Restoring Balance: Improving Treatment for Vestibular Disorders

When a child complains about words “swimming” on the page of a book or feeling dizzy when they stand up or walk down the stairs, it could be a vestibular problem happening deep within the inner ear. Traditionally these vestibular and balance disorders have been a challenge to diagnose. Until now. New testing equipment can help pinpoint the problem and help therapists customize treatment for the patient.

Having audiology, physical therapy, occupational therapy, sports medicine, rehabilitation medicine and otolaryngology (ENT) all under one roof, communicating with each other, makes for a unique program found at very few hospitals in the United States. Improving outcomes is the goal, and Children’s of Alabama’s team approach to vestibular and balance disorders can do just that.
Restoring Balance: Improving Treatment for Vestibular Disorders
Featured Speaker:
Jill Smith, AuD, CCC-A, FAAA
Jill Smith is director of the Hearing and Speech Department at Children's of Alabama. Smith grew up in Birmingham, completed her undergraduate and graduate work at Auburn University (1998, 2000), and completed her Doctorate in Audiology (AuD) at the Arizona School of Health Sciences in 2007. Smith has spent her career at Children's in several roles including audiology supervisor, diagnostic audiologist and cochlear implant audiologist. She collaborates with physician research at Children's, presents on the state and national levels, and serves as vice president of the Speech and Hearing Association of Alabama (SHAA). Smith received the Jerger Future Leaders of Audiology (JFLAC) award in 2014. In her free time, she enjoys being at home with her family, volunteering at her church and going to the gym.

Tiffany Kaczorowski (Host):  Welcome to Inside Pediatrics, a podcast brought to you by Children’s Hospital of Alabama in Birmingham. I’m Tiffany Kaczorowski and today we are talking with Jill Smith, who is an audiologist and Director of the Hearing and Speech Department here at Children’s of Alabama. Good morning Jill.

Jill Smith, AuD, CCC-A, FAAA (Guest):  Good morning.

Tiffany:  So, we are talking about vestibular imbalance and we have a program here at Children’s. First of all, explain to me the difference between vestibular and balance.

Jill:  So, if you think of balance as walking and your whole-body system. So, balance is a big – a global type of word, where vestibular is pinpointing directly in the anatomy, in the inner ear where the balance comes from. So, is it a problem more pointed versus a global problem is how we kind of consider balance versus vestibular.

Tiffany:  Okay, so when a parent is at home with their kid or maybe their kid is starting preschool or something like that; what are they noticing at home or on the playground that might indicate that their child has a vestibular or balance issue?

Jill:  So, if your child is saying I don’t you know when I get up, the room is spinning, not necessarily like when you get up and get a head rush, that’s pretty normal. But – or there is some specific locations when I bend over to wash my hair, every time, I get dizzy. Or you have an older child 5 or 6, trying to ride a bike and they just can’t get it. Or children that are having issues riding a bike, kids that say I’m reading and I’m looking up and looking down, but I feel funny or if a parent is noticing like different eye movements or even on the other spectrum of you are spinning around in a chair and kids love to spin around and feel dizzy; but if they spin and spin and spin and don’t feel dizzy; that would also be considered a red flag for someone.

Tiffany:  Interesting. Okay. Must most of your referrals are coming from a primary care physician like a pediatrician or a family practice doctor or even like maybe an ENT if they have seen.

Jill:  Sure, we get – take referrals from pediatricians that parents may have concerns. We also have a good bit of referrals from our concussion patients. So, children or even adults, teenagers who have had a concussion; it is very normal to feel dizzy after a concussion, 90% of patients that have had a concussion experience dizziness. But that should go away. So, patients that have felt dizzy for about a month or so longer, typically is when we get the referrals to start the process of testing to kind of pinpoint is this something anatomical because of the blow in the head or is this something that we need more physical therapy with and we are able to test and be able to tell.

Tiffany:  Okay now we have been working with kids who have dizziness issues, balance issues in hearing and speech. Our physical therapists, our occupational therapists; we have been doing this for a long time. But, in 2017, we acquired some equipment that raised the bar a bit.

Jill:  It did. Our physical therapists and occupational therapists have been treating vestibular imbalance disorders for years. And they have been doing a fabulous job. The equipment that the audiology department has acquired helps pinpoint where in the anatomy that dizziness is coming from. Is it somewhere in the inner ear? And there are different places in the inner ear that it could be coming from and that assists the physical therapists and the occupational therapists in their treatment and it can hone in on what exactly they need to be working on and make the treatment more efficient and hopefully help their outcomes and make the therapy process shorter.

Tiffany:  So, these kids and even some parents, they may call it the spin chair. It’s a rotary chair and you are not really spinning them fast, right?

Jill:  That’s right. One of the pieces of equipment that we were able to get this year is called the rotary chair and it looks for a kid it looks like a ride at Disney World. So, it’s a chair that has a back and it does spin. We put the child in the chair. We put some googles on them which they kind of look like virtual reality googles and what the audiologist is looking for is eye movement. So, when you turn to the right, your eyes should shift to the left and vice versa. So, when children or even teenagers are in the chair; they think of it as kind of a ride. And we are not spinning them around like the merry-go-round or a Ferris wheel. It’s pretty slow. There are different velocities that we will spin depending on what exactly we are looking for. But the – I think it is more intimidating to adults than it is children because they think it is kind of fun. They think they are getting on a ride.

Tiffany:  Right, and are they able to diagnose at that point, right then or is there some type of software that the test is entered into some type of software so then you get the results later or

Jill:  Yes, it does have to be analyzed a little bit. We don’t want to just take one test and say this is what you have, and this is it. We will do a series of tests. So, the interpretation does take a little bit to just put it all together. We definitely discuss that with the team and then with the parents.

Tiffany:  And where are these kids coming from? We talked a little bit about pediatricians, but sports medicine, you said some concussed children and then also some kids who we know have hearing loss.

Jill:  Sure, so, we do know from research, that children with hearing loss have a 50% greater chance of having dizziness and balance issues. Part of that is because of the way that we are made, our anatomy. So, this system, your organ for hearing is right next to your organ for balance, your vestibular system. So, they do have a higher risk of having balance problems. Especially children who undergo a cochlear implant surgery; they can also experience dizziness and balance issues after the cochlear implant, but if that persists, those are the children that we are kind of looking for to say you know is this something that we can work on with therapy and where exactly in the system do we need to be targeting.

Tiffany:  Okay, so really the chair and the other equipment that you have and really developing this program that we have now; that helps to customize the therapy.

Jill:  That is the perfect way to describe it. There is vestibular training for a physical therapist; the rehabilitation is very intense, that training. And they have lots of tricks and lots of things that they can do but having the audiology piece of it and the actual objective measures from the equipment; can help hone in on where anatomically that is – the issues are happening, and they can specify the therapy plan based on the tests from the audiologist.

Tiffany:  And you said sometimes it could be a quick fix. There might be something that some type of exercise or something that they can give to the child that helps them immediately.

Jill:  There are and that typically happens more in adults, but we have seen it here at Children’s with younger children. We had a child that was complaining of dizziness and sometimes with kids you are like are they really dizzy or are they just trying to get out of schoolwork. And so, to validate that for that family and to be able to say you know what, there’s a maneuver we can do to get his inner ear back in sync with itself and make him feel better and sometimes it takes a couple of times to come in and experience that with the audiologist or the physical therapist. But specifically, there is sometimes it’s actually a relief for families to say oh my gosh, there really is something going on. And he’s not just trying to get out of PE or football or whatever.

Tiffany:  Or like you were talking about with learning how to ride a bike. I mean that’s a milestone in a child’s life being able to learn how to ride the bike and to balance on the bike without the training wheels and so if the family is finding that their child can’t do it and the child is getting frustrated and they are getting down on themselves, I mean that could cause a whole host of other issues.

Jill:  And socially too. I mean who doesn’t want to get out and ride a bike. Same with reading. If kids are oh the words are swimming on the page, well, yes definitely we would always want to – I am sure pediatricians definitely would have said to families hey, maybe go get his eyes checked. Well, eyes are fine. Let’s look at some things that we can do. Why are you having that experience and having those feelings and feeling like you are dizzy every time you look up and down from the board? Those are definitely some things that we would want to evaluate.

Tiffany:  So, one of the things that we need to be proud of here at Children’s is we are the only comprehensive vestibular imbalance program in the state. We have the only – but also there are not many programs quite like ours that really are using that team approach. Explain that to me.

Jill:  So, when audiology was thinking about okay, expanding our scope of practice into the vestibular and typically, as audiologists go into pediatrics, they do not think of themselves as doing vestibular; that’s more of an adult thing. But over the past ten years, research has come out and this has been a big focus for pediatric audiologists. So, we kind of tapped into our PT and OT friends and said what do you all do in there? Oh my gosh. This is such a need. This is such a need. So, it beautifully put together as far as working together with the physical therapists, occupational therapists and audiologists and, so they went to a training last year in Delaware and saw how their team was working together and that’s where we discovered you know there’s not a whole lot of folks out there in this country that are doing this how we want to do it. We want our equipment to be in the same place as our staff, as our PT gym and work together as a team and staff these kids as a team to say what do you know that I’m missing or let’s think about this comprehensively than being in our silos. So, there’s only a couple of handfuls of programs throughout the country that do it in the way we do it. There are some programs that they may refer out to OT or refer out to the audiologists or whatever, but we feel like we have – we are very blessed and very fortunate here at Children’s to have everybody in the same house and to be able to talk to each other and to be able to staff these kids and have the physician support and have administrative support to be able to do that.

Tiffany:  So, we are very fortunate to be able to have everything all in one place. These kids are not going to another location to have different tests done and then just the communication piece I would imagine having everyone on the same campus to be able to discuss that child’s care and the next steps; that’s a huge benefit.

Jill:  That is huge, and each child is different just like with any diagnosis. Sometimes they – a child may have been in physical therapy for a while and then they come to audiology or maybe it’s a referral to say every time this kid stands up, he’s dizzy. Maybe that would be an audiology referral first. So, that’s how the team is working together to say let’s do this first and this and very systematically and do it child-centered instead of oh well what works best with our schedule. That’s certainly not how we want to play this out. We want to customize our program to the needs of the child.

Tiffany:  So, if people have any questions or they are interested in this, they want to know a little bit more; where can they go to find that?

Jill:  We have an email setup. It’s This email address is being protected from spambots. You need JavaScript enabled to view it. and that goes to our team. Families, parents, physicians, anyone can email and ask questions or go to our website.

Tiffany:  Thank you so much Jill. Enjoyed talking to you today.

Jill:  Thanks.

Tiffany:  Thanks for listening to Inside Pediatrics. More podcasts like this one can be found at pediatrics.