge about publications in

this area. Some subjects believed that they may have

read published recommendations at some time, but

could not recall the information. Along these lines,

one physician said, ‘I probably have come across

some guidelines buried in the blizzard. There’s only

so much you can keep up with’.

Barriers to providing care according topublished recommendationsItems which were perceived as barriers to providing

care to dizzy patients with possible VI according to

published guidelines primarily included lack of edu-

cation or knowledge, lack of exposure to dizzy

patients, general dislike for dizzy patients and time

constraints in clinic. The providers described their

experiences in obtaining clinical histories in patients

complaining of dizziness and several complained of

the vagueness in symptom descriptions given by

patients.

Lack of knowledge and ⁄ or educationAccording to the informants, one difficulty which

was perceived as a major barrier to providing care

according to recommended practice was lacking

knowledge about VI. Informants relayed perceptions

that they had not received adequate training in med-

ical school or residency, which adequately prepared

them for approaching dizzy patients, evaluating for

VI or managing patients with VI. Informants felt that

in general the area was not taught well in training as

illustrated in the following quotation: ‘There are not

many people out there teaching it (management of

patients with vestibular disorders) and it is not

taught very well at least in the places I have encoun-

tered teaching’. One informant cited a connection

between clinicians’ lack of knowledge and their lack

of interest in the following way: ‘I think there is a lot

of ignorance to explain why neurologists are less

interested in managing dizzy patients’. Still another

physician expressed an urgent need for educating the

basics of evaluating a patient with VI by stating the

following:

‘When I give oral practice boards to the neurology

residents I commonly ask them a question about a

patient comes to your emergency room with a

4-hour history of severe imbalance and when you

stand the patient up he falls to the left and has nys-

tagmus to the left. If the patient falls to the left and

has nystagmus mostly to the right where is the

lesion, and they say ‘What?’ So I get the feeling that

even here, some proselytizing is needed’.

Like or dislike of dizzy patientsProviders described experiences of being less inter-

ested about caring for dizzy patients in part, because

the patients frequently had trouble describing their

symptoms clearly.

‘You put up with a heck of a lot of vague unstead-

iness ⁄ dizziness types of complaints and very episodic

things. I do not like dizzy patients. Obviously the

person I can like a lot, but I do not like the present-

ing complaint. I have a bias against it; I will fully

admit to that.’

One provider communicated that the problem of

patients giving vague descriptions of their symptoms

influenced providers’ lack of interest in learning

about VI: ‘I think there is just a gut instinct when

you hear that a patient is dizzy. The symptoms are

so vague. They give you this diagnosis that nobody

wants to deal with, and because of that no one really

wants to learn about it’.

The negative perception of the differential diagno-

sis for dizziness being too expansive also influenced

providers’ reasons for disliking the experience of

evaluating patients. Others expressed concerns that

dizzy patients were complicated and were less enjoy-

able to evaluate in part, because the patients were

frustrated as a group because of the need to see

many physicians for their complaint:

‘Some of the dizzy patients are difficult because

some of them are very complicated, they have a little

diabetes, they are taking various medicines, they have



no earthly clue how to describe what is happening to

them so it takes forever to tease out what might be

orthostasis, what might be drugs, or what might be

in their vestibular system. It takes spending a lot of

time with frustrated people. I enjoy taking care of

them less than some other patients because they are

time consuming, and I would assume there is a vast

differential and it is frustrating. Oftentimes they have

seen multiple physicians along the way.’

Time constraintsProviders also voiced concerns about encountering

time constraints when evaluating a dizzy patient with

possible VI. A variety of opinions were expressed

recounting how patients with dizziness could be

more time-consuming and how other clinical duties

or more pressing patient complaints could compete

for the clinician’s attention. Physicians recounted

about how busy their schedules were and that the

time perceived to care for a dizzy patient may not be

reimbursed as well by third-party payers. One physi-

cian also expressed a complaint about BPPV patients

as a group taking more time in the clinical setting:

‘It takes time to deal with 40–50 patients, time to do

a Dix-Hallpike, and to do all these techniques. It is

time consuming especially if I diagnose BPPV, I’ve

got to treat it too’.

Other barriers to providing optimal care topatients with possible vestibular impairmentProviders’ concerns about challenges in providing

care to patients with possible VI were varied and

complex, ranging from concerns about the complexi-

ties of interpreting physical examination findings and

initiating effective treatment, to lacking diagnostic

equipment to problems communicating between

medical specialties among other issues. In this

respect, one physician said the following:

‘I think it’s a complicated area. It is not just learn-

ing the neuroanatomy. I think it is a little bit intimi-

dating for people to remember, ‘Ok, if it is a

nystagmus that’s this way, then it’s central, versus

that way, then it is peripheral. But then also knowing

there are exceptions to every rule, and I think most

people feel like they just want to kind of throw some

medication at it to see if they get better, but I think

there is also a limited amount that we can do at the

bedside. We don’t have the opportunity to test peo-

ple in chairs and spin them around and stuff.’

Suggestions for improvement

Attitudes about further educationVarying levels of interest in learning more about

evaluation and management of patients with possible

VI were expressed by providers. Some expressed a

desire to learn more because they encountered dizzy

patients often. Others were interested in learning

more information because they already had received

some information that interested them, as illustrated

in the following quotation from one provider: ‘I’m

learning that there are maneuvers that I had never

heard of. I think it would be very interesting to

know what those are. I think once you feel more

confident with the problem you then listen to

patients more carefully’.

Others expressed doubts how further education

would actually influence clinical practice. This per-

ception was influenced by providers already having a

routine as to how they referred their patients with

possible VI to specialists:

‘Further education probably is not going to change

too much what I do, but it may cut out maybe one

or two referrals. I don’t know that it would change

anything other than my level of confidence taking

care of dizzy patient.’

Suggestions for continuing educationSuggested formats for platforms to provide educa-

tional material were quite varied amongst the partici-

pants. Some believed that didactic instruction with

hands-on learning methods were most appealing,

while others expressed interest in the convenience of

using online learning modules. Computer-assisted

methods seemed the most feasible for several provid-

ers who expressed their concerns about not having

enough time to pursue learning in this area. Con-

trasting viewpoints pertaining to the preferences for

educational platform formats are illustrated by quo-

tations from the following two providers:

‘My preference would be if somebody were to

come up with a PowerPoint or some sort of video

production that could be accessible online or if we

were able to access it on one of our two educational

mornings a month where we get an hour of CME.’

This is one of those things with some of these

maneuvers that it would really help to perform them

on your fellow residents then be able to translate that

to patients. ‘See one, do one, teach one.’

Discussion

Subjects in this study were selected from clinical pro-

viders identified in a previous study by our group

(4), which found that dizzy patients were not rou-

tinely screened for VI based on available recom-

mended practices. Use of qualitative data in this

study obtained from some of the same providers in

the previous quantitative investigation allows trian-

gulation of results and hence, lends some insight into



why some providers may fall short of recommended

practices for screening patients for VI.

Perceptions of challenges encounteredby providersThe findings of this study enrich the understanding

of the challenges encountered by clinicians when

evaluating and managing dizzy patients with possible

VI. An assortment of factors and constraints are

faced by clinicians that hinder diagnosis of vestibular

disorders, which in turn influences how many

patients with VI are referred for treatment with

physical therapy. The providers discussed deficits in

their training about vestibular disorders, with some

providers voicing desires to learn more about the

care of patients with vestibular disease. The lack of

training contributed to clinicians secondarily express-

ing concerns about lack of confidence in caring for

patients with possible VI and resultant frustration.

Without prior training in the appropriate care for

patients with vestibular disease, providers are not

familiar with bedside tests for VI which makes it dif-

ficult to pare down a differential diagnosis. For

some, this contributes to making the evaluation of

dizzy patients less satisfying with the impression that

the evaluation is more like that of a fishing

expedition.

Lack of awareness of treatment options for VI neg-

atively influences rates of referral for vestibular reha-

bilitation. Most clinicians interviewed were not aware

of the role of vestibular rehabilitation in the treat-

ment of symptoms of vestibulopathy. Others com-

municated that they were aware of canalith

repositioning or other forms of vestibular therapy,

but expressed uncertainty about its benefits. Still oth-

ers endorsed trials with medication, such as mecli-

zine, as first-line treatment options for patients with

possible VI.

What remains unclear is why clinicians have not

identified their own lack of understanding in this

area of patient care, particularly as it may create lack

of confidence in patient care abilities or even frustra-

tion in medical practice. The pursuits of self-directed

lifelong learning, ongoing certification, medical

relicensure and the like are heavily dependent on the

ability of physicians to determine their own learning

needs and to find resources to meet them. Unfortu-

nately, studies indicate that physicians have a limited

ability to accurately self-assess medical competence

(30), which may be even more of an issue when care

of vestibular patients may not be emphasised in

training, thereby seemingly underscoring its lack of

importance.

A perception found among providers was the

belief that the evaluation of patients for vestibular

abnormalities takes more time than that available in

a typical outpatient setting, either related to the

problem that patients frequently could not describe

their symptoms quickly and clearly or being related

to the provider’s inexperience in gathering pertinent

historical information expeditiously. Although taking

a careful history is important and takes time, provid-

ers can be educated how to retrieve useful informa-

tion expeditiously in evaluating dizzy patients. For

example, one strategy could be to employ a question-

naire asking about symptom details, which the

patient fills out before his appointment. Answers on

the questionnaire could serve as a guide for the clini-

cian during the clinical encounter. Although not

practical for all patients, use of such a questionnaire

can oftentimes be useful not only in reducing time

in obtaining a history, but also in providing a writ-

ten confirmation of the patient’s description of the

dizziness. Patients can identify which descriptors

apply to their dizziness symptoms such as ‘spinning

sensation’, ‘light-headedness’ or ‘giddiness’. This is

particularly helpful when trying to gain historical

information that might otherwise be described in

vague terms.

Subjects provided valuable commentary regarding

other miscellaneous factors perceived as additional

barriers to providing care to patients with possible

VI. Some expressed concerns about how disorders of

the vestibular system can cross medical subspecialties

which otherwise might not frequently communicate

with one another, most commonly neurology and

otolaryngology. This can be a practical concern in

matters of patient referrals, when a primary care pro-

vider may not know which medical subspecialty in a

facility typically evaluates vestibular problems. In

addition, not all towns or facilities have vestibular

specialists, which emphasises the need for non-

specialists to familiarise themselves with some basics

of caring for patients with these common and quite

treatable disorders.

Study limitationsAlthough chosen to capture a range of experiences, a

limitation of this study was that it was based on the

interpretations of a convenience sample of clinicians

working in a practice area of one facility and affili-

ated clinics in a single metropolitan area; results

therefore may not be generalisable to all types of cli-

nicians in other areas or work environments.

Another limitation was the need to conduct inter-

views by telephone rather than in person. In doing

so, this limited the researcher from potentially gain-

ing observational data pertaining to gestures and

body language, which might have otherwise resulted

in a deeper insight into the experiences and attitudes



of the clinicians. Nonetheless, findings from these

interviews identified gaps in training, which should

be addressed and new directions that could be imple-

mented to educate providers caring for patients with

possible VI.

Attitudes towards further educationAlthough several providers expressed interest in

learning more about diagnosis and management of

VI, whether an educational intervention would suc-

cessfully translate to a change in practice behaviour

is unknown. Results from studies investigating effec-

tiveness of education in changing physician perfor-

mance are not very encouraging with findings that

the distributions of clinical practice guidelines are

some of the least effective techniques of continuing

medical education (31). Similarly, continuing medi-

cal education delivery methods such as conferences

have little impact on improving professional practice

(32). Interactive workshops can result in moderately

large changes in professional practice, however (32),

and audit and feedback have also been shown to be

moderately effective (33). Qualitative assessments of

clinicians’ perceptions of barriers to practice accord-

ing to guidelines provide valuable information

towards designing an effective educational interven-

tion, particularly as studies indicate that the effective-

ness of some interventions depends to a large degree

on the particular perceived barriers to change (34).

In conclusion, the complexity of difficulties

encountered by clinicians in diagnosing and manag-

ing patients with vestibular disorders highlights sev-

eral potential challenges to making changes in

clinical practice. The subjects’ experiences show that

caring for a dizzy patient with a possible vestibular

abnormality oftentimes is perceived as a complicated

issue and encompasses more than what would other-

wise be documented in a patient’s record. Awareness

of the role of vestibular rehabilitation needs effective

promoting, as rehabilitation professionals at this time

are as a whole being underutilised as sources for

treatment. These results indicate that one challenge

will be in making information about care for VI

patients readily available, simple to digest and clearly

relevant to clinicians. Overall, these results emphasise

the importance of the numerous barriers perceived

by clinicians to provide healthcare to patients with

possible VI, which potentially could be diminished

by enhancing communication amongst providers

within and between healthcare facilities as well as by

targeting educational efforts. If some of these barriers

could be overcome, patients would likely not only

reap greater therapeutic benefits, but also health care

costs for unnecessary physician hours and diagnostic

tests could be reduced.

Acknowledgements

This work was supported by Veterans Administration

Rehabilitation Research and Development RCD

#C3975V (SHP, RJT and CES). We thank Robert

Welch for his assistance in interviews and data analy-

sis. The authors were solely responsible for the study

protocol design, data analysis, data interpretation

and prepared the manuscript independently of the

funding source.

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Paper received February 2009, accepted March 2009



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