Adult balance services

In 80% of people with vertigo, symptoms result in a medical consultation, interruption of daily activities or sick leave. Dizziness in older people is associated with multiple predisposing risk factors and this population typically have more than one type of dizziness and are more likely to have cardiovascular and cerebrovascular disease. NICE has produced guidelines for the assessment and prevention of falls in older people. Accurate diagnosis allows both appropriate treatment and early recognition of life-threatening disease. The Department of Health has produced quality standards for people with long-term conditions. Conditions range from the common benign paroxysmal positional vertigo (BPPV) and migraine-associated vertigo through to complex neurological problems and systemic disease such as diabetes, autoimmune disorders, syndromic disorders and vascular disease.

A primary care workforce aware of, and alert to, balance and dizziness problems, and able to recognise the positive potential to improve patients’ symptoms and experiences with treatment and rehabilitation, is key in the provision of an effective balance service network.

Service delivery: These services provide appropriate care for balance disorders with a whole system approach to allow diagnosis of both otological conditions and systemic or neurological disease with balance manifestations. These are secondary or tertiary level services and to ensure high-quality person-centred care, these services are best delivered as a one-stop clinic providing a clinical vestibular assessment, investigations, diagnosis and management plan. GPs can refer directly to balance services but many referrals come from secondary or tertiary level such as ENT specialists, neurologists, geriatricians and audiovestibular physicians). Clear guidelines (opens PDF, 270KB) and criteria for referral enable seamless and rapid referral to specialist teams and centres for people with serious life-threatening or chronic, disabling conditions.

Requirements for service: The majority of patients with balance symptoms can be assessed and managed in primary and community care settings. This local service should at a minimum include a doctor, audiologist and physiotherapist, who are all trained and skilled in balance. The facilities and equipment required for the local balance service are specified in BAAP’s clinical standards (opens PDF, 199KB).

Patients with complex balance problems who cannot be diagnosed or managed in the local balance service and require specialist care, should be seen in a specialist balance centre with more medical specialties available and a wider range of diagnostic facilities. This service is best provided as a one-stop clinic providing a clinical vestibular assessment, investigations, diagnosis and management plan.

Patients with very complex balance disorders should be referred to tertiary centres, with supra-specialist interest and skills staffed by both clinical and academic consultant audiovestibular physicians, otorhinolaryngologists, neurologists, audiologists, psychiatrists/psychologists and physiotherapists. Specialist surgery, eg skull base surgery and cochlear implantation, may be undertaken in these centres. These regional and/or university centres have state-of-the-art facilities and are academic centres taking the lead in teaching and research. The facilities and equipment available includes a full range of visual, vestibular, balance and audiometric equipment to allow assessment of the labyrinth, eighth cranial nerve and central vestibular connections and interactions and evaluation of rehabilitative strategies and outcomes.

Workforce requirements: The provision of an effective, efficient balance service network relies on an integrated, seamless multidisciplinary team. A multidisciplinary team at a specialist centre normally includes audiovestibular physicians, audiologists, physiotherapists, psychologists, ENT specialists, neurologists and psychiatrists. A network approach enables optimal use of healthcare professionals and resources, and provides effective services to meet patient needs. The precise arrangement of the different levels of care and the professionals involved within the network should be flexible and managed according to local resources. Any professional such as a nurse, physiotherapist, occupational therapist or audiologist, who is implementing a vestibular rehabilitation programme requires specialist training.