Balance Matters: A neuro physical therapist’s journey to make “Sense” of Balance

Are you adding vestibular rehab to your telehealth sessions? 
We have the honor to learn from a pioneer in telehealth rehab, Sarah Gallagher, PT, DPT, NCS, the owner of South Valley Physical Therapy, the founder of the Dizzy Clinic and founder and chair of the Vestibular SIG Telehealth Task Force.

This interview was recorded a year ago prior to the pandemic when telehealth was not widespread.  COVID-19 has quickly changed the landscape of telehealth.  This interview is still extremely relevant as more clinics are transitioning to hybrid models and telehealth. This interview we mainly discuss the clinical applications regarding assessment and treatment during telehealth sessions? Tips on verbal instructions, observation skills and screening tools are discussed.

Before you begin providing services via telehealth or using telecommunications modalities, consider federal and state legislation and regulations that govern your practice, billing and coding issues.  Please check the APTA’s website with up to date info on telehealth resources and tips.

https://www.apta.org/your-practice/practice-models-and-settings/telehealth-practice

Dr. Sarah Gallagher PT, DPT, NCS graduated with her doctorate from MGH Institute of Health Professions in Boston, MA and completed an internship at Massachusetts General Hospital in acute care. After working several years in hospital settings, focusing in trauma, she transitioned to an outpatient setting.  South Valley Physical Therapy specializes in neurologic and vestibular rehabilitation and as an owner she collaborates with regional and national experts to ensure the evidence based and cutting-edge treatment. Dr. Gallagher identified that access to expert vestibular rehab is limited due to limited expertise in the state of Colorado, long travel distances, and dizziness impeding commuting to the clinic.  This problem led her to found The Dizzy Clinic which provides vestibular rehab via videoconferencing in 2017 as well as implemented tele rehab at South Valley PT for insurance reimbursement. She lectures at the University of Colorado PT school on vestibular rehabilitation and telehealth. She has presented at national conferences including CSM and several state APTA conferences on implementing tele rehab.  She also is the founder of the Colorado Vestibular Support Group, member of: APTA, Academy of Neurology and Vestibular SIG, Vestibular Disorders Association (VeDA). She participates in the APTA FiRST Council, Telehealth track, and is founder and chair of the Vestibular SIG Telehealth Task Force.  She authored an article for VeDA on telerehab with vestibular patients, published in January 2018. In 2020, she was awarded Colorado’s Outstanding PT of the year for her advocacy and training of telehealth.

References:

Turolla A, Rossettini G, Viceconti A, Palese A, Geri T. Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?. Phys Ther. 2020;100(8):1260-1264. doi:10.1093/ptj/pzaa093

van Vugt VA, van der Wouden JC, Essery R, et al. Internet based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice: three armed randomised controlled trial. BMJ. 2019;367:l5922. Published 2019 Nov 5. doi:10.1136/bmj.l5922

Tenforde AS, Hefner JE, Kodish-Wachs JE, Iaccarino MA, Paganoni S. Telehealth in Physical Medicine and Rehabilitation: A Narrative Review. PM R. 2017 May;9(5S):S51-S58. doi: 10.1016/j.pmrj.2017.02.013. PMID: 28527504.

“I think of optokinetics like I would think of a hammer.  A hammer can both drive a nail and pull it out. Optokinetics can push the vestibular system or it can make it challenging to use for your balance.” -Kenda Fuller

Kenda Fuller Bio:
Kenda Fuller, PT, was a pioneer in the practice of vestibular and balance rehabilitation in the 1980’s, certified by the American Board of Physical Therapy Specialists as a neurological specialist in 1990. She is responsible for the neurologic content in Pathology: Implications for Physical Therapists, Elsevier. She contributed to Umphred’s Neurological Rehabilitation by writing chapters on Balance and Vestibular Disorders.

Education has been a strong focus of her career as affiliate faculty at both University of Colorado and Regis University. She has provided extensive continuing education on balance dysfunction throughout the US. Invitations to give international lectures were associated with NeuroCom International, Inc which gave her access to interact with medical practitioners throughout the world.  She was instrumental in the development of testing and treatment software for the Proprio 5000, used to identify balance impairments and determine functional limitations. She created the Vestibular and Balance exercise program for Physiotools (https://www.physiotools.com), an electronic exercise product used worldwide.

As co-owner of South Valley Physical Therapy from 2002 to 2020, her independent practice has been focused on the care of patients with complex neurologic and orthopedic conditions causing imbalance. She understands the need to identify the impairments that lead to imbalance and determine best interventions to enhance functional status.

References:
Use of optokinetics based OKCSIB protocol in restoring mobility in primary progressive MS. 

Use of optokinetic chart stimulation to restore mobility and reduce ataxia in a patient with pseudo-Cushing ataxia. 

Repetitive optokinetic stimulation induces lasting recovery from visual neglect 

Randomized controlled trial on hemifield eye patching and optokinetic stimulation in acute spatial neglect. 

Combined Optokinetic Treatment and Vestibular Rehabilitation to Reduce Visually Induced Dizziness in a Professional Ice Hockey Player After Concussion: A Clinical Case.

Study of Optokinetic Stimuli as Treatment for Mal de Debarquement Syndrome. 

The effect of repeated exposure to visual motion stimuli on visual dependence in normal healthy subjects 

The Use of Optokinetic Stimulation in Vestibular Rehabilitation

The Effect of Optokinetic Stimulation on Perceptual and Postural Symptoms in Visual Vestibular Mismatch Patients. 

The Relationship between Saccades and Locomotion with Dr. Politzer

Dr. Politzer bio: 

Dr. Politzer is a leading optometric expert in diagnosing and treating vision problems in neurologic disease. For more than 38 years he has been caring for patients and presently staffs and runs his own private practice, Neuro-Sight Visioncare and vision clinics at multiple hospitals in Colorado and is also a consultant to many groups. He has had numerous presentations and publications on Neuro-Optometric Rehabilitation. He also has many inventions which include:

·The Vufine Visual Field Awareness System: a novel digital approach for enhancing visual field awareness after loss. 

·The Beam Splitter: a novel approach for enhancing visual field awareness after loss. A SONAR based approach to enhance awareness of visual field loss. 

·The Cyclo Prism for treatment of rotational strabismus following Cranial Nerve IV injury. 

·The Spot Patch, partial and selective occlusion for the treatment and management of double vision 

 Dr. Politzer said when he was teaching a course with a colleague a few years ago, he walked into Mayo hospital and he saw their moto which expresses his feeling  about health care.  "The Best interest of the Patient is the Only Interest". 

And I hope this is why everyone is listening today. To learn more for the interest of our patients or if you are a patient to learn and empower what you can do for yourself.

Resources:
If you want to watch eye movement videos about a wide range of problems and neurologic disease go to the, NOVEL, website.  https://novel.utah.edu
To view Shirley Wray's lecture   https://novel.utah.edu/Wray/ocular_motility.php. 

Other great resources on gaze training 

•Gunn SM, Lajoie K, Zebehazy KT, Strath RA, Neima DR, Marigold DS. Mobility-Related Gaze Training in Individuals With Glaucoma: A Proof-of-Concept Study. Transl Vis Sci Technol. 2019;8(5):23. Published 2019 Oct 9. doi:10.1167/tvst.8.5.23.

•  Lajoie K, Miller AB, Strath RA, Neima DR, Marigold DS. Glaucoma-related differences in gaze behavior when negotiating obstacles. Trans Vis Sci Tech. 2018;7:10