Treatment of Dizziness with Physical Therapy

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Treatment of Dizziness with Physical Therapy A
New Drug for Patient Management

• University of Arkansas Medical School Neurology
• Presenter Brian K. Werner, PT, MPT
• Werner Institute for Balance and Dizziness
• January 10, 2011

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Overview

• Why Physical Therapy for the Treatment of
  Dizziness?
• How do We Define Dizziness in Our Patients?
• What Patients Benefit from this Treatment?
• Why is this Treatment prescribed/for what types
  of patients?
• What are the Goals for Physical Therapy?
• When Should This Treatment Be Prescribed?
• How should this Treatment be used?
• What special precautions should be followed?
• What should the patient do if they forget a dose?
• What side effects can this Treatment cause?
• Can My Patient Overdose on this Medication?
• What other information should I know?

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The Dizziness Problem (Hain, 2010)

• Dizziness is the primary complaint in 2.5 all
  primary care visits 8 million/year visits
  (Sloan).
• Practically, there are far more patients with
  dizziness/ataxia than there are clinic openings
  with doctors with an interest in caring for
  them.

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The Dizziness Problem (Hain, 2010)

• There are four substantial causes of dizziness
• Otologic (40-50)
• Ex. BPPV, VN, SCD, Menieres
• Neurologic (10-30)
• Ex. VBI, Stroke, Migraine, Low CSF
• General medical (10-30)
• B12, Orthostatic Hypotension, DM (Hypoglycemia)
• Psychiatric/undiagnosed causes (15-50)
• Anxiety, Malingering, Exaggeration, Avoidance
  Behavior

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Physical Therapist

• Not a personal trainer or massage therapist
• All physical therapist must now attain a
  post-bachelor college graduate from Accredited
  Physical Therapy Schools
• Minimal Masters degrees
• MSPT Research Masters
• MPT Clinical Masters
• Doctorate of Physical Therapy (AR)
• Current PT at WIBD holds her doctorate (DPT)
• Will be required by 2020 for All Schools

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Physical Therapist

• Specializations
• Geriatric, Neurological, Orthopedic, Pediatric,
  etc.
• Similar to Medical Schools that provide
  specializations
• Vestibular
• Special Interest Group within APTA
• None yet
• Herdman Certification at Emory
• Advanced Certifications
• Werner Institute Internal Certification Program
• Annual
• Working on a ScD in Vestibular Science at UNLV
  (Nevada)
• Residency Program

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Dizziness is Like PainNon-Specific

• Dizziness
• Vertigo
• Lightheadedness
• Giddiness
• Visual Sensitivity
• Floating
• Wooziness
• Unsteady
• Dysequilibrium
• Behavior
• Fearful, Anxious, Exaggerated, Malingered

• Pain
• Sharp
• Shooting
• Radiating
• Dull
• Burning
• Aching
• Behavior
• Fearful, Anxiety-provoking, Exaggerated,
  Malingered

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Dizziness (Kroenke, 2001)
Non-Syncope
Added to the list.
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Why Physical Therapy for the Treatment of
Dizziness?

• Think of PT as a Medication/Drug
• You can prescribe it
• There are several forms of dizziness you can use
  it for
• There is a frequency and duration of PT
• There is a dosage
• There are precautions and contraindications
• You can overdose with it

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Why Physical Therapy for the Treatment of
Dizziness?

• Primary Reason Quality of Life!
• Persistent dizziness can lead to chronic
  invalidism, severely restricted lifestyle,
  occupational disability, degradation of fitness,
  mobility, and a balance system that can have
  damaging repercussions in later life (Yardley,
  1994).

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Why Physical Therapy for the Treatment of
Dizziness?

• Secondary Reasons
• Cost-effective medical management
• Ex. Average treatment for BPPV is 95 weeks, 3-5
  physician referrals, diagnostic (MRI, CAT, Blood
  Work)
• Dix-Hallpike test at bedside and Epley Maneuver
  about 80
• Reduce Prolonging Disorder
• Many patients with dizziness avoid movements or
  activities that trigger their symptomsprolonging
  the disorder PTs are great at getting patients
  to do things they dont want to do

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Brand Names for Physical Therapy for Dizziness

• Vestibular Therapy/Rehabilitation (VR)
• Balance Retraining Physical Therapy (BRPT)
• Habituation Training
• Adaptation Training
• VOR training
• Canalith Repositioning Maneuvers
• Epley, Semont, Lempert, Gufoni,
  Asperella-Vanuchi, Nylen-Barany Maneuver
• VoodooWhat is the Evidence it Works Better than
• Tincture of Time
• Medications
• Combinations of Each

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What Does This Medication Comprise ofIts Make-up?

• Adaptation Training
• Used to assist restoring gaze stability
• Trains the VOR to work with CNS oculomotors
• Habituation Training
• Helps desensitize the patient to
  positions/movements
• Canalith Repositioning Maneuvers
• Epley, Semont, Lempert, Gufoni, Apiani
• Several types need to be specific

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What Does This Medication Comprise ofIts Make-up?

• Static and Dynamic Balance Training
• Gait Training
• Strengthening/Endurance Training
• Manual Cervical Therapies
• Education, Education, Education

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Top DoctorsOn VR Therapy

• Timothy Hain, MD (Rehabilitation Institute of
  Chicago)
• Vestibular rehabilitation therapy is frequently
  worthwhile, but selection of the best type
  depends on both the diagnosis and the healthcare
  situation.
• F. Owen Black, MD (Legacy Clinical Research and
  Technology Center, Department of Neurotology
  Research, Portland, Oregon, USA NASA Scientist)
• Properly conducted and supervised vestibular
  rehabilitation therapy ameliorates a wide variety
  of peripheral and central balance disorders in
  patients of all ages.
• Edwin Monsell, MD, PhD (Neurotologist, ARO
  Researcher, Detroit, MI)
• Exercises have long been an accepted strategy
  for managing the dizzy patient. Indeed, exercises
  have been the main strategy recommended for
  patients with stable, chronic symptoms of
  imbalance and motion intolerance.
• Thomas Brandt, MD (Institute of Clinical
  Neurosciences University of Munich, Munich,
  Germany)
• A gradual program of physical exercise under the
  supervision of a physiotherapist improves the
  central vestibular compensation of a peripheral
  deficit vestibular disorder.

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Top DoctorsOn VR Therapy

• Robert Baloh, MD (UCLA School of Medicine)
• Clinicians have long felt that vestibular
  compensation occurs more rapidly and is more
  complete if the patient begins exercising as soon
  as possible after the occurrence of a vestibular
  lesion. The goal of vestibular exercises is to
  accelerate the process of vestibular compensation
  and improve the final level of recovery.
  Controlled studies in animals and humans indicate
  that exercising can accelerate the recovery of
  balance after a peripheral vestibular lesion
• Michael Strupp, MD (Department of Neurology,
  University of Munich, Munich, Germany)
• The efficacy of physiotherapy in improving
  central vestibulospinal compensation in patients
  wit vestibular pathology has been proven in a
  prospective, randomized, and controlled clinical
  study and confirmed in a meta-analysis.

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Top DoctorsOn VR Therapy

• Cochrane Collaboration (2007) Reviewed Vestibular
  Therapy for Unilateral Vestibular Disorders
• 32 Randomized Clinical Studies Identified 11
  excluded (Total - 21)
• Studies addressed the effectiveness of vestibular
  rehabilitation against control/sham
  interventions, non-vestibular rehabilitation
  interventions, or other forms of vestibular
  rehabilitation.
• Two Primary Findings
• 1. Repositioning Maneuvers should be used with
  BPPV versus VR
• 2. There is moderate to strong evidence that VR
  is a safe, effective management for unilateral
  peripheral vestibular dysfunction

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Tincture of TimeWait and See

• What is the optimal time to wait before starting
  a VR program?
• BPPV ? Immediately (AAN, 2007 AAO, 2008)
• Common Statements about VN Patients will recover
  naturally within
• 2 weeks - 6 weeks - 2 months?
• 6 months to a year?
• Is the recovery complete or partial?
• Similar to allowing tissue to heal on its own, it
  can cause it to be fragile and increase risk for
  re-injury more easily
• What is the most cost-effective approach to
  management?
• Physical Therapy

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Tincture of TimeWait and See

• Lucy Yardley, PhD (Department of Psychology
  Southampton, UK)
• At 18 months, 24 of respondents were more
  handicapped due to dizziness
• 20 had recurrent dizziness
• 20 improved
• Kroenke, K (2000)
• In US, 50 of patients at 3 month follow-ups
  continued to complain of symptoms
• 33 reported handicapped because of symptoms
• Conclusion
• Maybe we should rethink when patients should
  start therapy.

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Medication Management of the Chronic Dizzy Patient

• David Solomon, MD (University of Pittsburg
  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)

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Goals for Physical Therapy and 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 patients ability to perform
  daily activities.

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What Diagnoses Benefit the Most From VR?

• BPPV/BPPV
• Vestibular Neuritis/ Neuronitis/ Labyrinthitis
• Chronic Dizziness (Idiopathic)
• Dysequilibrium with Age
• Menieres Disease (Stable)
• Surgical
• Less Than One Attack Per Month
• Post Surgical (ANR, PLF)
• Central Vestibular (Brainstem, Cerebellar)
• Central (MS, PD, Stroke)

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BPPV

• When Should This Treatment Be Prescribed?
• Within the first 1-3 days of onset if possible
  (AAN, 2006).
• What is the Average Treatment Time?
• 1-4 visits unless atypical (BPPV)
• What are Contraindications?
• Cervical DJD/DDD
• VBI

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BPPV (Pollak, 2002)

• When Should This Treatment Be Prescribed?
• If BPPV is recalcitrant
• Once BPPV resolves, patient continues to have
• Oscillopsia
• Adaptation Training for VOR
• Dysequilibrium
• Static/Dynamic Balance Training
• Positioning Dizziness
• Habituation Training
• What is the Average Treatment Time?
• 2-3 times a week for 6-8 weeks
• What are Contraindications?
• None

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Unilateral Vestibular Hypofunction (VN, ANR,
post-PLF/Menieres

• What Symptoms are You Treating?
• Oscillopsia
• Adaptation Training for VOR
• Dysequilibrium
• Static/Dynamic Balance Training
• Positioning Dizziness
• Habituation Training
• When Should This Treatment Be Prescribed?
• Once patient has resolved static balance
  compensation
• Patient is asymptomatic as long as he/she does
  not move
• What is the Average Treatment Time?
• 2-3 times a week for 6-8 weeks
• What are Contraindications?
• None

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Dysequilibrium with Age

• 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 Prescribed?
• Once disorder is identified with functional
  balance testing in office
• TUG, Single Leg Stance
• What is the Average Treatment Time?
• 2-3 times a week for 12-24 weeks
• What are Precautious/Contraindications?
• Dementia/Alzheimer's Disease
• Severe Lumbar Disease
• Severe Panic Attack/Fear

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What Patients May Not Benefit From This Treatment?

• Mal De Debarquement Syndrome
• Many times the symptoms are driven by
  non-vestibular mechanism
• Many patients have behavior overlay that requires
  medication
• Unstable Menieres disease
• Requires a medication management and possibly
  Neurotology Consultation for surgical management
• Perilymphatic Fistula
• Requires a medication management and possibly
  Neurotology Consultation for surgical management
• Eustachian Tube Dysfunction
• Requires a medication management and possibly
  Neurotology Consultation for surgical management

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What Devices Do We Use to Monitor the
Medication/Treatment

• Computerized Dynamic Posturography
• Improvement in Scores (SOT/MCT) supports CNS
  compensation

Improved Scores Supports CNS Compensation and a
decrease in fall risk.
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What Devices Do We Use to Monitor the
Medication/Treatment

• Videonystagmography
• Rarely performed after the initial
  evaluationhowever
• CNS Compensation
• Improved/reduced nystagmus with spontaneous and
  positional nystagmus tests
• Resolution of BPPV with Dix-Hallpike under VNG
• Particularly with OMNIAX system
• Improvement with Oculomotor responses

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What Devices Do We Use to Monitor the
Medication/Treatment

• Vestibular Autorotational Testing (VAT)
• Improved scores (GAIN, PHASE) and a reduction in
  Asymmetry (CNS compensation)

Improved Scores Support CNS Compensation
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InVision Gaze Testing

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

Improved Scores support CNS Compensation
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Future Presentations

• Bedside Treatment of BPPV
• Physical Therapy Management of MS
• Physical Therapy Management of PD
• Vestibular Diagnostics in Neurology
• Videonystagmography
• Computerized Dynamic Posturography
• Rotational Testing

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References