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.
The Vestibular Disorders Association (VEDA) surveyed of hundreds of people suffering with a vestibular disorder and the results were published in the journal Otology & Neurotology in 2016. The results are as we would have predicted based on reported patient experiences prior to their initial visit to BalanceMD and are in keeping with many blogs and newsletter articles we have written on this subject over the past decade.
The purpose of the survey was to collect information on vestibular patients’ experiences with healthcare providers as they searched for answers to their problems – what they were told was causing their symptoms and what treatments they were given.
Some findings from the study are as follows:
Meniere’s disease was the top diagnosis given – 25% of those in the survey reported being diagnosed with Meniere’s disease. We know that Meniere’s actually represents a very small portion of vestibular disorder patients, less than 5%. On the other hand, only 18% of those in the study received the diagnosis of vestibular migraine, while nearly 50% actually have migraine as the underlying cause of their symptoms. Most experts place the Migraine:Meniere’s ratio 20-30:1. This highlights the popularity of the Meniere’s diagnosis and the under recognition of vestibular migraine. Take home point: Meniere’s disease is a relatively rare condition and causes a specific type of hearing loss. Most who have been diagnosed with Meniere’s without hearing loss actually have a migraine syndrome as the underlying cause of their dizziness or vertigo spells.
Nearly half reported being treated with canalith repositioning maneuvers (such as the Epley maneuver) for BPPV, but only 15% reported being diagnosed with BPPV. In essence, over 30% of patients underwent an Epley maneuver, but never had BPPV. Take home point: BPPV is commonly over diagnosed. While there is no harm in doing an Epley maneuver, treating for a condition that isn’t present doesn’t work and appropriate treatment is delayed while the Epley maneuver is repeated unsuccessfully over weeks or months. There are several known types of BPPV amenable to immediate cure with a unique canalith repositioning maneuver over 90% of the time.
Close to 9% were diagnosed with bilateral vestibular hypofunction(weakness of both vestibular nerves). The actual number of patients with bilateral vestibular hypofunction is < 1%. The reason for this large discrepancy is that most facilities offering vestibular testing do not have a rotary chair. The diagnosis of “bilateral vestibular hypofunction” likely comes from weak caloric (air blown in the ears to induce nystagmus) responses in both ears. The best way to confirm (or refute) bilaterally weak vestibular nerves is the rotary chair. With bilateral vestibular hypofunction, the rotary chair test will be markedly abnormal. Take home point: Unfortunately, most facilities who perform vestibular testing do not have a rotary chair and will mis-diagnose a significant number of patients they test.
At BalanceMD, we have the knowledge, technologically advanced vestibular system test equipment and experience to accurately diagnose and effectively treat dizziness and vertigo no matter what the cause. Call 888-888-DIZZY (3499) or visit our website for further information.
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.
When many patients arrive at our medical clinic, BalanceMD, they report that they were diagnosed with “vertigo”. Vertigo is defined as the sensation a person has that they or objects around them are moving when they are not. There are many medical conditions that might include vertigo as a symptom, most commonly migraine, benign paroxysmal positional vertigo (BPPV), vestibular neuritis or labyrinthitis, and Meniere’s disease.
Vertigo is a symptom, not a diagnosis, much in the same way that chest pain is a symptom, not a diagnosis. There are many things that might cause chest pain, such as a heart attack, pneumonia, or a broken rib. As it is important to determine the underlying cause of chest pain, it is also important to determine the underlying cause of vertigo.
While there are many conditions that might cause vertigo, there are only a handful that present most commonly and are listed above. Differentiating between these conditions is best accomplished with a detailed clinical history, physical exam, and when needed, vestibular function testing and an audiogram (hearing test). While migraine is the most common cause of recurrent spells of vertigo, BPPV is a vertigo-causing condition which can be quickly identified and cured. Typical symptoms of BPPV include brief vertigo often lasting 10-15 seconds and triggered by lying back or sitting up in bed, rolling over in bed, and looking up or down. Benign Paroxysmal Positional Vertigo is easy to evaluate and to treat. If BPPV is not present, then vestibular function testing is typically necessary to evaluate for other inner ear or brain-related causes of vertigo.
Vestibular function testing is the test of choice in the identification of an underlying cause for vertigo. This type of testing analyzes both inner ear and brain function associated with vertigo. Vestibular function testing includes Videonystagmography (VNG), rotational chair, Vestibular Evoked Myogenic Potential (VEMP) and an audiogram.
Once the underlying cause for dizziness or vertigo is determined, a targeted treatment can be administered. Because of advancements in our knowledge and technology over the past 20-25 years, we are much better able to arrive at a precise diagnosis. We now know that while meclizine (Antivert), a commonly prescribed medication for those suffering with vertigo, may reduce vertigo symptoms for some conditions, it does not fix the underly problem causing vertigo. Those who have been given meclizine (Antivert) for treatment of the symptom of vertigo and continue to suffer with vertigo should seek an evaluation from a specialist who is able to arrive at a diagnosis for the cause of vertigo and administer the most appropriate treatment and/or cure.
In a 2011 survey by the Vestibular Disorders Association (VEDA), it was determined that those suffering from dizziness (the “dizzy” patient) were on average seen by 4-5 doctors before receiving the correct diagnosis. As is the case with any medical condition, without the correct diagnosis, the most appropriate treatment cannot be administered.
Symptoms of dizziness are typically subjective and an accurate diagnosis at first may not be straight forward. Many patients suffering from dizziness typically see several doctors and undergo multiple tests while accumulating large medical bills and no answers. The time “dizzy” patients spend in this process can be months to years and may result in painful fall-related injuries while seeking help from various healthcare practitioners.
“Dizzy” patients may initially be seen by their primary care physician or go to an urgent care facility or emergency room, then, as the potential underlying cause for dizziness can be diverse, referred to ENT (Ear, Nose and Throat – aka Otolaryngologist), a neurologist and/or cardiologist. Studies reveal that many undergo brain or sinus CT and/or MRI scans, carotid doppler studies, EEG, EKG, echocardiogram, tilt table testing, and blood tests, all of which have low yield in arriving at the correct diagnosis for most “dizzy” patients. Vestibular suppressant medications, such as meclizine, diazepam or promethazine, typically offer little relief and the majority of “dizzy” patients do not significantly benefit from PT (physical therapy).
The knowledge and technology we have available today in the diagnosis and treatment of the “dizzy” patient has advanced significantly and is different than what would have been considered standard of care just 20 years ago. At the initial visit to a physician experienced in vestibular disorders, the “dizzy”patient will be given the most likely diagnosis and a short list of differential diagnoses. Vestibular function testing and an audiogram (hearing test) are generally the most valuable tests to obtain for the “dizzy” patient, and will help confirm or refute the diagnosis suspected by clinical information obtained in the history and physical exam.
Arriving at the correct diagnosis is vitally important because effective treatment of “dizziness” depends on the diagnosis. One cause of dizziness requires a specific sequence of head movements which can result in an instant cure, another cause is treated by reducing dietary sodium and/or a diuretic medication, while the most common cause of dizziness improves or resolves with a migraine-preventative medication, and other causes benefit from a specialized form of PT (physical therapy) known as vestibular rehabilitation therapy.
Especially in this age of high deductible health insurance plans, patients are seeking the most expedient and accurate diagnoses and the most effective treatment in a cost-effective manner. With the advanced diagnostic and treatment capabilities available today, “dizzy” patients should no longer have to see 4-5 doctorsbefore receiving the correct diagnosis.