OTE 30                Transcript
EPISODE 30


[INTRODUCTION]


[00:00:00] ANNOUNCER: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Start today. Speechtherapypd.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On The Ear, you can receive $20 off in annual subscription when you use code Ear21. Just head to speechtherapypd.com to sign up and use code Ear21, E-A-R-2-1 for $20 off your annual subscription.


[00:00:48] DS: You're listening to On The Ear, an audiology podcast sponsored by speechtherapypd.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor and lifelong learner.


While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues and students. Let's go. We are live and On the Ear, brought to you by speechtherapypd.com.


[INTERVIEW]


[00:01:35] DS: A 2016 study by M. Dawn Nelson and others published in the Journal of the American Academy of Audiology examined a 10-year survey trend in audiologists in vestibular assessment and rehabilitation. They found an increase in the number of audiologists providing vestibular services in the previous decade. And most respondents agree that audiologists were the most qualified professionals to conduct vestibular assessment.


However, less than half of the surveyed audiologists felt that their graduate training was enough to be proficient in assessment, and far fewer than that felt audiologists were equipped to complete vestibular rehabilitation. More and more of us are specializing in vestibular, it's definitely a growing field. So, how do we improve the training of audiologists in this specialty and ultimately, the outcome for these patients.


Today's guests are making that happen, one Dose of Dizzy episode at a time. Dr. Liz Fuemmeler is a vestibular and concussion audiologists and Hearing and Balance specialists of Kansas City. She specializes in the evaluation and treatment of vestibular and balance disorders, especially following a head injury or concussion. Her concussion protocol is based on her residency in Mayo Clinic's returned to play clinic where she focused on finding objective, physiologic evidence to identify the presence and extent of vestibular issues following a concussion.


This evidence played a critical role in ensuring concussions were properly diagnosed and athletes were not returning to their sport prematurely. She is actively involved in scientific research, collecting normative data, and concussion specific vestibular tests.


Dr. Daniel J. Romero is a postdoctoral vestibular fellow and licensed audiologist in the Department of Hearing and Speech Sciences at Vanderbilt University Medical Center. He earned his Au.D from Northern Illinois University and PhD with an emphasis in vestibular science from James Madison University, go Dukes. Daniel has coauthored six publications and given over 15 presentations at nationally recognized conferences, such as the American Balanced Society and AAA.


He currently serves as advisor on the student Academy of Audiology Advisory Committee for the American Academy of Audiology and ad hoc reviewer for multiple peer reviewed scientific journals. He and Liz cohost an awesome vestibular focus podcast called A Dose of Dizzy. It's such a good one, you guys. I love how they break down a topic, give you lots of cool insights from their personal perspective professionally. They're also just like funny and down to earth people which makes it a much more enjoyable learning experience. I'm a big fan and I'm just so grateful that you guys would join me for an episode of On The Ear. We have not covered much vestibular. So, I'm very excited for this conversation.


[00:03:52] DR: Thank you very much. We’re happy to be here.


[00:03:54] DS: Okay. So, can we start with just like the number, right? I haven't been to an American Balance Society conference, but it doesn't feel like, at least in among my friends who are audiologists, many of us are specializing in vestibular or balance related issues. Hopefully, everyone took at least a course in graduate school on this, but it feels like such a small specialty. But from my experience when I did see some dizzy patients, there's a lot of them. So, where's this disconnect coming from here?


[00:04:25] LF: That's a good question. Yeah. And you're right. Especially, the vestibular audiology world is super small. I feel like those of us that are doing it full time, we know of every single person in the field, but there is a huge disconnect. I think part of that is just lack of awareness of who is in charge of dizzy patients because there's so many professionals that are actually involved in managing dizziness. It's interesting, I always hear from patients who's helping manage their dizziness, but chiropractors and physical therapists, urgent care. There are so many people involved that I think a lot of people don't think of audiology first. A lot of people don't even know what audiology is.


[00:05:01] DR: Right. Yeah, just to bounce off, Liz, it's a very multidisciplinary field. And honestly, too, it could — relative to everything else that, you know, audiology in and of itself, is a relatively new profession compared to some of the other ones. But vestibular science is sort of relatively like the new kid on the block…


[00:05:23] DS: It’s the new, new.


[00:05:23] DR: Yes, it's the new new. It's new in terms of the clinical assessments that we perform today. 65% of them were not available 20 years ago, and the clinical practice is new, and so is the research, but that also makes it very exciting, because there's so many different areas to now branch off to.


[00:05:44] DS: Yeah, that's a good point, because I feel like maybe that's having an impact on why more audiologists aren't involved is because there isn't this — this sounds like a bad way to put it, like older generation of people who have tons of experience here who are then in the educational setting, teaching new Au.D students, it's like we have to wait for the catchup between people with more experience to then come back in and train. It seems like such a small group that no one's really getting that intense training, I guess, at a graduate level, but maybe it's something that's reserved more for the externship year. I'm curious when you all decided, like, I want to focus on vestibular, was it before you even started in Au.D program? Was it after? How did that come about?


[00:06:24] LF: Daniel, you have a better story.


[00:06:26] DR: So, I guess my — since undergrad, I have actually known that I wanted to get into vestibular science. I took my first hearing science course and at the undergraduate level, and I think this is sort of where a disconnect also happens is at the undergraduate level, students don't necessarily get exposed to the vestibular system. Mainly, their hearing courses, and audiology courses are focusing on more the auditory system. I think that's one of the big disconnects, especially at the undergraduate level.


But anyway, I knew for sure that I wanted to dive into this area, and it was just mainly off of interest in the vestibular system and how it functions, the physiology behind it. That's kind of how, I would say what carried me through, was just a passion for this specific area. So, whether it was getting additional exposure during my graduate program or conducting research as far as during my audiology program, I knew that I wanted to have a focus on the vestibular system, in and of itself.


[00:07:38] LF: I feel like you're a rarity, Daniel. I feel like that is very rare to know like from undergrad. I always describe my experience into vestibular as a game of Plinko. I don't know if you guys ever watched Plinko. It was like my favorite game to watch on the Price Is Right. 


[00:07:54] DS: When you’re sick on the Tuesday with your grandma, you watch the Price Is Right. You hope they play Plinko.


[00:07:59] LF: We miss Bob Barker. But yeah, I just feel like I kept getting directed into the vestibular realm. I applied for a T35, which is a research experience that you can do summer of your second year of your Au.D. And I applied at Boys Town National Research Hospital, and I decided I'm like, “You know what I'm going to put vestibular.” I was like, “I don't know much about it. I don't like it from what I've known about it”. But I got an incredible mentor. And I think since that, then I got a vestibular placement. Then I got an incredible fourth year that really focused on vestibular. So, I just kept getting Plinko’d into vestibular and I had way too much good training to desert it. So, I just stuck with it.


But I think, it's just been, every single day, it's really hard. I think it's exhausting. And talking to people who've been vestibular for a number of years, it's hard, for sure, because every single patient is so different. But it's also a fun challenge. And I think you know, there's part of it, you get to use the diagnostic, the puzzle, part of my mind that I really like about figuring out problems. That's all vestibular is. And you may see a patient just once, but the diagnosis that you give them can totally change their life, literally.


[00:09:07] DS: Wow. Yeah, that's a good insight. And I like that you guys have such different paths. But I think if there's somebody out there listening who's currently involved in vestibular training, they're definitely like in one of those two categories, right? Like you've known for a long time, or you just happen to get some critical exposure to it at some point in your training, and it really drew you in. That's awesome. It's funny to think, you get to have these amazing mentors. I can't throw this away. What would my mentor think, they put all this time in, to me. That's a good thought.


So, I know we're all pretty young at this, like in this world. But I'm curious if you guys have any insights into how vestibular training has evolved for audiologist over the years, like any insights into when it was really — because it's been a part of the scope of practice. I mean, I looked back at some like, I don't know, it was like a AAA or ASHA document, I want to say from like the early 2000s and vestibular was in there. But is it just from this anatomy perspective that we're so focused on the inner ear that we definitely get a good understanding of the vestibular system because it's got some similarities? Or just any insights into like how we kind of got here in terms of how audiologists are involved in vestibular?


[00:10:10] DR: Yeah. Liz and I were just really talking about this recently. As far as how we've gotten there, I think a lot more opportunities within the last 15 years, has become available to students. Liz mentioned that T35 opportunity, and that's a really, really great experience for Au.D students. And there's also different vestibular postdocs. So, after you finish your Au.D, if you wanted to further specialize in vestibular science, you can do so at a number of different institutions. Mayo Clinic has one, Vanderbilt.


So, not only the opportunities, but I would also say the assessments or the clinical tests that we perform on a day to day basis, the oldest one being of course, the VNG, which caloric test has been the sort of the core, is at the heart of the VNG, which hasn't really changed much in probably the last 80 years. But with regard to some of the the other tests, VEMPs or vHITs, rotational chair, as far as how we think about them contemporary, those tests really have evolved very much in the last 15 to 20 years.


[00:11:22] DS: Okay, yeah. So, that's really helpful. One of the things, that study that I mentioned to it, was Nelson et al, maybe, yeah, from 2016. They also had noted over that 10-year span from 2006 to 2016, or 2005 to 2015, that those core assessments were also part, those didn't really change as being part of the core assessment, with the VNG and caloric, and maybe, I don't know if like headshake, or vHIT. It was all kinds of same core tests that haven't changed over time.


So, I thought that was really interesting, because the means, we haven't really come up with a better gold standard for some of this assessment and that it has been the same for a while, not necessarily a bad thing. It's just also kind of interesting. So, how do you see I guess, either the training of audiologists itself or the assessments or maybe this is two totally separate questions, but how do you all see, let's start with like, the training of audiologists in vestibular assessment, maybe rehabilitation, how do you see that changing in the future from where we are now?


[00:12:18] LF: It's a great question. I think one of the biggest driving forces in the next year that we're going to see is with over the counter hearing aids being passed. We are going to be forced into being a more diagnostic focused profession, which I don't think is a bad thing. But I do think it's going to be a little bit of a shakeup. I think, like I said, that's going to be very good to increasing the general audiology student to being more well-rounded in every part of our field. And really operating, we always say at the practice I work at, “You should operate at the top of your degree” and like, really perform as best as you can for what your degree trained you for.


I think with vestibular, we're noticing a trend even amongst like American Balance Society, which is a small little subset society that focuses on vestibular, even in the last three years, the number of students attendees have increased dramatically. So, we know students are more involved in getting in vestibular research, diagnostics, clinical cases. Students are definitely looking to learn more vestibular and I think generally, that more awareness is going to result in more future professionals that are working at universities that are offering placements for students, that are talking at conferences like the whole nine yards.


[00:13:31] DS: Definitely. I think that's a really good insight. And I personally, when I was going through my Au.D program, they hired a new faculty member who I believe is the mentor and dissertation advisor for Daniel, who was awesome. I knew that previous students, they had struggled through the vestibular class, because I think the person who taught it was maybe not vestibular trained. They were maybe an engineer or something who had some background between the two things. So, this person was clinically trained in vestibular sciences, had her PhD, so she was a researcher. So, she like, really knew the ins and outs of the vestibular system and assessments and rehabilitation.


It really made the class more interesting to us, to us students who really hadn't had any previous experience whatsoever and I think a couple who were like, “Oh, this is interesting. Like, I could see myself considering a PhD now or like focusing on this clinically.” And without that educator, like being exciting and inspiring, I don't know that that would have happened.


[00:14:27] LF: Yeah, I think that's a good point, too. Because the one thing that I always heard and I felt this way before I got into vestibular, and this is why we started the podcast that we do, but vestibular is very inaccessible to a lot of students. It's complex. You don't get the basis that you would get in how to perform an audiogram. You don't get the same type of basis in most programs. So, I think, increasing awareness of vestibular, the more professionals that get involved and who mentors you or what resources you turn to can completely transform how you feel about it. Most of us, the way that I felt, I was not very keen on vestibular because it was so complex. And I'm like, “I don't even want to try to learn this, because there's only one class at my university. So, it's obviously not that important for me to learn about.” It's just such a subset of academic programs that I was like, “It's okay, I don't have to pay that much attention.” And then I had incredible mentors along the way. And I'm like, “Wait, this is incredible.”


[00:15:21] DR: Yeah, for sure. I mean, Liz has touched on it there, for sure. A lot of it really does have to come down — I think comes down to like your early education to it. How was your introduction to the just to the topic? What were your classes like, and there's just a lot of variability across different programs. But with regard to having somebody coming in with that — I think that's sort of like the beauty of the Au.D and PhD is because you're you're able to sort of bridge a lot of the things and make things much more interesting to students that are that are learning this topic. So, I think also, not only it has to do with the background of the person teaching it, but also just the overall…


[00:16:07] DS: I guess, kind of like the interest level of the students, and I think another thing that isn't really offered or I've never seen it really anywhere is a university clinic, which are usually smaller. I mean, I guess there are definitely some larger ones that do, but that incorporate vestibular because usually, the university clinic is going to be mostly full of the early Au.D students, right? The first year, second years, and in my experience, I haven't, I mean, I guess to be fair, I haven't seen too many other Au.D programs, but they don't have vestibular clinic offered that early on to students that young. Maybe it's because it's a higher-level class that isn't taught until later. But I do think that exposure makes it feel more attainable and not so foreign, by the time you're looking for clinical experiences in your third or fourth year. You know what I mean? If you hadn't had that chance to even see like, what is this equipment like, you wouldn't even know that you had that passion the entire time.


[00:16:59] LF: I think part of it too, is we may get into this later, but some vestibular equipment is pretty expensive. I think that makes access hard, whether you're a student that's looking for an off campus clinical placement, or you're at a university, many times the audiology department or if whether university or hospital, they're not like the breadwinners of the department. So, I think it is hard to advocate for the type of equipment that you would need to have a comprehensive vestibular lab, and that's why most of the time, it's larger university medical centers that are the ones that have the strong vestibular programs.


[00:17:33] DR: And most students really don't get a whole lot of exposure to clinical vestibular testing until their externship year or unless they're actively seeking it out during their second and third years.


[00:17:45] DR: Yeah, that's a really good point. And I do hope we talk a little bit about just sort of the barrier of the equipment itself, because I do — I feel like even right now, like I've always been interested in vestibular testing, but there's no way the small clinic I work for could afford like a rotary chair or anything like that. But I'm hoping you guys will share some small ways audiologists can start to incorporate at least a little bit of balanced care. Before we get into that, though, I know that your podcast, at least on social media often is asking like, “What are you guys interested in? What do you want to hear us talk about?” Which I love. And so, I was curious, looking through the episode titles, it's clear what a lot of people have questions about. But I'm curious, maybe not just through the podcast, but through professional, professionally, or students that you've talked to, whether it's about evaluation or intervention, what are the biggest concerns like the most common questions you get from other clinicians?


[00:18:31] LF: Great question. I feel like when we started out to make the podcast, I will say we thought we would focus on test disorder, test disorder, like every other episode, because there's — like we talked about before, many new tests, and constantly we're like changing the parameters for how we test like even VEMPs, for example, we're still like ironing out exactly how we like to test VEMPs. And then of course, disorders, there's like a million different ways that all these tests could incorporate together. I always explained to like friends and family how many tests I do in two hours. I'm like, “I do like 14 tests.” And there could be a million different ways that this all presents.


So, I feel like a lot of times, we get the most questions on results and like how to interpret for different disorders. What this plus this, plus this means, and it's really hard to learn because it's never textbook, ever. There's always something so messy about it and I think that's what's hard to teach to students.


[00:19:27] DR: Yeah, for sure. The real world is messy. Everything is like, so bad. But that's sort of what makes you the expert as far as the interpretation of it all because it really does come down to taking the results that you just obtained and how does it fit into the clinical profile that of the patient that you're seeing. And for sure, like Liz had mentioned those, interpreting those results is very common, a common question that we do get. But also, too, we've had people ask, how do we advocate for vestibular to other medical professionals such as PTs or primary care physicians. Counseling patients, different things like that.


So, I feel like yeah, Liz, we sort of started out with this test disorder, test disorder, but it's sort of has branched out into — it seems a lot of our listeners are sort of tapping into us for different reasons.


[00:20:23] LF: And even like the marketing, I mean, I'm in private practice, which is kind of rare for a vestibular audiologist to be in private practice, just because again, like cost is a barrier and all these other aspects. But everything from like billing and coding, I feel like sometimes I get questions with that, or like marketing, marketing, a vestibular program. I mean, just everything you can think of vestibular, we've probably received a question or a suggestion on because it's just very new to people.


[00:20:47] DR: Yeah. And so small, you got to look to the outspoken experts to be helpful there. I think that's a really good insight there too, Daniel, about the aspect of interpretation. Because a lot of the reason people are drawn, like if they're in the audiology versus speech undergrad bubble, they like the diagnostic rigor of audiology, right? Like it's not as vague sometimes, as some speech disorders can be, it can be a lot more concrete. I know vestibular can be very much between like concrete and vague. I really liked that idea of it takes the person with the expertise to come up with a conclusion here, based on all of these different pieces of evidence. In audiogram, and diagnosing a hearing loss, is not nearly as many components. Sometimes it can get really complicated and you can have multiple etiologies and mixed losses and things like that.


But for the most part, you don't see as many of those things. Whereas with vestibular testing, I mean, in just the few that I've seen them, every one of these, like you guys said, every one of these is totally different. There's no pre written report I can use because every single person has such a different result here. So, I thought that's a really good insight there.


[00:21:55] LF: And that's another reason that I felt very adamant about having something to keep me accountable to keep learning because, one thing I've learned working for a few years is I learned something new every single day in vestibular, which I feel like it's very rare, because you're never like, “Oh, I got this. This patient's totally in the bag. I know what they got.” Because you have something that surprises you, either some way that they present with their symptoms, or the way that their test results come out. I mean, you have to be on your toes all the time.


And I think since vestibular research is so new and changing every day, you have to be very in the know of what's going on. And that's why, Daniel has been a such a great resource for me and why the podcast has, because it's kept me on my toes as a clinical person to say, “What's going on? And what do I need to change with how I practice?”


[00:22:44] DR: And I'll say the same thing about Liz, because yes, I do primarily focus on research, but having that clinical perspective, and during my postdoc, now, I do see patients as well. So, I think it's also important for a researcher to have that clinical background as well, because it sort of keeps a check on your research. So, it's sort of like the, the Yin to the Yang kind of thing that everyone — the research and clinic, it definitely complements each other all the time.


[00:23:10] DS: Yeah, that's actually a great segue to the one of the things I wanted to ask which is, so hopefully, everyone who is now a clinician has some kind of at least a course, in vestibular, and hopefully a little bit of exposure to a vestibular clinic or something like that. But for those who always had that interest, but never really found opportunities to get any direct experience with that, what can they be doing to improve their proficiency, maybe not become, full experts. I know that's going to take some — a lot of continuing ed to reach that point where you're going to be comfortable to take on a caseload or start a clinic, that kind of thing.


But at least to have some kind of proficiency in this area, where if you had someone come in, and their primary complaint was hearing loss, but then you learned they had a significant vestibular symptom, or you then realize that their hearing wasn't their problem, but they had had some kind of vestibular episode. What do you say to audiologists out there who are in that position and kind of don't know how to navigate those conversations because they didn't really get that much experience with it?


[00:24:08] LF: I will say step one, I say this to students who come through our clinic all the time, I feel like schooling and even your externship is your orientation, and your actual training starts when you become a professional, and it never really stops. So, I think everybody has the capacity to get into whatever part of our field that you want. But it's not always going to come easy. You're the one that's in charge of your education. You may not have gotten it through your program, but that doesn't mean you can't get it.


Programs, both Daniel and I were really involved at the student Academy of Audiology and I feel like I have empathy towards programs who can offer the most, best comprehensive program out there, because it's really hard and it's expensive and it's hard to keep people on staff. So, I think it's really up to you. You're the professional, it's your career, it's your reputation on how you want to expand your education. And there's resources out there, could there be more? Always. But even going to a talk at one of the audiology conferences that you wouldn't typically go to, connecting with your colleagues, I feel like a great resource has been many of our professional organizations that you can connect and ask questions. That's how you learn. You learn through cases and seeking it out yourself.


[00:25:20] DS: That's great. That's excellent. I think that's perfect advice. That illustration of training, even through the externship, and then exposure and then training after you become a professional and that it's ongoing is such a good reminder. It's one of the reasons I love doing this podcast is I talk to people who are experts or also learners in a lot of different contexts, and I learned so much from it. So, I also believe in that philosophy, but I've never heard it worded so eloquently. So, thank you for that. I'm going to be stealing it from you.


[00:25:50] LF: Thank you. You can.


[00:25:52] DS: How about just ways to begin incorporating some aspects of vestibular care whether, oh, help me out here. My brain is just blanking right now because I don't normally do this. Is it a Gold — not a Goldberg?


[00:26:02] LF: Oh, a Romberg, some Berg.


[00:26:05] DS: Romberg, right? There are little some, Goldbergs. There are some bedside testing that we can do to at least then, and this is one of the things I tell all the students I see is like one of the most important things once you have your first job is you like establish your network of, I need somebody who's really good with vestibular, someone who's really good with tinnitus. Like if you're not specialized in those things, know people who are who you can refer to you. So, should we be doing some of that bedside testing? Is that helpful then to the person who is the specialist? And if we are interested, where do people even go to begin learning that kind of information?


[00:26:38] DR: With regards to bedside, we actually just did an episode on this. But there's a wide variety of different bedside tests that are very, very useful, and in certain cases, can tell you pretty much, can give you a really good idea as to what the underlying issue is with the patient that's right in front of you, without even putting any set of goggles on them. You had mentioned the Romberg, there's the Fukuda, there's the headshake. There are all kinds of different tests that can really try to help identify more or less peripheral vestibular impairments. But at least give you a good idea.


Aside from the bedside testing, there's also a bunch of different questionnaires that vestibular audiologist would routinely use. The most common questionnaire is the Dizziness Handicap Inventory. That's not necessarily going to tip your hat as to what in most cases, what's going on with the patient, but it is going to tell you how their dizziness or balance issue is affecting their quality of life, which is just as important, as you know, with any clinician working with the patient. 


[00:27:44] LF: I also feel like it's just — well, I was just going to say, I feel like, if vestibular is so foreign to you that you're not even totally sure how to spell it, it may just be best to ask if the patient is dizzy or has balance issues. And especially, we know the incidence of hearing loss and vestibular disorders, especially in children, but even in adults, and just asking the question, because most of the time, and Daniel and I talk about this statistic all the time, but dizzy patients will typically see four to five medical professionals before they receive a diagnosis for their symptoms. I think at a certain point, many primary care, whoever they're seeing, just doesn't know what to do so they dismiss that complaint a lot of times.


I think being someone who asks about it is really important because a lot of people do not associate audiology with dizziness. And so, I think just saying, “Do you have dizziness? Or spinning vertigo?” as people call it, “Or balance issues?” And if they say yes, refer them to someone in your network or someone that you know.


[00:28:45] DS: That's awesome. On top of that, I just feel like there is not enough training with those kinds of bedside things. I think incorporating more inventories or questionnaires can be really critical into an intake form. The most recent episode I listened to of Dose of Dizzy was on case history. And in our case history is always a question along the lines of do you have dizziness or imbalance or it might even say, we also have something about you have a history of falls, which can also help kind of tease that out. But some of the things you guys talked about in that episode were great as someone who doesn't see these patients, but understanding what kind of questions you like to ask can be really insightful for the kinds of things that I should probably be asking to know when it's right to refer someone.


Is there anything you guys want to speak to like on that topic of case history and things that could jump out at you like right off the page?


[00:29:37] DR: Liz had mentioned, asking the simple question, “Do you experience dizziness or balance problems?” Now, taking it a little step further, with regard to dizziness, “What does that even mean?”. That just means so many different things and dizziness can result or can come from a variety of different areas in the body. So, what I like to do first is really just to try to parse out what their sensations or what the sensations that they're feeling. So, I always try to ask them how — go ahead and describe the dizziness without using the word dizzy. What sensations are you actually feeling? And what we're trying to figure out, ultimately, what we're trying to figure out is the person experiencing true vertigo?


Now, true vertigo, that's going to be that spinning sensation, could be tilting sometimes, but most of the time, it is going to be that true spinning sensation. Everything else is going to be lumped into basket known as dizziness.


[00:30:30] LF: And even you know, I think a lot of times we talked about this in our episode related to this as well. But case history is probably one of the most important parts. I always say we diagnose using case history and we support our diagnosis with our test results. Because most of the time, I should say, and this is why I'm always kept on my toes, because just as soon as I figure it out, I'm wrong. But your case history, you can really parse out which professional they need to see. For example, if you're talking to someone, and this is very typical, you see, let's say an eighty-year-old man, who's saying he gets dizzy. He's dizzy, every time he sits up, he's dizzy every time he stands up. Okay, well, if you parse that through, and it's not a spinning, it's more of a lightheadedness, probably related to blood pressure. Do they need to go to a full vestibular evaluation for this? Maybe not. That may be something that their primary care can mitigate.


I mean, obviously, we're used to seeing those types of issues as well. But that would be something where they would save an assessment with a vestibular audiologist and be directed more immediately to who they need to be with.


[00:31:31] DR: Right. That's spot on. With regard to — on the flip side of that, just to talk about the patient or the case history itself, one thing you also have to keep in mind is that, patients are typically or can be poor historians.


[00:31:50] LF: It’s very hard to describe. I will say, dizziness is so complicated, and it means something different to everybody. So, it is very typical to not be able to describe it.


[00:31:58] DR: So, while the case history is very, very crucial, ultimately, you have to sort of look at what evidence do you have to support an inner ear balance disorder, and that's going to ultimately come from your clinical tests.


[00:32:15] DS: Yeah, I like the the balance between those two. And I definitely have some patients who are like fantastic reporters. They can give — so I see a lot of cochlear implant patients too, and there's oftentimes vestibular problems associated with that. Sometimes, the way they describe it is like, with so much detail, and so interesting, I'm like, “Wow, this is probably really helpful for the person who would be able to help you with this.” And then on the other end, I've got people where they're like, “I don't know. I just don't feel good. I need to sit down.” I'm like, okay, “But is it spinning? Or do you just feel like you need to sit?”. “I don't know, maybe I'm spinning, I don't really know”.


So, it's interesting how there are so much variability, not only like, as we referred to earlier, just with the testing being so different for each person, but also just in their own ability to describe what's going on. That's a really good point and how similar those words can be to one person, whether it's lightheadedness, or spinning or dizziness or imbalance, all of those words can mean almost the same thing to one person and drastically different to another. It's a helpful reminder.


Awesome. Okay, so kind of circling back then to a minute ago, we talked about the equipment being really expensive. I'm really curious, Liz, your perspective being in private practice. So, obviously, it's clear that if someone wants to get involved in vestibular care, and they're not already, it's going to take some extra clinical training in some way. But also, if they wanted to, incorporate some kind of balance into their care, what do they do? Because actually, I couldn't tell you like a quote for a piece of equipment, but I have to assume it is way up there because they are big and technical, and heavy. So, what are the recommendations you would make to someone who is — they've got the training, they're ready to take the plunge. But the equipment barrier is there.


[00:33:59] LF: Yes. Great, great question. I feel like we get this one a lot, even with the podcast. But it's a really good time to be in private practice for vestibular. And I'm saying this because in the last few years, there's been the addition of new vestibular codes. And I think that's been a huge barrier, even at the university level, is we haven't had a code for billing VEMPs. We haven't had a code, we still don't have a code for billing vHIT. We're using the 92700, which is just your basic filler code that doesn't typically get paid.


So, I think that's been a huge barrier for a lot of people who are trying to not only do vestibular, maybe to teach students, but also to make money or even pay off their equipment. Something as basic as breaking even. So, I think it's a very good time to enter vestibular because we've seen an increase in billing and codes. As far as equipment, you can have a fairly comprehensive vestibular lab without having all the equipment. It's obviously ideal. We're kind of a unique private practice because we do have a rotary chair, which is obviously probably four times your car, or maybe five, or maybe six.


[00:35:04] DS: Oh, it's that far up there. I didn’t even have a ballpark. That is wild.


[00:35:10] LF: I guess it depends what type of car you drive.


[00:35:12] DS: It's probably quintuple mine. Yeah, I get the point, nonetheless.


[00:35:17] LF: But yeah, I mean, it is very, very expensive. However, there's some simple math. And it's true, you're buying a real ear measurement system, which I feel like this is always a big debate as well. It's like, that's so expensive. And it is, but I feel like it's easier in vestibular to justify the price because you have a code to bill for it. And actually, they pay okay. And especially if you're doing a comprehensive vestibular assessment, you're going to make okay money, and you're going to make probably pretty good money to be able to pay off your equipment fairly soon.


So, I think it's actually benefits the clinician who is more comprehensive, because like I said, I probably do 14 tests in two hours. I like to be kind of speedy, but I think that's pretty typical, like two to three-hour appointments for vestibular. And if you're being comprehensive, it's very doable to pay off the equipment. A lot of the manufacturers, of course, will offer payment plans and ways to make it more accessible to you. But I think, in general, and we've talked about what equipment would be ideal, you'd obviously want a VNG system, that's probably the most basic of everything. Most clinics have an evoked potential system that you can use for VEMPs. So, if you're using an ABR system, or have one in the clinic, you can use that for your VEMPs, which is wonderful, or ECOG, if you're still doing that, I'm not.


And then beyond that, it just gets more fun on what you can add, rotary chair, you can add vHIT. Some of those smaller computer-based like vHIT are a little bit more accessible to most clinicians and you could have vHIT in replacement of your rotary chair, to begin with, and then as you grow, add more expensive equipment, but it's very doable. I just think it's overwhelming when you think about the huge chair that's worth more than your car being bolted to the floor.


[00:36:59] DS: That's a good point. But hey, on the weekend, you can use it for like a joy ride, you can just ride in circles and…


[00:37:04] LF: Yes. It's also a transportation device. So, do you really need a car? I mean, come on.


[00:37:08] DS: So, to that insight about kind of billing and coding. I know that there are rumblings legislatively from a federal level in terms of audiology reimbursement, like we mentioned earlier with over the counter or the Medicare Audiologist Access and Act. So, I'm curious where you see, like, do you feel, and you can be honest here, is the future bright when it comes to billing and coding for vestibular services? And then maybe if you guys have some insight, too, I know that physical therapy is also in this world. So, is there a struggle? I'm so far removed from this. Is there a struggle there between the disciplines to establish roles? Or is it we all kind of get along here? How has that gone so far?


[00:37:49] LF: That's a great question. So, first of all, I will say our clinic just recently started employing a vestibular physical therapist. I feel like I've learned a lot more about this. I feel like the roles are fairly separate when you're talking about billing and coding. When you're talking about patient management, a lot of people think we do the same thing. But when you're looking at the actual tests that you perform, and the outcome that we get, we actually work really synergistically together. It's a very good partnership of using each of our talents. I've loved having a physical therapist, she's great. She finds cervical origins, vertigo that I've never been great at assessing.


So, I feel like that is not so much of an overlap, especially when it comes to billing coding. I feel like the future is always slightly grim when you're talking about coding and billing for any profession, any time. Because I think the more you use a code like the more it's used, and we've both, Daniel and I both learned quite a bit about this from being involved nationally with organizations, but the more code is used, the less likely you're going to be paid more in the future, because they only have a certain amount of budget, and they have to allocate it.


So, I think the more people that get involved in vestibular, it probably will lead to a slight decrease in our reimbursement potentially, because that's how it's been trending. But I think that's true with audiology, overall. And some things have increased in pricing as well. It just kind of depends. I think it's very important that we're well rounded with how audiology bills because some codes are not utilized at all and those are worth a lot. And then all of a sudden, they start getting used more and then they get tanked. So, it's an interesting world to be in.


[00:39:22] DR: Right. I mean, it's about it. Especially, I think the biggest example is with the caloric code. I mean, it's probably a 10th of what it used to be. But it's still our most billed code, I would have to say. But yeah, no, we're just trying to slow down that slope, but it seems like, as time goes on, it is always going to decline just a little bit.


[00:39:47] DS: That's rough. It's definitely rough.


[00:39:49] LF: It's true of everywhere, like everything audiology, though.


[00:39:51] DS: Totally, totally.


[00:39:52] LF: It's not specific to us, unfortunately.


[00:39:55] DS: With equipment, that’s multiple cars. You don't want to be stressing about that side, definitely. I definitely get that. I'm curious, maybe you guys have such different histories in terms of how you got here, and you kind of have briefly shared some of those settings. But I'm curious, I mean, it sounds like there are — it’s not like just a medical setting for an audiologist to work with the similar I mean, Liz's in a private practice, sounds like you guys have been in maybe some kind of university clinic before or a hospital. I'm just curious what some of the settings are that you've seen, or maybe just people you've connected with, through professionally. What kind of settings you're seeing audiologists and who are maybe not doing, like fully vestibular, but at or at least incorporating some of it into their care?


[00:40:36] DR: Yeah, I would say probably the two most common areas that have a similar audiologist is going to work in are going to be hospitals, and private practice. I haven't come across and Liz, if you have, let us know, but I haven't come across a lot of university clinics that perform vestibular assessments as part of their regular standard of care. Yeah, I would say for the for the majority, I've personally, my externship was at a hospital. I'm now at a university medical center. So, I would say it's more or less a combination of that, as well as private practice. But also known some audiologists that have worked in industry. So, manufacturers for these very expensive pieces of equipment. We also see some audiologists working in industry doing research for some of their products. So, I would say it's pretty similar to other settings that audiologists work in overall in general.


[00:41:37] LF: I mean, I know for example, because this has been something that's transitioned since I started my grad school, but I went to Purdue and they bought equipment. I think the second year I was there, they bought rotary chair and literally everything under the sun. And they actually just started seeing patients in the clinic, because it's been a big task to get the vestibular lab up and going. I know it's possible to see them in the clinic. I think majority are hospital’s ENTs. I feel like it's more rare to find someone in a private practice, like audiology owned private practice that's incorporating it.


But I do know there is a big push. Richard Ganz trains a lot of private practices to incorporate vestibular care and that's a really accessible way for a lot of people to start in vestibular, because he'll bring a team to you or you to them, and train you with how you can start incorporating this. I feel like it's been a similar push to what we've seen with some of the cochlear implant manufacturers who are trying to tap in on private practice and expand the repertoire for what those audiologists are providing.


So, I think it's kind of similar to see that growth. But I agree. It's like same settings as what you'd expect. I'd feel like the the least amount of vestibular audiologist are actually in universities, because that's a lot of the programs I know utilize clinicians who are at like a hospital or private practice to help teach their classes.


[00:42:56] DS: Yeah, that's a good insight. So yeah, so it sounds like the settings can be kind of the same. Yeah, the ones that I've interacted with have either been in hospitals or like a part of an ENT clinic that also sees dizzy patients. How has that collaboration worked for you all in the past? Because I know that otolaryngologists are a big part of what we do is audiologists, have you guys seen good collaboration there? Have you butted heads? What's been the relationships that you've had so far?


[00:43:24] LF: I feel like one of the best, I mean, I think most audiologist feel this way in general, but neuro otologists, I feel like I've had the most incredible experience working with when it comes to dizziness because they understand and really value what tests that we bring and, value us as professionals part of their diagnostic plan, because a lot of times they need our testing to help figure out is it Meniere's disease? It is 3PD? Is it some of these big higher vestibular issues? So, I feel like I've had the best experience even now working with neuro otologists just because of how their training has taken them to their role.


[00:44:01] DR: Yeah, I have to agree. I've also been fortunate to be around some pretty incredible neuro otologists and just, you know, general ENTs. But I've also heard horror stories of other individuals bumping heads with some of the other professionals. But I would also say that there's also a really good collaborative relationship with vestibular audiologists and neurologists. And so that, I would say that's probably almost half of — could be up to half of the referrals can come straight from neurology and not even come from the ENT department. So, yeah, as a vestibular audiologist, you’re working really closely with not just ENT, but also other disciplines like that.


[00:44:41] LF: Yeah, you think about where and I always talk about this, I do the marketing for our practice. So, I'm always thinking about where referrals come from. But neurologists are huge because if dizziness is a neurologic sign, so a lot of people get referred to neurology if they say they have dizziness. And a lot of times, if it's not something that they can quickly identify or figure out, they're also looking for a resource for, “Okay, where do we go next?”


But the other big ones like urgent cares and emergency departments because we know that like one in three people who go to the ER have dizziness is a primary symptom. And so, a lot of ERs are looking once they rule out all the big scary stuff, they're like, “Okay, where do we go? Where do we go next?” So, there's a lot of professionals who work very well with vestibular, especially once they discover what you do and how you can help their patients.


[00:45:27] DS: That's awesome. I think one of the trends I'm hearing in this whole conversation is like, if you're the kind of professional or clinician who really is interested in and excited about, like interprofessional collaboration. I mean, as an audiologist, there are other professionals I work with, but I wish like, in some ways, I'm like, “Oh, it would be great to have more people on this team when it comes to hearing loss.” In some situations, there's a reason for that. But it sounds like in this world, it's kind of required. You might need your vestibular PT who's really focused on the rehab, and the neuro otologist, or the neurologist who's focused on, whether it's the medical etiology, or whatever. And then as audiologist, whether it's within diagnostics, or, you know, the counselling journey for this. I mean, there's so many people who kind of have to be on this team. It's not really even optional.


[00:46:13] LF: I feel like it's definitely expanded my awareness of just other medical disorders that I don't know I would have had exposure to if I wasn't forced to through my patients. But especially since I specialized in concussion, I feel like I've had the opportunity to even work with like optometrists, and like people that I would never even have an overlap with. But I may see something weird going on with the eyes, or I do some screening and concussion with ocular motor stuff, and it's really neat how many different professionals we work with.


[00:46:44] DS: Okay, that's another great transition. Because I was really curious if you all had a like an interesting case, or a patient that's going to stick with you throughout your career who either is a good reminder of why balanced care is important, or why you're interested in this. And I'm curious, Liz, too, it's been a weird trend and like the last few podcast episodes, so we had Dr. Julius Fredrickson on. He's an SLP. But he's also a researcher specifically on the brain and he's looking at aging. And then their study on aging was like, abruptly halted when the pandemic started. And they actually started looking at how COVID changes the brain, and he says, if you're like a clinician who's working with people who are having like long-haul COVID symptoms, whether it's like processing or brain related problems, their research is like showing that there might be a good connection to, TBI, maybe concussion literature in terms of expectations, and rehabilitation. Still like really early, but that's a cool connection.


And then we also had Dr. Gail Whitelaw, who talked about kind of like auditory processing disorders and possibly amplification as an option for them. She's worked a lot with people who've also had concussions, and some TBI. So, it's been like a repeated pattern this year to talk about concussion in some way. And now, this is cool to get kind of a vestibular take on it as well. So, I'm curious. I mean, I don't know too much about — in fact, I don't know much at all about concussion and balance, and I'm curious if whether you want to break it down via a case or if you just have an interesting story, where those worlds collide for you.


[00:48:11] LF: Oh, my gosh, I was just talking with Daniel about this, because I was trying to think of interesting cases, and I honestly feel like it's just every single day, there's some patient whose life is dramatically changed by our testing and that sounds very drastic. But like I said, many people are visiting so many medical professionals who don't want to deal with dizziness, or don't know how to deal with dizziness. I feel like number one, they're just happy to talk dizzy with somebody, like someone who's interested and wants to listen to them, because most of the time, that is the number one thing that gets dismissed. It's kind of like tinnitus. I feel like it's one of the things that gets dismissed very often, and the people who are suffering from it are really suffering from it.


So, I can think of so many cases, head injury cases where like, I had a 21-year-old baseball player who was kind of close to going pro. And he got hit in his temporal bone by a baseball, and he went through a typical concussion rehab protocol with a physical therapist, which looks way different from vestibular rehab, not way, but enough different. Finally, like, eight months later, he found — they were Googling and they like found me and they were just looking for help because he hadn't gotten better. He like still couldn't play baseball. And so, I did a full eval on him and my concussion eval looks just a tiny bit different from typical vestibular.


But of course, he already knew he had hearing loss. He was wearing a hearing aid in the ear that he got hurt. But he also had a complete vestibular loss on that side, which, it's first of all crazy, because he had of course been seen by people who diagnosed his hearing loss and he had been fit with a hearing aid, but nobody had really dove into his balance symptoms and his dizziness that he was having. So, of course, I did like the whole game. I did rotary chair. I did calorics, VEMPs, everything. Everything indicated that the side that he was hit on, he didn't have any vestibular function like his caloric was so minimal, like I had to continue doing it, making sure it wasn't me.


But this was so important for this patient, because he had always been told that he was going to get better. And it was a hard conversation, especially since he wants to go pro, and he could, that he may not fully compensate. Because when you have one vestibular system that's contributing nothing, you're not going to probably get to the pre injury level that you were at. Just because he's such a high performing athlete, he's going to notice the difference between 97% better and 100% better, and he may not get to 100%. I think that information was super critical for him and his parents who especially wanted to see him succeed. It's actually turned out to be a really interesting case. I should write a case study on it, but I never write because it's too much work.


I've seen him for like 10 months, and he still has a spontaneous nystagmus, he still has an abnormal rotary chair. And so, he's just been sent back to neurology to get an MRI again, because I'm like, something is not right. It's weird for a 21-year-old to not be able to compensate and the fact that he still has a spontaneous nystagmus and all this jazz. So, I don't know, I'll be interested to see what his MRI shows because he may have something even bigger going on. And a lot of times that's true with vestibular, like my tagline in our clinic is always, “Everybody has a tumor unless proven otherwise”. Because you seriously can miss things. Sometimes you're the first person to like see signs of MS, or a huge like skull-based tumor. I was just telling Daniel, I helped discover like a skull-based tumor that like had to be operated on immediately, basically, for this young female, just because of abnormal eye movements.


I mean, it's just wild the stories that you get from vestibular because some of them could be lifesaving, or at least life changing. Some of them are as simple as just like, not having a 75-year-old fall and break their hip, which is also amazing when you can help them with that.


[00:51:56] DS: I almost put that in the intro to talk about how we are literally in a pandemic of falls in the elderly population, and how that is definitely, at least in one of my clinic rotations, that was something that we talked about a lot, is like how many older adults they see, and how it's not always related specifically to like the inner ear balance system, but like still kind of falls within our scope of practice and just like you said, other things can be caught, when it might not win, sometimes it's just a blood pressure issue. But it's all really, really interesting. Thank you for sharing that. I mean, I think that's a story that's definitely going to inspire a student out there who isn't so sure about taking the plunge into like leaning into vestibular, and that's such a cool thing that you get to see.


Daniel, I'm curious if you have any of them that you want to share?


[00:52:37] DR: Yeah. With regard to, you know, the story that Liz shared, there's just so many times as a clinician, that you're coming across these patients who are just looking for help. Liz had mentioned earlier that the average dizzy patient sees four to five different professionals. And so by the time they get to you, it may be months after their initial episode of dizziness, and if it is and underlying vestibular impairment, you go through compensation as you're traveling, trying to seek answers, and maybe the only answer that you receive, because you go through these compensation process, you may be functionally back to normal, but you may still not know if you had a vestibular insult, and you may not find that out until your vestibular testing.


So, you go through all of these different professionals, and patients who are dizzy, are just really, really looking for answers. As audiologists, we can help provide that to them. I would say, with regard to just patients that I've seen, the most gratifying situation that why I love working with dizzy patients is or just patients who have something simple as Benign Paroxysmal Positional Vertigo or BPPV. Those patients, typically they're going to end up in the ER. It could be a pretty violent episode of vertigo, and everyone seems to remember their first episode of vertigo with BPPV. They either think that they're having a stroke or having a heart attack and if not treated properly, that BPPV is — sometimes it does really resolve on its own naturally but oftentimes, sometimes it won't and they may go through these different several different spells of vertigo or positional vertigo that they have no idea why it's happening and they're going to all these different professionals, telling them, “Yes, your heart’s okay. Everything's okay. All of these boxes are getting checked off.”


So, by the time they come to you, they may be a little bit more frustrated at why they're not they're not receiving the answers, and the vertigo that they're experiencing is very real. So, when you're able to diagnose that in two hours and treat it in eight minutes. They are really, oftentimes amazed at what you're able to do for them and very grateful and those patients I love working with.


[00:55:14] LF: I always talk about when I'm talking to professionals about when to send for dizziness evaluations, like Daniel mentioned, dizziness is so scary. I think many people haven't experienced it. So, you don't realize how terrifying it is because you do think you're dying, or you're having a stroke. A lot of people live in fear of “When is this coming back? Should I expect this to come back?”


So, even if the dizziness has passed, it still can be beneficial to get an assessment from vestibular audiology, just for someone who's used to talking about dizziness knows what types of dizziness disorders exist, both in vestibular and outside of vestibular, because I feel like the greatest thing I can give, even if the test results don't indicate something is whether they should expect this to happen again, what the test results indicated, because otherwise, you're just kind of living in fear. And a lot of people will stop driving, stop working, because they don't want it to happen again. It's embarrassing. It's scary. It's nice when you can provide that comfort of whether they should expect it or what they should be doing to prevent it again.


[00:56:15] DS: Yeah, I've actually got a guy on my caseload right now. He's in his, I want to say he's like in his mid-50s and he's a gasoline truck driver. So, he drives the big tanks of gasoline from station to station. He got his first cochlear implant, I want to say earlier this year or late last year, and he is a rock star. He is one of my star performers with his implant. But in the last, I guess, two months, he has started to have these, like sudden vestibular attacks that last about an hour according to him, with true spinning. And it doesn't sound like BPPV to me, but I also — I have asked him, are you seeing any patterns here? When you're wearing your implant or when you're not wearing your implant? And then he through like, a long line of questioning, trying to find some kind of pattern here. “Yeah, well, I also saw a doctor like two weeks ago, and they told me my blood pressure was really low.” His heart rate was also very, very low. And I was like, “Well, is there any connection between those two?” He was like, “Well, I haven't ever checked my blood pressure when it was happening.” Maybe we should try that.


So, he's scheduled with someone locally to do a vestibular evaluation. I don't know if that's — last time I saw him was a few weeks ago. So, I don't know if that's happened already. But he's just another one of those examples of like, just like what you said, it's scary. He and his wife are like, I can't have one of these episodes while I'm driving a gas truck. I don't know what's going to happen. So, you're so right, that it's going to impact their quality of life way beyond like, “I was uncomfortable for a little while”. It's like I fear for my life when this happens. So, it's a really great insight, and a really good reminder to have that empathy for these patients. I remember, this is like, a little sad, but I remember I had a supervisor at one point along my student journey, who saw some vestibular patients, and there was just like, a lot of resentment there like dizzy patients are so annoying, or like they just complain blah, blah, blah. And it was such a like, different take on that where I hear a lot of like — I guess, not a lot, but I've heard similar complaints from people also work some with tinnitus patients where it's just, if you don't take the time to empathize with how much this is actually impacting their quality of life, it can sound like complaining. “Oh, like you had BPPV. You were spinning for a minute, you're fine.” But you're so right that that fear, when it could happen at any time, and they are so confused, and they don't understand what's causing it.


And like you said, if they're seeing four or five professionals, it would feel like to them that the professionals don't know what's causing it either, which makes it even more scary, right? So, those are just really great helpful reminders. I really appreciate you guys sharing that.


[00:58:39] LF: Yeah, and I do think vestibular I don't mean to dog on the audiology professionals because obviously I am an audiologist. But I love vestibular because it's such a functional implication when you have dizziness or balance disorders. It prevents people from going to work, from driving, from like walking outside and exercising and, like so many functional implications to people's health. I feel like it was harder for me, as an individual to convince people that they have a hearing loss and use my test results. It felt more like an uphill battle when I was doing predominantly hearing loss and hearing aids because people functionally can get around their hearing loss for a good amount of time. Not everybody, obviously. But it was such an uphill battle for me to be like, “I know you can turn your radio up higher. I know you don't feel like you have a problem”. But like with dizziness, you do not have to convince someone. I mean, you say how is your dizziness and an hour later, they're still talking, you know, like they are desperate for people to hear them, because functionally, it's destroying their quality of life.


[00:59:41] DS: That's a really good insight. That's great. Wow. Okay, we are at the end of our time that really flew by. And it was just really helpful to me personally. I'm hoping a lot of the clinicians out there feel the same way. I'm curious as we kind of wrap up If there's any other last insights you would share, we have a lot of student listeners, young clinicians, and also, we have a good amount of SLPs. Is there any, like last little bit of thing if you had, just to share with a different audience from your typical dose of dizzy listener?


[01:00:08] DR: With regard to, I would say, vestibular science, especially the research part, area, it's very much in its infancy, there is just so many exciting areas that I am personally looking forward to, and hopefully contributing to some of the science here in the next several years. But there's just so much that we still don't know, as far as the effects of a vestibular impairment on the human body. We know that it is an independent risk factor for falling. So, that's a huge — we had definitely touched on that with regard to the older population.


But there's also a lot of emerging evidence to suggest that vestibular impairments are associated with cognitive decline and spatial memory. So, your ability to know where you parked your car, could there is evidence to suggest that that skill or that ability to know where you parked your car, that spatial memory is linked to the vestibular system, and then when there is an impairment, that may affect some of that. So, there's just a whole — I always like to think of this as the the new frontier. I think with regard to the auditory system, the research or if you compare just the body of literature between the auditory system, the vestibular system, the vestibular system is, yeah, there's a lot out there, but it's still not as much as the work that has been done in the auditory system. And so, there's still so many different areas, just trying to understand its physiology, that I'm really excited about.


[01:01:48] DS: Something to be excited about. I love it.


[01:01:49] LF: I feel like, the thing that I am always trying to do daily with each patient is be as comprehensive as possible, and I think part of this comes from working in private practice, where I don't have the safety net of being with other professionals who also may ask the questions for me. I think it's a good way to practice. It's very autonomous. But I would encourage, if it's a speech language pathologist, we also employ on our practice, so I feel like I've really been stretched outside of what I normally ask. But I really try to ask every patient and especially my concussion patients about cognitive and memory concerns. I ask about tinnitus and sound sensitivity, where I don't necessarily address that. But I have a colleague that does, and really tried to capitalize on vision issues. So, I can refer to optometry.


Because you may be the only person that's asking this, because what I've noticed with especially chronic dizzy patients, is at a certain point, some providers stop listening. I think I, understand why, because it's a lot and a lot of times, they're chronically dizzy, and they have a lot of anxiety associated to that. But you may be the first person to ask that. You may be the first person to notice a balance concern, especially in our therapy colleagues, they see these patients a lot more than we do. So, I would encourage everybody to ask questions, maybe outside of your dominion, because you may be the only one that's asking it, and you may know who to send them to for help.


[01:03:08] DS: That's awesome. That's awesome. That's such a usable advice from both of you guys. I really appreciate that. Okay, well, that takes us to the end of our time, sadly. I know that you guys are currently at the end of your first season or second season? Or are you kind of on a break?


[01:03:22] LF: Yeah, first season.


[01:03:23] DS: First season's over. But where can people find you if they have more questions, if they want to probe your brains for your vestibular expertise? What's the best way to reach you all?


[01:03:32] DR: Probably, I would say our Instagram @adoseofdizzypodcast. We also have an email account that you can reach us directly at it's, adoseofdizzypodcast@gmail.com.


[01:03:44] DS: Awesome, awesome. I'm so grateful that you all joined me. And if you guys ever have anything specific in the future, you want to break down even in more detail whether it's a specific disorder or a test, or maybe a new piece of research published by the great Daniel J. Romero that is worth discussing, because it's just a hot topic, you guys are welcome back anytime. Thanks so much for joining me.


[01:04:05] DR: Thank you for having us.


[01:04:06] LF: Thank you. We appreciate it.


[END OF INTERVIEW]


[01:04:09] DS: That's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education, through speech therapy PD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes. Just head to speechtherapypd.com/ear. That’s speechtherapypd.com/ear.


[END]
        © 2021 On The Ear