Physical therapists at Cabell Huntington Hospital have branched into vestibular therapy.

It is not unusual for physical therapists (PTs) to develop niche practices to help patients with very particular needs. Cabell Huntington Hospital’s Outpatient Rehabilitation and Balance Center has been helping patients with balance disorders caused by diseases and/or damage to the vestibular nerve since summer 2003.

The center is the brainchild of B. Joseph Touma, MD, an ear, nose, and throat (ENT) specialist, who, after finishing his medical training at the University of Pittsburgh Medical Center, Pittsburgh, approached several hospitals in the environs of Huntington, WV, with the idea of offering vestibular rehab. When the administration of Cabell Huntington Hospital heard Touma’s idea, it immediately began to take steps to implement it. “There was a need,” says Jeff Ashton, one of the five PTs who works at the satellite center. “There is a large number of ENT patients in town,” he says.

Today, the 4,000-square-foot facility, which is in the basement of the building where Touma and his father, Joseph, provide ENT treatments, sees between 35 and 55 patients daily. Many of them are referrals from Touma’s practice—B. Joseph is the medical director of the balance center—but they are also referred from the other ENT group in town.

The treatment, like all rehab, is individualized. “A large part of what we do depends on the patient,” Ashton says. “There are several different pathologies we have to address.” These pathologies range from the congenital—such as Menniere’s disease—to the viral.

Treating Dizziness

Though specific treatments change from patient to patient, the process by which the PTs at the balance center receive and evaluate the patient is the same.

Typically, the patient reaches Touma’s office through a referral from a general practitioner. Touma follows a medical approach with the patient. For instance, if the patient is suffering from a viral infection that is affecting the vestibular nerve, he will treat it with medication. If the infection has passed and the patient has not recovered and is experiencing dizziness, then Touma will refer the patient to the balance center.

The PTs, using specialized equipment to evaluate ocular motor response, moving in different planes, and bending over, then develop a set of repetitive exercises that allow the central nervous system to recover. Ashton describes the therapy as “very movement based.”

And it is deceptively simple, sometimes as simple as teaching the patient how to reposition his or her head to allow the dizziness and other symptoms associated with damage to the vestibular nerve to pass and regain his or her balance. It is the ability to work with patients one on one that is the added value the PTs bring to the ENT environment. “ENTs don’t have time to take patients through this process,” Ashton says. “For them, it’s mostly medicine and surgery.”

The PTs also bring something else to the table, adds Damian Southard, PT. “We have the ability to treat the entire individual,” he says. “We take into account [other] factors such as the muscles and posture.”

This whole-body approach is critical, because the PTs are treating primarily elderly patients who have seen more than their balance affected by the damage to their vestibular nerve.

Older Demographic

Though Ashton and Southard see patients from across the demographic spectrum, the majority of their patients are older.

This is because in younger or more active patients, the effects of a viral infection often resolve on their own. In older patients, because they are afraid of falling, they stop moving and affect robotic-like movements to protect themselves. Over a long period of time, these patients will begin to lose muscle strength while remaining constantly dizzy and off-balance.

This is where the whole-person approach comes into play. In addition to vestibular-evaluation equipment, the center functions as a typical rehab facility with cardiovascular-exercise equipment, treadmills, stationary bicycles, weight machines, and free weights.

The equipment helps patients improve their strength and balance quickly, but there is more to vestibular therapy than working with the therapist. As Southard learned during the center’s early days, what a patient did or did not do at home was as important as the office visit.

This particular patient was older and resistant to coming into the office. But when he did come in and do his exercises, he improved both physically and psychologically. When the patient returned for his next visit, he was again resistant and had deteriorated physically. Southard discovered that the patient did not continue his therapy at home, so any gains he made at the center were negated. “You have to do it daily, and not have a ‘doctor mentality’ [that is, a mentality that treatment is just for the office],” Southard says. “You have to treat it as a life-changing activity and do it every single day. That’s why people come back to us—they don’t stick with their program.”

Ashton says that compliance, in general, is very high because the patient sees the benefits of the therapy. “If the patient didn’t have vestibular rehabilitation, they would have to learn to live with the dizziness because medications and surgery does not make it better,” he says. “There’s no other direction [except rehab] for them to turn to.”

In addition to the gym area, the center also boasts several mat tables, a mini-trampoline with a bar hanging from it to aid in balance exercises, a rebounder, three treatment tables, a traction room, and a room housing the vestibular-evaluation system.

The staff consists of five PTs and one physical-therapy assistant. Each therapist works four 10-hour days. On a recent day, Ashton says that two therapists and the assistant were on duty, and they had 33 patient visits. This makes for a busy office, but “we’re not individually overwhelmed,” Ashton says.

With 3 years of experience in providing vestibular therapy under their belts, Ashton and Southard are knowledgeable and confident in their ability to provide the best treatment to their patients. This was not always the case. 

Building confidence

By their own admission, the biggest challenge facing Ashton, Southard, and the other therapists at the center was their lack of knowledge about vestibular therapy. “In the beginning, there was a learning curve,” Ashton says. “We didn’t have a lot of confidence in ourselves. We were a little intimidated by what we needed to do.”

The hospital assisted their therapists by providing training to the therapy staff. “We’re very fortunate that we work for a hospital that’s very supportive,” Ashton says.

Ashton adds that though the early days were a little rocky from an effectiveness perspective, the therapy was useful to patients—and certainly no one was harmed by the staff’s inexperience in this area.

The more confident Ashton of today says that, “Once you know how the [vestibular] system works, treatment is fairly simple.” From this understanding of the system comes knowledge of the pathologies that can affect it and the strategies that can be used to address this problem.

The benefits to the Huntington-area vestibular patients are underscored by the benefits the center has derived working with Touma and the other ENTs in the area.

Win-Win

The reason for the success is simple. “It’s a symbiotic relationship,” Ashton says. “It has benefited the department greatly and has increased our referrals. There’s competency on both sides—the ENT and the rehab.”

Southard says that this competency is reflected in how the ENT group treats the PTs. “It’s unique,” he says. “Many times they call and consult about a patient with us, and [vice versa].”

The key to the business relationship hinges on the personal relationship that the PTs have with Touma. “Dr Touma is a nice guy, and there’s mutual respect between us,” Ashton says.

This respect is reflected in the good communication the two groups have with each other. Touma is available via phone, pager, and face-to-face contact throughout the day.

And being in the same building is helpful as well. “I think it’s fantastic to have the ENT practice upstairs,” Southard says.

Ashton says that in those rare instances when Touma is needed immediately, the therapists can go upstairs and catch him between cases. And this access goes both ways. There are times when Touma will send a patient to the clinic to get evaluated on the various vestibular systems—whether or not he intends to send that patient on to therapy.

The therapists and Touma built their relationship early in the center’s existence. They traveled together to the site of the provider of the vestibular equipment to learn how to use it.

There is no question that the relationship between the center and the Touma clinic is a strong one. Ashton says that the biggest misconception people have is that the center is part of the ENT’s practice.

Taboo

Though there is an evident business and professional relationship between the Touma clinic and the Outpatient Rehabilitation and Balance Center, patients are not automatically channeled to the hospital PTs.

Patients come to the center via referral from either the Touma group or the other ENT practice in Huntington. But the center is not the only option open to them.

Before the center opened its doors, there was a PT in private practice who offered vestibular therapy. She left town shortly after the younger Touma returned from school, but has recently returned to Huntington and has begun offering vestibular therapy again. “She provides therapy on a small scale in terms of the equipment she uses,” Ashton says. But patients are free to go to her or to any other therapists with whom they feel comfortable. In some cases, it is simply a matter of geography. There may be a therapist much closer to the patient’s home, making it both more convenient and conducive for treatment. “Dr Touma does not say that you must go to the therapists downstairs,” Ashton says.

And even if he did, the physical therapist sees ethical problems with this sort of arrangement. Under the federal Stark rules (and their more strict state versions), it is illegal for physicians to self-refer to entities in which they have a stake. This is not the case in the situation under which Ashton works, but an exclusive referral leaves a bad taste in his and Southard’s mouths. “I think the treatment is important,” Southard says. “I think it’s important you look at what’s best for the patient.”

Vestibular therapy has proven to be a win-win proposition for the therapists at Cabell Huntington Hospital and the ENTs at the two practices in town. And just because it is offered by a hospital with the resources to outfit a center does not mean that vestibular therapy is out of reach for therapists in private practice.

Setting up Shop

Like any business decision, pursuing vestibular therapy should reflect the market’s needs. If a patient market is not adequately served, then it might make sense to add it to the therapy menu. “You don’t need to spend lots of money to offer vestibular therapy,” Ashton says.

Southard echoes Ashton. “Any time you can get a niche market and offer something in the community that is not being provided, [you will capture business] and build respect for your practice,” he says.

As the Huntington center shows, the “therapy” side of vestibular therapy can be provided with simple one-on-one instruction and standard therapy gym equipment. Much of its effectiveness comes from the therapist’s knowledge base, not from the high-priced equipment.

The ENT–PT alliance that has been forged in Huntington does not fall into the typical specialty physician-therapist model, but it is a reflection of the realities of medicine and the world of business. “No matter what it is that you do, one thing you have to remember: Things are always changing, and you must be willing to change,” Southard says.

C.A. Wolski is a contributing writer for Physical Therapy Products.