The Defense Health Agency’s Hearing Center of Excellence offers a specialized course to train clinicians how to treat dizziness and imbalance in patients with mild traumatic brain injury, otherwise known as concussion.

Ears are essential for our vestibular sense, also known as the movement, gravity, or balance system, which allows for smooth movement. Located inside your inner ears, the vestibular system helps with balance while walking or running and with staying upright when standing or sitting. Patients may develop vestibular disorders after a concussion from blunt or blast trauma, or from other illnesses that cause balance issues.

The Military Vestibular Assessment and Rehabilitation training includes movement techniques, visual exercises, and vestibular exercises to treat balance issues.

The MVAR training evolved out of a course sponsored by the American Physical Therapy Association that is considered the gold standard for vestibular rehabilitation training.

Historically, medical personnel less familiar with the role of the vestibular system had few options to treat dizziness and imbalance and would often simply wait to see if these issues resolved over time. If symptoms did not get better patients were treated with medications to suppress their symptoms, but these medications did not fix the underlying pathology.

“The existing APTA course really focused on civilians and not service members. It also did not focus on the unique demands of the military. That's where we got inspired to use the APTA course as a springboard and move into some kind of military-specific vestibular assessment and rehabilitation course,” said U.S. Army Lt. Col. Carrie Hoppes, the director of the Army-Baylor University Doctoral Program in Physical Therapy at the U.S. Army Medical Center of Excellence at Joint Base San Antonio-Fort Sam Houston, Texas.

The course was developed by Hoppes and then-U.S. Army Capt. Karen Lambert, the officer in charge of the Traumatic Brain Injury Section of Physical Therapy at Walter Reed Army Medical Center from December 2007 to August 2010.

Basic and Advanced MVAR Courses, and Great Reviews

The week-long, hands-on MVAR course focuses on mechanisms of injury less common in the civilian world, such as blast-related trauma and combative blunt trauma. In addition to teaching exercises and movements to help restore balance in patients with a concussion, the course highlights return-to-duty requirements and considerations.

Basic and advanced courses are available to DHA and Department of Veterans Affairs medical personnel. There is also a regional option for clinics that require training for multiple members of their medical staff.

For the regional course, the MVAR team travels to military hospitals and clinics to assess what medical personnel are already doing to address dizziness in patients with TBIs and inner ear disorders and to increase capabilities to improve quality of care.

U.S. Army Maj. Garry Dredge, the chief of Sports Medicine at the Desmond Doss Health Clinic at Schofield Barracks, Hawaii, took the basic course in December 2022.

With local clinic coverage now available, “patients no longer have to make the time-consuming and inconvenient trip from Schofield Barracks to Honolulu for care,” Dredge said. “This change is expected to lead to faster recovery times and improved patient outcomes.”

“The course highlights the critical importance of a thorough, accurate, and timely assessment for patients with vestibular issues,” Dredge said. While assessment and treatment concepts “may have been touched on in physical therapy school, this course provides an in-depth explanation of why a detailed assessment is so crucial for this patient population.”

“The course stresses that every patient with vestibular disorders presents differently and that a one-size-fits-all approach is not effective,” Dredge said. He added the plan of care is based on each patient's unique presentation, needs, and goals.

The training “emphasizes the importance of a collaborative and integrated approach to care … with other disciplines such as TBI providers, occupational therapists, and behavioral health specialists providing comprehensive care to address all aspects of the patient's condition,” he said.

“The advanced course is directed at DHA and VA professionals who are already evaluating and treating patients in specialty TBI centers within the Defense Intrepid Network, and includes topics such as differential diagnosis, medical and surgical management, and advanced rehabilitation for vestibular dysfunction,” Hoppes said.

Both courses blend a lecture/lab training model to allow health care professionals to practice techniques and receive instant feedback from instructors. At the end of the course, students take a lab-based competency test where they select a case, walk through a full exam for dizziness, come up with a diagnosis, and describe treatment for a mock patient.

To date, more than 620 DHA and VA personnel have taken the basic or advanced course, and there are wait lists to enroll because it is in demand.

Gaps Filled

Guidance in the MVAR training aligns with leading clinical practice guidelines for vestibular disorders.

“Already, there's a robust clinical practice guideline from the American Physical Therapy Association for individuals with a unilateral hypofunction, meaning one vestibular system is not working optimally,” Hoppes said.

A clinical practice guideline for Benign Paroxysmal Positional Vertigo “tells you that you don't need additional imaging and diagnostic studies, you can do the tests and the treatments we teach in our MVAR course to effectively resolve this condition,” Hoppes explained. BPPV occurs when crystals in the inner ear become out of place and is the most common cause of dizziness and vertigo.

Yet those with this condition can only be treated appropriately if they’ve had a correct diagnosis. Only 8.7% of individuals with BPPV have documentation that they received the appropriate treatment, according to HCE.

If someone goes into the emergency department to seek treatment for BPPV, “the workup is over $2,000, because we're not doing what we need to be doing,” Hoppes said. “If we follow the guidelines, it's a matter of positional testing and repositioning to treat that disorder and we don't have to give them medications and have them lose any time,” Hoppes said. The repositioning maneuvers each treat a specific type of BPPV.

MVAR’s Future

Portions of the course are online, as are supplemental training materials such as videos and home rehabilitation training exercises; however, “HCE has stopped short thus far from bringing the whole course online as we feel very strongly that the in-person learning environment is critical for hands-on lab training, as well as clinician networking that takes place organically in the live training environment,” Hoppes emphasized.

Down the line, MVAR educators want to follow up with those they have trained “and shadow them in clinic and provide clinical mentorship as a bridge that offers robust support after the continuing education course,” she said.

“We are trying ' to ensure we have these skills across the Military Health System because these patients are everywhere,” Hoppes said. “We want to educate people that there's this great course, and it's going to help you in your practice with people who have a mild TBI, and even perhaps more severe TBI.”