We’ve all heard the idiom “if I had a nickel for every time…. I’d be rich”. At BalanceMD, this phrase applies to when physical therapist Stephanie Ford is told by her patients “you have a different approach”. Stephanie specializes in vestibular rehabilitation therapy (VRT), a specialized form of physical therapy (PT) that focuses on treating the sensory part of balance. Frequently, we see patients who have had physical therapy elsewhere for their dizziness or balance problems, but they did not feel it was effective. We are told they worked on the stationary bike, did arm/leg exercises with stretchy bands, walked a “tightrope” and stood on one leg.
There is more to balance than being able to walk a tightrope or stand on one leg. Those activities can be used as measures of balance, but when do we need to walk a tightrope in our daily life? Most of the time, having trouble with balance is not due to leg or abdominal weakness. It’s a problem with the sensory part of balance (vision, sensation in the feet, and the inner ear) OR the brain’s ability to put together this sensory information and come up with the correct response under various conditions.
Improving the sensory part of balance is what VRT offers – it is different than typical physical therapy in that it focuses on getting the brain to use sensory information better to improve balance under a variety of conditions, not just hard surfaces, but also soft and uneven surfaces. The exercises are quite simple but very effective. They may involve standing on the floor with eyes open, eyes closed, feet close together, then progressing to standing on a cushion, or moving the head while walking. The exercises need to be challenging, gradually progressing the type of exercise based on the underlying problem(s) while also ensuring safety in practicing these exercises at home.
At BalanceMD, our patients are often surprised when they start feeling better about their balance within 1-2 weeks of beginning their custom exercises. As the exercises progress, they feel more confident and safer to do their normal daily activities again.
So, VRT is a “different approach”, and a very effective one for improving balance and reducing or eliminating dizziness.
I you or someone you know are suffering from dizziness or imbalance that might improve with VRT, please give us a call at (888) 888-DIZZY (3499) to schedule an appointment.
Very few physicians have ever heard of ‘3PD’, which stands for Persistent Postural-Perceptual Dizziness. 3PD is a new name for a medical condition formerly known as ‘phobic postural vertigo’ or ‘chronic subjective dizziness’. As the features, diagnostic criteria and treatment options of 3PD have been refined over the years, 3PD will appear for the first time in the ICD-11 (11th version of the International Classification of Diseases), being released in 2017. So, if you are a healthcare provider and have never heard of 3PD, this article offers the opportunity to be on the leading edge of being able to recognize this condition in your patients. If you are someone who suffers from dizziness that no one has been able to treat effectively, see if the description of 3PD below resembles your symptoms.
What is 3PD? 3PD is a non-vertiginous (non-spinning), waxing-waning dizzinessand/or unsteadiness, persisting for at least 3 months, with symptoms present at least 15 days per month, but typically daily. 3PD often follows a separate triggering event (vestibular neuritis, vestibular migraine, Meniere’s, head injury) that caused dizziness, vertigo or unsteadiness. With the anxiety or worry over an underlying sinister cause (i.e., tumor) of these dizzy symptoms or with the anticipation of having another vestibular attack, symptoms of 3PD develop.
What are the symptoms of 3PD? The symptoms of 3PD include dizziness and /or unsteadiness, worse when upright, head or body in motion, and in visually busy environments, becoming worse later in the day. Worsening of symptoms in grocery or large stores, when reading, scrolling on the computer or cell phone, and with exposure to complex patterns on carpeting, wallpaper or clothing, is common. Fatigue and trouble concentrating may develop. The dizziness and/or unsteadiness becomes intrusive and the symptoms of 3PD have been called elsewhere (www.neurosymptoms.org) the “balance equivalent of tinnitus”.
How is 3PD treated? Once other causes are ruled out with appropriate vestibular function and/or other diagnostic testing, a combination of medications, such as benzodiazepines and SSRIs, and vestibular rehabilitation therapy is often effective. With significant underlying anxiety, cognitive behavioral therapy may also be helpful.
What is BPPV?
BPPV (Benign Paroxysmal Positional Vertigo) is a common inner ear disorder that causes brief spells of vertigo (spinning sensation) triggered by a change in head position. For example, lying back or rolling over in bed, getting up from bed, looking up or down results in brief, 10-15 seconds of vertigo and usually no dizziness any other time. BPPV is caused by“crystals” normally present in one part of the inner ear, but become detached and displaced into another part of the inner ear where they cause vertigo with changes in head position. However, there are many patients diagnosed with BPPV who do not fit this description of symptoms or have a different cause of positional vertigo, yet are often diagnosed and unsuccessfully treated as though they had BPPV.
Why is BPPV Over-diagnosed?
BPPV has gained popularity as a diagnosis because it is a benign condition that causes vertigo and is readily diagnosed and immediately cured by a skilled healthcare provider. Patients often joke about “having a few loose rocks” in their head. BPPV is a common condition, but there are many more people diagnosed with BPPV than actually have BPPV.
How is BPPV Treated?
BPPV is treated by a “crystal repositioning maneuver” (CRM), which is designed to move the “crystals” by gravity back to where they originated, where they may be dissolved. The type of CRM utilized depends on the type of BPPV. For example, one form of BPPV is treated with a modified Epley or a Semont maneuver and another type with a Lempert roll. There is also a type of BPPV where the “crystals” are actually stuck to a membrane in the inner ear and is treated with a headshake of Gufoni maneuver. BPPV is no longer treated by the old fashioned Brandt-Daroff or Cawthorne-Cooksey exercises, or with medications, such as meclizine (Antivert). We are actually able to cure BPPV in one visit over 90% of the time with the appropriate CRM. Unfortunately, we see many patients incorrectly diagnosed with BPPV undergoing a modified Epley maneuver dozens of times unsuccessfully.
What else causes positional vertigo if it’s not BPPV?
Because migraine is the most common cause of dizziness/vertigo and can cause positional symptoms, the most common correct diagnosis in those mis-diagnosed with BPPV, is vestibular migraine. Other conditions which may cause positional dizziness include inner ear nerve weakness, blood pressure changes and even brain tumors. Obviously, it is very important to be certain of the cause of vertigo, as we don’t want to ineffectively treat for a condition that isn’t present and we don’t want to miss a more sinister cause.
Feeling dizzy or having spells of vertigo (an illusory sense of motion usually described as ‘spinning’) can be quite troubling to most people. Of utmost concern is whether these symptoms represent something serious, such as a brain tumor. Rest assured, isolated symptoms of dizziness or vertigo are an extremely rare presenting sign of a brain tumor. To quote Arnold Schwarzenegger in ‘Kindergarten Cop’ (using his Austrian accent) “It’s not a tumor!”
Despite this, at least in the United States, it is the norm to proceed with a neuro-imaging study, such as CT or MRI, of the brain to “rule out” brain tumor, stroke, or multiple sclerosis (MS). There have been several studies concluding that doing CT and MRI scans for ‘dizziness’ or ‘vertigo’ in the absence of other neurologic signs or symptoms and in the absence of asymmetric hearing loss is not cost effective and rarely leads to a diagnosis.
Consider the following quote from Australian neuro-ophthalmologists who specialize in vestibular disorders:
“Balance disorders are common, while brain tumors are rare. An isolated balance disorder is thus rarely the presenting symptom of a brain tumor, and some physicians, particularly in countries infested with lawyers, worry about missing a brain tumor” – Hirose & Halmagyi, 1996
What country do you think they are referring to (“infested with lawyers”)?
On the other hand, vestibular function testing [which includes video-nystagmography (VNG), rotary chair, vestibular evoked myogenic potential (VEMP) and audiogram(hearing test)] assesses for both central (brain) and peripheral (inner ear) causes for dizziness and vertigo and can be quite helpful in localizing ‘where’, and then ‘what’ is causing the problem. Vestibular function testing has been demonstrated to be much more accurate and much more cost effective than MRI or laboratory tests in determining the cause of dizziness and vertigo.
‘Dizziness’ and ‘vertigo’ are symptoms, not diagnoses. Proper treatment of vestibular disorders is based on first determining the cause of dizziness or vertigo. Determining the cause of symptoms begins with a thorough history and physical examination followed by vestibular function testing in select patients.
Some causes of dizziness, vertigo and imbalance can be treated by physical therapy (PT) alone. This type of PT is called Vestibular Rehabilitation Therapy (VRT), and it has been proven effective through decades of scientific research and positive patient outcomes. However, only a minority of patients with dizziness benefit from VRT, so it is quite important to first determine the underlying cause of dizziness to assess whether VRT is the most appropriate intervention.
VRT can treat vestibular (balance) system disorders caused by:
- A weak or damaged inner ear nerve
- Cervicogenic (neck-related) dizziness
- Imbalance with risk of falls due to visual motion sensitivity
- Neuropathy (reduced sensation in the feet)
- Age-related imbalance (often with a fear of falling)
- Multiple unrelated factors together causing imbalance
The focus of VRT is not particularly related to your physical strength or endurance, but on the sensory brain and inner ear systems which control your balance. The brain uses vision, vestibular (inner ear) and proprioception (your sense of where your limbs are in space) to allow you to move safely and without falling.
Vestibular rehabilitation therapy helps the brain adapt to any weaknesses in these three systems and improves the use of these systems to decrease dizziness and improve balance and stability.
Vestibular rehabilitation therapy is a highly specialized area of physical therapy, requiring specific and extensive training in the field beyond physical therapy school. Most non-VRT therapists treat dizziness sporadically or not at all. Vestibular therapists need additional specialized training to understand balance disorders and to stay current in this fast-developing area of PT.
A typical patient is seen once a week for one to two months. After an examination and diagnosis of the cause of dizziness, a home exercise program is designed to help with the specific symptoms. Once VRT is concluded, it is important to continue the program to maintain its benefits.