vestibular rehabilitation therapy

“You Have a Different Approach…”

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52745683 - vector illustration of a woman with vertigoWe’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.

3PD is a New Name for a Common and Under Recognized Cause of Dizziness

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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.

Treating Dizziness Without Medication

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Walking on road copySome 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.

Meclizine Has Limited Use for Dizziness

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meclizineAntivert (meclizine) is one of the most popular and commonly prescribed medications for dizziness. However, there is no scientific evidence supporting it’s benefit and in fact, we now have evidence against it’s use, especially long-term use.

Meclizine is an antihistamine with anticholinergic, central nervous system and labyrinth (inner ear) depressant effects, so meclizine may cause drowsiness, confusion, memory impairment, and slow reaction time.

While migraine is the most common (and most under recognized) cause of dizziness, making up approximately 60% of all dizzy patients, Benign Paroxysmal Positional Vertigo (BPPV – aka the “crystal” problem) is second, making up about 15%. In neither condition is meclizine indicated. Meclizine would have minimal, if any benefit for migraine and may help blunt the vertigo associated with BPPV, but we are now able to instantly cure those suffering from BPPV, so why use meclizine at all?

Meclizine may be helpful short term in acute vestibular disfunction (sudden onset of vertigo), such as in vestibular neuritis (without hearing loss) or labyrinthitis (with hearing loss), an attack of Meniere’s, or to reduce motion sickness during travel. When used for these conditions or situations, only a short course, perhaps 3-7 days, should be prescribed.

Chronic use of meclizine is never indicated. Use of meclizine in the elderly, especially in the setting of peripheral neuropathy and/or vision loss from cataract, glaucoma or macular degeneration, may cause more imbalance and lead to painful falls. Chronic use of meclizine following vestibular nerve damage (such as with vestibular neuritis or labyrinthitis, trauma, or Meniere’s) will actually prevent the brain from adjusting and will reduce the effectiveness of vestibular rehabilitation therapy (a specialized form of physical therapy).

If you know of anyone who takes meclizine on a regular basis, please let them know there likely is a better treatment option available. As we are now better able determine the underlying cause of dizziness and vertigo, we have also developed more effective, targeted treatments.

Migraine is THE Most Common Cause of Dizziness

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What seems to be the most under-recognized, yet most common cause of dizziness or vertigo is not an inner ear condition at all – it is migraine. This condition is known as “vestibular migraine” or “migraine-associated dizziness” or “migrainous vertigo”. The main reason it seems to evade diagnosis is that many suffering from this condition are not having headaches at the time they are dizzy. In fact, many patients haven’t had a headache in years or even decades. Patients usually (but not always) have a history of what sounds like migraine headaches, but they will often refer to headaches as “sinus” headaches.

Symptoms of “vestibular migraine” are quite variable, being different from one patient to another and different within the same patient over time. Dizziness and/or vertigo may be reported with a duration of seconds to decades. Patients often have difficulty in describing their symptoms. Morning predominance of dizzy symptoms and visual motion sensitivity are typical. Visual motion sensitivity might include activities such as driving and shopping for items on shelves (especially in big box stores), or being bothered by patterns on clothing or carpeting. Light and/or noise sensitivity are only sometimes present.

Diagnosis of vestibular migraine includes ruling out other causes by vestibular function evaluation (Videonystagmography or VNG, Rotary Chair, Vestibular Evoked Myogenic Potential or VEMP, and an Audiogram). MRI and CT scans or blood tests are rarely necessary.

In the past, many patients suffering from spells of vertigo without hearing loss had been diagnosed with “Vestibular” Meniere’s. However, “Vestibular” Meniere’s is no longer considered a valid diagnosis. The vast majority of these patients were (and likely still are because low salt diet, diuretic, and/or inner ear surgery aren’t helpful treatments for migraine) suffering from “Vestibular” Migraine.

Treatment of vestibular migraine includes recognizing and avoiding trigger factors, and depending on frequency and/or duration of symptoms, preventative migraine medications. In some cases, in particular when motion sensitivity is prominent, a specialized form of physical therapy (PT) known a Vestibular Rehabilitation Therapy (VRT) can be helpful.

Vertigo Sufferers Have Trouble Receiving Correct Diagnosis

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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.