Treatment of Treatment of Dizziness with Dizziness with

Physical Therapy – A Physical Therapy – A New Drug for Patient New Drug for Patient

ManagementManagementUniversity of Arkansas Medical School – University of Arkansas Medical School –

NeurologyNeurology

Presenter: Brian K. Werner, PT, MPTPresenter: Brian K. Werner, PT, MPTWerner Institute for Balance and Dizziness Werner Institute for Balance and Dizziness

– – January 10, 2011January 10, 2011

OverviewOverview Why Physical Therapy for the Treatment of Why Physical Therapy for the Treatment of

Dizziness?Dizziness? How do We Define Dizziness in Our Patients?How do We Define Dizziness in Our Patients? What Patients Benefit from this Treatment?What Patients Benefit from this Treatment? Why is this Treatment prescribed/for what types Why is this Treatment prescribed/for what types

of patients?of patients? What are the Goals for Physical Therapy?What are the Goals for Physical Therapy? When Should This Treatment Be Prescribed?When Should This Treatment Be Prescribed? How should this Treatment be used?How should this Treatment be used? What special precautions should be followed?What special precautions should be followed? What should the patient do if they forget a What should the patient do if they forget a

dose?dose? What side effects can this Treatment cause?What side effects can this Treatment cause? Can My Patient Overdose on this Medication?Can My Patient Overdose on this Medication? What other information should I know?What other information should I know?

The Dizziness ProblemThe Dizziness Problem (Hain, 2010)(Hain, 2010)

Dizziness is the Dizziness is the primary complaint in primary complaint in 2.5% all primary care 2.5% all primary care visits = 8 million/year visits = 8 million/year visits (Sloan). visits (Sloan). ““Practically, there are Practically, there are

far more patients with far more patients with dizziness/ataxia than dizziness/ataxia than there are clinic there are clinic openings with doctors openings with doctors with an interest in with an interest in caring for them.”caring for them.”

The Dizziness ProblemThe Dizziness Problem (Hain, 2010)(Hain, 2010)

There are four substantial There are four substantial causes of dizziness:causes of dizziness: Otologic (40-50%)Otologic (40-50%)

Ex. BPPV, VN, SCD, Ex. BPPV, VN, SCD, Meniere’sMeniere’s

Neurologic (10-30%)Neurologic (10-30%) Ex. VBI, Stroke, Migraine, Ex. VBI, Stroke, Migraine,

Low CSFLow CSF General medical (10-General medical (10-

30%)30%) B12, Orthostatic B12, Orthostatic

Hypotension, DM Hypotension, DM (Hypoglycemia)(Hypoglycemia)

Psychiatric/undiagnosed Psychiatric/undiagnosed causes (15-50%)causes (15-50%)

Anxiety, Malingering, Anxiety, Malingering, Exaggeration, Avoidance Exaggeration, Avoidance BehaviorBehavior

Physical TherapistPhysical Therapist Not a personal trainer or massage Not a personal trainer or massage

therapisttherapist All physical therapist must now attain All physical therapist must now attain

a post-bachelor college graduate from a post-bachelor college graduate from Accredited Physical Therapy SchoolsAccredited Physical Therapy Schools Minimal Masters degreesMinimal Masters degrees

MSPT – Research MastersMSPT – Research Masters MPT – Clinical MastersMPT – Clinical Masters

Doctorate of Physical Therapy (AR) Doctorate of Physical Therapy (AR) Current PT at WIBD holds her doctorate (DPT)Current PT at WIBD holds her doctorate (DPT) Will be required by 2020 for All SchoolsWill be required by 2020 for All Schools

Physical TherapistPhysical Therapist SpecializationsSpecializations

Geriatric, Neurological, Geriatric, Neurological, Orthopedic, Pediatric, Orthopedic, Pediatric, etc.etc.

Similar to Medical Schools Similar to Medical Schools that provide that provide specializationsspecializations

VestibularVestibular Special Interest Group Special Interest Group

within APTAwithin APTA None yet None yet

– – Herdman Certification Herdman Certification at Emoryat Emory

Advanced CertificationsAdvanced Certifications Werner Institute Internal Werner Institute Internal

Certification ProgramCertification Program AnnualAnnual

Working on a ScD in Working on a ScD in Vestibular Science at Vestibular Science at UNLV (Nevada)UNLV (Nevada) Residency ProgramResidency Program

Dizziness is Like Pain…Dizziness is Like Pain…Non-SpecificNon-Specific

DizzinessDizziness VertigoVertigo LightheadednessLightheadedness GiddinessGiddiness Visual SensitivityVisual Sensitivity FloatingFloating WoozinessWooziness UnsteadyUnsteady DysequilibriumDysequilibrium BehaviorBehavior

Fearful, Anxious, Fearful, Anxious, Exaggerated, MalingeredExaggerated, Malingered

PainPain SharpSharp ShootingShooting RadiatingRadiating DullDull BurningBurning AchingAching BehaviorBehavior

Fearful, Anxiety-Fearful, Anxiety-provoking, provoking, Exaggerated, Exaggerated, MalingeredMalingered

Dizziness (Kroenke, Dizziness (Kroenke, 2001)2001)

***Motion Intolerance***Motion Intolerance

BehavioralBehavioralLightheadednessLightheadedness

Pre-SyncopePre-Syncope

DysequilibriumDysequilibrium

VertigoVertigo

DizzinessDizziness

Non-SyncopeNon-Syncope

*** Added to the list.

Why Physical Therapy for Why Physical Therapy for the Treatment of Dizziness?the Treatment of Dizziness? Think of PT as a Think of PT as a

Medication/DrugMedication/Drug You can prescribe itYou can prescribe it There are several There are several

forms of dizziness forms of dizziness you can use it for…you can use it for…

There is a frequency There is a frequency and duration of PTand duration of PT

There is a dosageThere is a dosage There are There are

precautions and precautions and contraindicationscontraindications

You can overdose You can overdose with itwith it

Why Physical Therapy for Why Physical Therapy for the Treatment of Dizziness?the Treatment of Dizziness? Primary Reason:

Quality of Life! Persistent dizziness Persistent dizziness

can lead to chronic can lead to chronic invalidism, severely invalidism, severely restricted lifestyle, restricted lifestyle, occupational occupational disability, disability, degradation of degradation of fitness, mobility, and fitness, mobility, and a balance system that a balance system that can have damaging can have damaging repercussions in later repercussions in later life (Yardley, 1994).life (Yardley, 1994).

Why Physical Therapy for Why Physical Therapy for the Treatment of Dizziness?the Treatment of Dizziness?

Secondary Reasons:Secondary Reasons: Cost-effective medical Cost-effective medical

managementmanagement Ex. Average treatment for Ex. Average treatment for

BPPV is 95 weeks, 3-5 BPPV is 95 weeks, 3-5 physician referrals, physician referrals, diagnostic (MRI, CAT, diagnostic (MRI, CAT, Blood Work)Blood Work)

Dix-Hallpike test at Dix-Hallpike test at bedside and Epley bedside and Epley Maneuver – about $80Maneuver – about $80

Reduce Prolonging Reduce Prolonging DisorderDisorder

Many patients with Many patients with “dizziness” avoid “dizziness” avoid movements or activities movements or activities that trigger their that trigger their symptoms…prolonging the symptoms…prolonging the disorder – PT’s are great at disorder – PT’s are great at getting patients to do getting patients to do things they don’t want to things they don’t want to dodo

Brand Names for Physical Brand Names for Physical Therapy for DizzinessTherapy for Dizziness

Vestibular Vestibular Therapy/Rehabilitation (VR)Therapy/Rehabilitation (VR)

Balance Retraining Physical Balance Retraining Physical Therapy (BRPT)Therapy (BRPT)

Habituation TrainingHabituation Training Adaptation TrainingAdaptation Training

VOR trainingVOR training Canalith Repositioning Canalith Repositioning

ManeuversManeuvers Epley, Semont, Lempert, Gufoni, Epley, Semont, Lempert, Gufoni,

Asperella-Vanuchi, Nylen-Barany Asperella-Vanuchi, Nylen-Barany ManeuverManeuver

Voodoo…What is the Evidence it Voodoo…What is the Evidence it Works Better than:Works Better than: Tincture of Time…Tincture of Time… MedicationsMedications Combinations of EachCombinations of Each

What Does This Medication What Does This Medication Comprise of…Its Make-up?Comprise of…Its Make-up?

Adaptation TrainingAdaptation Training Used to assist restoring gaze stabilityUsed to assist restoring gaze stability Trains the VOR to work with CNS Trains the VOR to work with CNS

oculomotorsoculomotors Habituation TrainingHabituation Training

Helps desensitize the patient to Helps desensitize the patient to positions/movementspositions/movements

Canalith Repositioning ManeuversCanalith Repositioning Maneuvers Epley, Semont, Lempert, Gufoni, ApianiEpley, Semont, Lempert, Gufoni, Apiani

Several types – need to be specificSeveral types – need to be specific

What Does This Medication What Does This Medication Comprise of…Its Make-up?Comprise of…Its Make-up?

Static and Dynamic Static and Dynamic Balance TrainingBalance Training

Gait TrainingGait Training Strengthening/Strengthening/

Endurance TrainingEndurance Training Manual Cervical Manual Cervical

TherapiesTherapies Education, Education,

Education, Education, Education…Education…

Top Doctors…On VR Top Doctors…On VR TherapyTherapy

Timothy Hain, MDTimothy Hain, MD (Rehabilitation Institute of Chicago)(Rehabilitation Institute of Chicago) ““Vestibular rehabilitation therapy is frequently worthwhile, Vestibular rehabilitation therapy is frequently worthwhile,

but selection of the best type depends on both the diagnosis but selection of the best type depends on both the diagnosis and the healthcare situation.”and the healthcare situation.”

F. Owen Black, MDF. Owen Black, MD ((Legacy Clinical Research and Technology Center, Legacy Clinical Research and Technology Center, Department of Neurotology Research, Portland, Oregon, USA; NASA Scientist)Department of Neurotology Research, Portland, Oregon, USA; NASA Scientist) ““Properly conducted and supervised vestibular rehabilitation Properly conducted and supervised vestibular rehabilitation

therapy ameliorates a wide variety of peripheral and central therapy ameliorates a wide variety of peripheral and central balance disorders in patients of all ages.”balance disorders in patients of all ages.”

Edwin Monsell, MD, PhDEdwin Monsell, MD, PhD (Neurotologist, ARO Researcher, (Neurotologist, ARO Researcher, Detroit, MI)Detroit, MI) ““Exercises have long been an accepted strategy for managing Exercises have long been an accepted strategy for managing

the dizzy patient. Indeed, exercises have been the main the dizzy patient. Indeed, exercises have been the main strategy recommended for patients with stable, chronic strategy recommended for patients with stable, chronic symptoms of imbalance and motion intolerance.”symptoms of imbalance and motion intolerance.”

Thomas Brandt, MDThomas Brandt, MD (Institute of Clinical Neurosciences University (Institute of Clinical Neurosciences University of Munich, Munich, Germany)of Munich, Munich, Germany)

““A gradual program of physical exercise under the supervision of a A gradual program of physical exercise under the supervision of a physiotherapist improves the central vestibular compensation of a peripheral physiotherapist improves the central vestibular compensation of a peripheral deficit vestibular disorder.”deficit vestibular disorder.”

Top Doctors…On VR Top Doctors…On VR TherapyTherapy

Robert Baloh, MD Robert Baloh, MD (UCLA School of (UCLA School of Medicine)Medicine) Clinicians have long felt that vestibular compensation occurs Clinicians have long felt that vestibular compensation occurs

more rapidly and is more complete if the more rapidly and is more complete if the patient begins patient begins exercising as soon as possibleexercising as soon as possible after the occurrence of a after the occurrence of a vestibular lesion. The goal of vestibular exercises is to vestibular lesion. The goal of vestibular exercises is to accelerate the process of vestibular compensation and accelerate the process of vestibular compensation and improve the final level of recovery. Controlled studies in improve the final level of recovery. Controlled studies in animals and humans indicate that exercising can accelerate animals and humans indicate that exercising can accelerate the recovery of balance after a peripheral vestibular lesion…the recovery of balance after a peripheral vestibular lesion…

Michael Strupp, MD Michael Strupp, MD (Department of (Department of Neurology, University of Munich, Munich, Germany)Neurology, University of Munich, Munich, Germany) ““The efficacy of physiotherapy in improving central The efficacy of physiotherapy in improving central

vestibulospinal compensation in patients wit vestibular vestibulospinal compensation in patients wit vestibular pathology has been proven in a prospective, randomized, pathology has been proven in a prospective, randomized, and controlled clinical study and confirmed in a meta-and controlled clinical study and confirmed in a meta-analysis.”analysis.”

Top Doctors…On VR Top Doctors…On VR TherapyTherapy

Cochrane Collaboration (2007) Cochrane Collaboration (2007) Reviewed Vestibular Therapy for Reviewed Vestibular Therapy for Unilateral Vestibular DisordersUnilateral Vestibular Disorders 32 Randomized Clinical Studies Identified – 11 excluded 32 Randomized Clinical Studies Identified – 11 excluded

(Total - 21)(Total - 21) Studies addressed the effectiveness of vestibular Studies addressed the effectiveness of vestibular

rehabilitation against control/sham interventions, non-rehabilitation against control/sham interventions, non-vestibular rehabilitation interventions, or other forms of vestibular rehabilitation interventions, or other forms of vestibular rehabilitation.vestibular rehabilitation.

Two Primary Findings:Two Primary Findings: 1. Repositioning Maneuvers should be used 1. Repositioning Maneuvers should be used

with BPPV versus VRwith BPPV versus VR 2. There is moderate to strong evidence that 2. There is moderate to strong evidence that

VR is a safe, effective management for VR is a safe, effective management for unilateral peripheral vestibular dysfunctionunilateral peripheral vestibular dysfunction

Tincture of Time…Wait Tincture of Time…Wait and See and See What is the optimal time to wait before What is the optimal time to wait before

starting a VR program?starting a VR program? BPPV BPPV Immediately (AAN, 2007; AAO, 2008) Immediately (AAN, 2007; AAO, 2008)

Common Statements about VN: Patients Common Statements about VN: Patients will recover naturally within:will recover naturally within: 2 weeks - 6 weeks - 2 months?2 weeks - 6 weeks - 2 months? 6 months to a year?6 months to a year?

Is the recovery complete or partial?Is the recovery complete or partial? Similar to allowing tissue to heal on its own, it Similar to allowing tissue to heal on its own, it

can cause it to be fragile and increase risk for can cause it to be fragile and increase risk for re-injury more easilyre-injury more easily

What is the most cost-effective approach What is the most cost-effective approach to management?to management? Physical TherapyPhysical Therapy

Tincture of Time…Wait Tincture of Time…Wait and See and See

Lucy Yardley, PhD Lucy Yardley, PhD (Department of Psychology – Southampton, UK)(Department of Psychology – Southampton, UK)

At 18 months, 24% of respondents were more At 18 months, 24% of respondents were more handicapped due to dizzinesshandicapped due to dizziness

20% had recurrent dizziness20% had recurrent dizziness 20% improved20% improved

Kroenke, K (2000)Kroenke, K (2000) In US, 50% of patients at 3 month follow-ups In US, 50% of patients at 3 month follow-ups

continued to complain of symptomscontinued to complain of symptoms 33% reported handicapped because of symptoms33% reported handicapped because of symptoms

Conclusion: Conclusion: Maybe we should rethink when patients should Maybe we should rethink when patients should

start therapy.start therapy.

Medication Management of Medication Management of the Chronic Dizzy Patientthe Chronic Dizzy Patient

David Solomon, MDDavid Solomon, MD (University of Pittsburg (University of Pittsburg – Neurology Department)– Neurology Department)

“There is no role for chronic treatment of dizziness or vertigo with meclizine, scopolamine, or other antihistamine or anticholinergic medications.”

These are appropriately used acutely in the first days to a week after a vestibular crisis, and on a daily basis when significant nausea or spontaneous spells of vertigo are expected.

Patients may wish to keep some on hand as “security,” but habitual use of these agents generally is not helpful and may be counterproductive to the central compensation process.”

(Chronic Dizziness, 2003)

Goals for Physical Therapy Goals for Physical Therapy and VRand VR

The goals of vestibular physical therapy are (Whitney, S, 2003): to optimize function, decrease dizziness, improve balance and the

ability to walk, decrease fear and

anxiety, prevent falls, increase gait speed, decrease stiffness, and improve the

patient’s ability to perform daily activities.

What Diagnoses Benefit the What Diagnoses Benefit the Most From VR?Most From VR?

BPPV/BPPV+BPPV/BPPV+ Vestibular Neuritis/ Neuronitis/ Vestibular Neuritis/ Neuronitis/

LabyrinthitisLabyrinthitis Chronic Dizziness (Idiopathic)Chronic Dizziness (Idiopathic)

Dysequilibrium with AgeDysequilibrium with Age Meniere’s Disease (Stable)Meniere’s Disease (Stable)

SurgicalSurgical Less Than One Attack Per MonthLess Than One Attack Per Month

Post Surgical (ANR, PLF)Post Surgical (ANR, PLF) Central Vestibular (Brainstem, Cerebellar)Central Vestibular (Brainstem, Cerebellar) Central (MS, PD, Stroke)Central (MS, PD, Stroke)

BPPVBPPV When Should This When Should This

Treatment Be Treatment Be Prescribed?Prescribed? Within the first 1-3 Within the first 1-3

days of onset if days of onset if possible (AAN, 2006).possible (AAN, 2006).

What is the Average What is the Average Treatment Time?Treatment Time? 1-4 visits unless 1-4 visits unless

atypical (*BPPV+)atypical (*BPPV+) What are What are

Contraindications?Contraindications? Cervical DJD/DDDCervical DJD/DDD VBIVBI

BPPV+ (Pollak, 2002)BPPV+ (Pollak, 2002) When Should This When Should This

Treatment Be Treatment Be Prescribed?Prescribed? If BPPV is recalcitrantIf BPPV is recalcitrant Once BPPV resolves, Once BPPV resolves,

patient continues to have:patient continues to have: OscillopsiaOscillopsia

Adaptation Training for Adaptation Training for VORVOR

DysequilibriumDysequilibrium Static/Dynamic Balance Static/Dynamic Balance

TrainingTraining Positioning DizzinessPositioning Dizziness

Habituation TrainingHabituation Training What is the Average What is the Average

Treatment Time?Treatment Time? 2-3 times a week for 6-8 2-3 times a week for 6-8

weeksweeks What are What are

Contraindications?Contraindications? NoneNone

Unilateral Vestibular Unilateral Vestibular Hypofunction (VN, ANR, Hypofunction (VN, ANR,

post-PLF/Meniere’spost-PLF/Meniere’s What Symptoms are You What Symptoms are You Treating?Treating? OscillopsiaOscillopsia

Adaptation Training for VORAdaptation Training for VOR DysequilibriumDysequilibrium

Static/Dynamic Balance TrainingStatic/Dynamic Balance Training Positioning DizzinessPositioning Dizziness

Habituation TrainingHabituation Training When Should This Treatment When Should This Treatment

Be Prescribed?Be Prescribed? Once patient has resolved static Once patient has resolved static

balance compensationbalance compensation Patient is asymptomatic as long Patient is asymptomatic as long

as he/she does not moveas he/she does not move What is the Average Treatment What is the Average Treatment

Time?Time? 2-3 times a week for 6-8 weeks2-3 times a week for 6-8 weeks

What are Contraindications?What are Contraindications? NoneNone

Dysequilibrium with AgeDysequilibrium with Age What Symptoms are You Treating?What Symptoms are You Treating?

Oscillopsia (Gaze Instability) Adaptation Training for VOR paresis

Unsteady Gait/Instability Static/Dynamic Balance Training

Positioning/Positional Dizziness Habituation Training Canalith Repositioning Maneuvers

Disuse/Deconditioning Strength/Endurance Training

When Should This Treatment Be When Should This Treatment Be Prescribed?Prescribed?

Once disorder is identified with functional balance testing in office

TUG, Single Leg Stance What is the Average Treatment What is the Average Treatment

Time?Time? 2-3 times a week for 12-24 weeks

What are What are Precautious/Contraindications?Precautious/Contraindications?

Dementia/Alzheimer's DiseaseDementia/Alzheimer's Disease Severe Lumbar DiseaseSevere Lumbar Disease Severe Panic Attack/FearSevere Panic Attack/Fear

What Patients May Not What Patients May Not Benefit From This Benefit From This

Treatment?Treatment? Mal De Debarquement SyndromeMal De Debarquement Syndrome Many times the symptoms are driven by non-Many times the symptoms are driven by non-

vestibular mechanismvestibular mechanism Many patients have behavior overlay that requires Many patients have behavior overlay that requires

medication medication Unstable Meniere’s diseaseUnstable Meniere’s disease

Requires a medication management and possibly Requires a medication management and possibly Neurotology Consultation for surgical managementNeurotology Consultation for surgical management

Perilymphatic FistulaPerilymphatic Fistula Requires a medication management and possibly Requires a medication management and possibly

Neurotology Consultation for surgical managementNeurotology Consultation for surgical management Eustachian Tube DysfunctionEustachian Tube Dysfunction

Requires a medication management and possibly Requires a medication management and possibly Neurotology Consultation for surgical managementNeurotology Consultation for surgical management

What Devices Do We Use to What Devices Do We Use to Monitor the Monitor the

Medication/TreatmentMedication/Treatment Computerized Dynamic Computerized Dynamic

PosturographyPosturography Improvement in Scores (SOT/MCT) Improvement in Scores (SOT/MCT)

supports CNS compensationsupports CNS compensation Improved Scores Supports CNS Compensation and a decrease in fall risk.

What Devices Do We Use to What Devices Do We Use to Monitor the Monitor the

Medication/TreatmentMedication/Treatment VideonystagmographyVideonystagmography

Rarely performed after Rarely performed after the initial evaluation…the initial evaluation…however:however:

CNS CompensationCNS Compensation Improved/reduced Improved/reduced

nystagmus with nystagmus with spontaneous and spontaneous and positional nystagmus positional nystagmus teststests

Resolution of BPPV with Resolution of BPPV with Dix-Hallpike under VNGDix-Hallpike under VNG

Particularly with Particularly with OMNIAX systemOMNIAX system

Improvement with Improvement with Oculomotor responses Oculomotor responses

What Devices Do We Use to What Devices Do We Use to Monitor the Monitor the

Medication/TreatmentMedication/Treatment Vestibular Autorotational Testing Vestibular Autorotational Testing

(VAT)(VAT) Improved scores (GAIN, PHASE) and a Improved scores (GAIN, PHASE) and a

reduction in Asymmetry (CNS reduction in Asymmetry (CNS compensation)compensation)

Improved Scores Support CNS Compensation

InVision Gaze TestingInVision Gaze Testing

The Computerized Illegible E Test The Computerized Illegible E Test (Mallinson and Longridge, 2006)(Mallinson and Longridge, 2006)

Improved Scores support CNS Compensation

Future PresentationsFuture Presentations

Bedside Treatment of BPPVBedside Treatment of BPPV Physical Therapy Management of Physical Therapy Management of

MSMS Physical Therapy Management of PDPhysical Therapy Management of PD Vestibular Diagnostics in NeurologyVestibular Diagnostics in Neurology

VideonystagmographyVideonystagmography Computerized Dynamic PosturographyComputerized Dynamic Posturography Rotational TestingRotational Testing

ReferencesReferences