Turning vestibular service delivery on its head
Innovative new technology and an expanded service at a Queensland hospital is helping patients with dizziness and vertigo find the balance they need to live their best lives. InMotion speaks with the state’s first vestibular consultant, physiotherapist Leia Barnes, about her passion for vestibular physiotherapy and the rapid changes taking place in the field.
Eleven years ago, there was no designated public health position for vestibular physiotherapy in Queensland. Instead, vestibular physiotherapy was traditionally embedded in a service where someone had an interest in it, such as in rehabilitation or musculoskeletal physiotherapy.
Now, taking up the mantle as Queensland’s first consultant vestibular physiotherapist, Leia Barnes APAM MACP is changing how vestibular physiotherapy is perceived and valued in the Queensland healthcare system and beyond.
‘If I can help pave the way for other vestibular physiotherapists and have vestibular physiotherapy recognised in its own right as a specialty position in Queensland Health, that is something the profession can be proud of,’ says Leia, an APA Neurological Physiotherapist.
‘Queensland Health can also benefit from having someone spearhead what’s next in vestibular physiotherapy in the state.’
The journey to the role she is in today began more than 15 years ago. In the past, Queensland Health allied health positions were paid according to a Professional Officer scale.
Considerable work went into the changeover to a new scale with clear work level statements. The current scale has an eight-level health practitioner (HP) structure.
Across Queensland, HP6 positions are generally held by those in management roles, such as deputy directors of larger hospitals or directors of smaller hospitals or teams (management stream).
However, provisions were also put in place for clinical HP6 positions (clinical stream), allowing clinicians to be recognised at an expert level of knowledge, skills and experience with state/national-level leadership in that clinical area.
This decision, made 15 years earlier, meant that Leia would have the opportunity for expert-level vestibular skills to be formally recognised and promoted within the health system.
‘When the new HP scale was created, there was provision within the scale for clinicians to be recognised at the HP6 and HP7 level. Work roles and responsibilities were described for each level of the HP scale and existing positions were evaluated against the described roles and responsibilities.
'Lead clinicians working in established areas of physiotherapy such as musculoskeletal, cardiorespiratory and neurology were appointed to the relevant HP level after their roles were evaluated and matched to responsibilities assigned against HP6 or HP7 work level statements.
'Due to the emerging status of vestibular physiotherapy at the time of the HP level evaluations, no position within this area of physiotherapy was evaluated to match the role and responsibilities of an HP6 level clinician.
'This meant that there was a clear gap in statewide clinical leadership for vestibular physiotherapy,’ Leia says.
‘That was an exciting prospect for me, so I worked with my Director of Physiotherapy to identify what statewide clinical service gaps existed and how my existing HP5 role could be expanded to meet those clinical needs and fill the identified gaps.
'In doing so, we created a clear plan to achieve something that hadn’t been done before in Queensland Health.
‘As my role expanded to encompass responsibility for statewide service provision, my existing HP5 role description was updated to reflect these new responsibilities.
'In 2020 I began the process to have my updated role description evaluated against the HP work level statements.
'The following year there was an internal and external peer review process, external to our health district, and they reviewed my application and re-evaluated my role to be at HP6. So I’ve been in this new HP6 role for about 15 months now.’
Part of her remit is to oversee the vestibular physiotherapy service offered at Logan Hospital, a Metro South Health hospital in Brisbane’s south-east.
In the past five years alone, the vestibular service where Leia is based has doubled its number of staff. This growth coincides with an eight per cent annual growth rate in emergency department dizziness presentations, of which there are approximately 20,000 every year in Queensland.
‘It’s been a team effort. In the past two to three years, there’s been astronomical growth in our service.
'I came on in 2016 at three days a fortnight—that’s one physiotherapist at 19 hours a fortnight. We now have six vestibular physiotherapists in our team.
'Everyone has worked very hard to build both local and statewide services and we’re continuing to work hard, with the backing of Associate Professor Bernard Whitfield.
'It’s important to have a consultant who will go in to bat for your service. We wouldn’t be where we are today without the team behind me and walking with me and Dr Whitfield cheering us on, paving the way and assisting with the health system hierarchy.’
Leia thrives on working with passionate, like-minded colleagues who are heavily invested in building a vestibular service of excellence.
As a clinician, she regularly uses vestibular rehabilitation strategies to help people find relief from their dizziness and imbalance.
Recently, Leia has overseen the arrival and application of some of the biggest technological advancements in vestibular services in the history of Queensland Health.
The Complex Vestibular Service at Logan Hospital now boasts the only Bertec Computerised Dynamic Posturography Immersive Virtual Reality (CDP/IVR) equipment in Queensland and is the first in the Southern Hemisphere to use it for treatment (one other machine is used in research at the University of Canberra).
The $400,000 machine, a core piece of equipment used to treat dizziness at the hospital’s Virtual Reality and Balance Clinic, was shipped over from the United States and began helping patients in 2021.
Patients are harnessed into the Bertec CDP/IVR equipment, which combines immersive virtual environments with dual- balance force plate technology.
This helps to assess a patient’s balance responses and the dynamic force plate also sways with the patient’s postural movements to enable practitioners to perform a sensory organisation test.
‘The Bertec CDP/IVR can also look at other balance responses,’ Leia says.
‘It can look at how well the muscles respond to repeated perturbation and the level of postural sway as well as the limits of stability. It can track all of that. It’s a high-tech balance assessor.
‘The virtual reality component allows you to change the environment for the patient. It is technically what we would call semi-immersive.
'So if the patient is walking through a virtual park, we can add in distractions; we can have birds fly in front of them, position chairs or boulders for them to move around.
'We also have shopping centre scenes, castle and flying scenes. And of course we have driving as well—many different ways to challenge their balance using virtual reality. It’s certainly an excellent piece of equipment that we have access to.’
The Bertec CDP/IVR system complements the new TRV Chair, a multiaxial repositioning chair that arrived last year from Denmark and is designed to help treat patients with benign paroxysmal positional vertigo, which causes dizziness, vertigo, unsteadiness and nausea on head movement or position change.
Leia says they were able to purchase both pieces of equipment due to separate applications made in 2019 and 2020 to Queensland Health via its Queensland Technology Future Fund, which earmarked a significant budget for new technologies.
Through varying purchase processes, it so happened that both pieces of machinery arrived at Logan Hospital around the same time.
‘Prior to Logan Hospital getting the grants, Queenslanders would have to travel interstate to access a multiaxial repositioning chair. There’s a TRV Chair at the University of Melbourne and two other repositioning chairs in Melbourne and Sydney,’ Leia says.
The arrival of the two new pieces of technology meant that Logan Hospital’s Virtual Reality and Balance Clinic and TRV Clinic could both begin operating in January 2022.
The clinics are now receiving referrals from across Queensland, some parts of northern New South Wales and more recently Western Australia—with the potential for the clinic to accept patients Australia-wide as the need arises.
Running parallel to the clinics is another service Leia is heavily involved with—Dial-a-Dizzy—a statewide telehealth emergent vertigo hotline (see below). The Logan Hospital Complex Vestibular Service includes the Virtual Reality and Balance Clinic, the TRV Clinic and Dial-a-Dizzy.
Leia says that on any typical day, a doctor or physiotherapist from another hospital will call Dial-a-Dizzy on 1300 4 Dizzy and ask for help with a patient who is experiencing dizziness.
Dial-a-Dizzy has been set up at six rural and remote hospitals so far— Cooktown, Beaudesert, Goondiwindi, Longreach, Mount Isa and Weipa—with more facilities coming on board soon.
Providing clinical advice to other health and medical practitioners is part of Leia’s responsibilities as a consultant (HP6) level clinician, including mentoring advanced (HP5) level physiotherapists.
Leia says she regularly conducts mentoring sessions with advanced level physiotherapists about vestibular service set-up, all performed on an online platform.
‘I also mentor other physiotherapists across Australia.
'Recently I’ve been mentoring a physiotherapist setting up a service in Perth and I’m currently providing advice to a team in Newcastle as they set up their new vestibular service,’ Leia says.
‘I’ve been assisting in other areas across different states as well. A key thing for me is mentoring at a strategic, service-development level as well as at the clinical level.
'As part of Dial-a-Dizzy, I’m acting as a clinical adviser to medical teams across the state in rural and remote hospitals.
'In that role I’ve had the opportunity to travel to Longreach, Mount Isa and Goondiwindi to train the medical, nursing and allied health teams in assessment and management of dizzy patients in the emergency department setting. It’s an exciting step because we’re looking to grow that even more.’
Leia’s passion for vestibular physiotherapy has its roots in her early life, when she experienced vertigo as a child and as a teenager. She went on to learn that she was experiencing vestibular migraines.
One of her lecturers at the University of Queensland, Nancy Low Choy, a leader in vestibular physiotherapy in Queensland, piqued Leia’s interest in the field after asking her about the migraines.
‘It was Nancy who started asking about my dizziness; I didn’t realise that you could actually do something about dizziness.
'That really came to a head in my new grad year when I was mentored by Natalie Rando-Orr, who is also a leader in vestibular physiotherapy,’ Leia says.
‘And when I was younger I remember watching a TV program about a person who had a traumatic brain injury after a motor vehicle accident. They needed to learn how to walk again and I was blown away by the fact that there was a profession that could teach people how to do that.
‘That’s when I learned about the role that physiotherapists play in hospitals and that’s when I decided I wanted to be a physiotherapist, based on the understanding that you could become a neurological physiotherapist.
'It was always my goal to be in neurological rehabilitation. And I have always wanted to work in the public health system.’
Leia says vestibular physiotherapy is a wonderful pursuit for anyone who enjoys the intellectual challenge of understanding the rules of a complex system.
‘I’m really drawn to things making sense in terms of when things follow laws. I have a bit of a joke that if you enjoyed maths and algebra you’ll probably find yourself enjoying vestibular physiotherapy because the peripheral vestibular system follows laws.’
Phone a friend for vertigo
The first physiotherapy-led telehealth advisory hotline for emergent vertigo, Dial-a-Dizzy, has already completed more than 100 telehealth consultations across Queensland since the service started in January 2022.
Dial-a-Dizzy offers specialist advice to help patients presenting to emergency departments with acute dizziness, vertigo and imbalance.
This extends to patients in rural, regional and remote areas who might otherwise have been medically evacuated for urgent investigation and treatment.
We work with the local treating team to provide onsite care for vestibular (inner ear) conditions such as benign paroxysmal positional vertigo or help with early recognition of stroke signs, which allows the emergency doctor to quickly respond and escalate management,’ says consultant vestibular physiotherapist Leia Barnes.
The service operates on a telehealth basis, with remote emergency department clinicians dialling in to a Logan Hospital Dial-a-Dizzy clinician to conduct a patient examination.
Leia says the unique service is part of the Complex Vestibular Service, in partnership with the Integrated Specialist ENT Service at Logan Hospital and the Healthcare Improvement Unit, Queensland Health.
‘Videos of eye movements obtained using special infrared goggles can then be uploaded for the Dial-a-Dizzy clinician to interpret before providing a report to the remote clinician,’ Leia says.
‘Early Department of Health data demonstrated that in Queensland, 50 per cent of emergency department dizziness presentations resulted in admission.
'For Dial-a-Dizzy, 82 per cent of our emergency department referrals have resulted in safe discharge home, which means that only 18 per cent go on to admission.
'This is an excellent outcome when compared to statewide data. We are excited to show that not only is our service helping patients with dizziness, but we are also helping to reduce bed pressures in Queensland hospitals.’
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