This is the first study investigating agreement between physiotherapists and ENT specialists in diagnosistic and management of patients within ENT primary contact physiotherapy-led vestibular clinic. Innovative allied health primary contact models of care are increasingly being utilised to improve patient access to timely and appropriate care. These models of care utilise experienced AHPs operating at full or advanced scope of practice to take on specific tasks usually performed by a medical specialist. For patients with vestibular dysfunction referred to ENT, physiotherapists are well positioned to provide initial contact. Physiotherapists working at full scope are responsible for diagnosing and providing treatment for specific vestibular disorders, arranging audiological assessment, identifing risk factors for conditions that require further medical investigation and management, and facilitating onward referral to other professionals for further intervention such as ENT, neurology, psychology, and general practitioner. This study found that physiotherapists who saw patients independently and in lieu of an ENT specialist made comparable decisions to an ENT specialist regarding diagnosis and onward management of vestibular disorders. This paper provides support for the competency of physiotherapists in managing patients referred to ENT with vestibular dysfunction and the safety of ENT primary contact physiotherapy-led vestibular clinics.
We found that physiotherapists and ENT agreement on categorised diagnosis was substantial. The primary contact physiotherapy-led initial appointment is extensive, including a comprehensive subjective history, objective outcome measures for balance and functional gait, vestibular assessment utilising video Frenzel goggles and video head impulse test, and same day audiology assessment including audiometry, tympanometry, outeracoustic emission and speech audiometry. An ENT initial appointment under the traditional medical model does not have the time or resources to complete such a comprehensive vestibular assessment. ENT would commonly refer to physiotherapy and audiology for such assessment to be completed after the ENT initial assessment, further delaying diagnosis and treatment. In addition to the shorter waiting times to attend the primary contact physiotherapy-led vestibular clinic, physiotherapy treatment commences immediately, further improving timely access to diagnosis and treatment.
Agreement between physiotherapy and ENT on requesting MRI brain and CT head were near perfect. Whilst there were several discrepancies in ordering an MRI brain there were no adverse MRI findings or outcomes where physiotherapy did not recommend MRI brain. One MRI brain requested by physiotherapy only, found an abnormality requiring neurosurgery monitoring. Repeat audiology testing finding deterioration in SNHL prompted an MRI brain highlighting the importance of audiology. Physiotherapy was more cautious in recommending CT head.
Agreement for onward management to ENT, neurology or physiotherapy was substantial to near perfect. There was variability in recommending ENT review however medical record review post study completion found physiotherapists recommendations for onward management to ENT was appropriate without adverse outcomes. Clear communication pathways are essential between physiotherapy and ENT to accomodate changes to onward management plans during physiotherapy monitoring and treatment. Case discussion with ENT should be routine when symptoms are not resolving with physiotherapy management, as ENT specialists are best placed to consider factors such as medical management for Meniere’s disease, and coexisting ENT conditions such as middle ear conditions. Agreement between physiotherapy and ENT for onward management to neurology was near perfect with physiotherapy recommending neurology review more frequently, resulting in important diagnostic findings and two required neurology reviews. Experienced physiotherapists are well positioned to identify subtle neurological deficits accounting for the bias to referring to neurology. Clear referreal pathways to neurology is recommended for an ENT primary contact physiotherapy model. Physiotherapists were more likely to recommend ongoing physiotherapy management compared to ENT. Physiotherapist’s and ENT’s bring different perspectives to the assessment accounting for the variability.
Results of this study supports a primary contact physiotherapy-led vestibular clinic and a multi-disciplinary team approach between PT, ENT and Audiology. There are very few papers reporting on such clinics. Similarly, United Kingdom physiotherapy-led vestibular clinic includes audiology assessment with close ENT access[23]. They reported that vestibular physiotherapy is essential to a primary contact ENT model and adds value, efficiency with high cost-effectiveness[23]. Conversely, a United Kingdom ENT-consultant-led balance clinic including an initial ENT assessment with referral to audiology and physiotherapy for management as deemed required by ENT, concluded a multi-disciplinary balance clinic is ideal[24]. We believe a multi-disciplinary approach to assessment and management of patients with dizziness is required, however may best be achieved via a physiotherapy-led primary contact service, with communication and referral links to audiology, ENT and neurology. Further research may be warranted to determine the cost-effectiveness comparisons of such services.
An acknowledged limitation is ENT did not assess the patient in person, leaving the ENT to make management decisions based on written information and the vestibular physiotherapy assessment. Whilst people with dizziness are commonly referred to ENT, an ENT vestibular assessment would often not be as comprehensive as a vestibular physiotherapist. Another limitation is that the recommendation for further audiology assessment was not captured. Audiology vestibular function tests, such as caloric testing, vestibular evoked myogenic potentials, and videonystagmyography are commonly utilised by both physiotherapists and ENT to assist with vestibular diagnosis and are frequently utilised in our service, however the recommendation for such testing was not captured as part of this study and could be considered for future research.