Transcript Treatment of Dizziness with Physical Therapy

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
Overview
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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?
The Dizziness Problem (Hain, 2010)
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Dizziness is the primary
complaint in 2.5% all
primary care visits = 8
million/year visits
(Sloan).
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“Practically, there are far more
patients with
dizziness/ataxia than there
are clinic openings with doctors
with an interest in caring for
them.”
The Dizziness Problem (Hain, 2010)
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There are four substantial causes
of dizziness:
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Otologic (40-50%)
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Neurologic (10-30%)
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Ex. VBI, Stroke, Migraine, Low
CSF
General medical (10-30%)
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Ex. BPPV, VN, SCD, Meniere’s
B12, Orthostatic Hypotension,
DM (Hypoglycemia)
Psychiatric/undiagnosed
causes (15-50%)
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Anxiety, Malingering,
Exaggeration, Avoidance
Behavior
Physical Therapist
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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)
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Current PT at WIBD holds her doctorate (DPT)
 Will
be required by 2020 for All Schools
Physical Therapist
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Specializations
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Geriatric, Neurological,
Orthopedic, Pediatric, etc.
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Similar to Medical Schools that
provide specializations
Vestibular
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Special Interest Group within
APTA
None yet
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– Herdman Certification at
Emory
Advanced Certifications
Werner Institute Internal
Certification Program
 Annual
Working on a ScD in Vestibular
Science at UNLV (Nevada)
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Residency Program
Dizziness is Like Pain…NonSpecific
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Dizziness
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Vertigo
Lightheadedness
Giddiness
Visual Sensitivity
Floating
Wooziness
Unsteady
Dysequilibrium
Behavior
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Fearful, Anxious,
Exaggerated, Malingered
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Pain
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Sharp
Shooting
Radiating
Dull
Burning
Aching
Behavior
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Fearful, Anxiety-provoking,
Exaggerated, Malingered
Dizziness (Kroenke, 2001)
Non-Syncope
Vertigo
***Motion Intolerance
Dysequilibrium
Dizziness
Behavioral
*** Added to the list.
Lightheadedness
Pre-Syncope
Why Physical Therapy for the
Treatment of Dizziness?
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Think of PT as a
Medication/Drug
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You can prescribe it
There are several forms of
dizziness you can use it
for…
There is a frequency and
duration of PT
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There is a dosage
There are precautions and
contraindications
You can overdose with it
Why Physical Therapy for the
Treatment of Dizziness?
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Primary Reason:
Quality of Life!
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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).
Why Physical Therapy for the
Treatment of Dizziness?
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Secondary Reasons:
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Cost-effective medical
management
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Ex. Average treatment for
BPPV is 95 weeks, 3-5
physician referrals, diagnostic
(MRI, CAT, Blood Work)
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Dix-Hallpike test at bedside
and Epley Maneuver –
about $80
Reduce Prolonging Disorder
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Many patients with
“dizziness” avoid movements
or activities that trigger their
symptoms…prolonging the
disorder – PT’s are great at
getting patients to do things
they don’t want to do
Brand Names for Physical Therapy
for Dizziness
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Vestibular Therapy/Rehabilitation
(VR)
Balance Retraining Physical Therapy
(BRPT)
Habituation Training
Adaptation Training
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Canalith Repositioning Maneuvers
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VOR training
Epley, Semont, Lempert, Gufoni, AsperellaVanuchi, Nylen-Barany Maneuver
Voodoo…What is the Evidence it
Works Better than:
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Tincture of Time…
Medications
Combinations of Each
What Does This Medication
Comprise of…Its Make-up?
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Adaptation Training
Used to assist restoring gaze stability
 Trains the VOR to work with CNS oculomotors
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Habituation Training
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Helps desensitize the patient to
positions/movements
Canalith Repositioning Maneuvers
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Epley, Semont, Lempert, Gufoni, Apiani
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Several types – need to be specific
What Does This Medication
Comprise of…Its Make-up?
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Static and Dynamic
Balance Training
Gait Training
Strengthening/Enduranc
e Training
Manual Cervical
Therapies
Education, Education,
Education…
Top Doctors…On VR Therapy
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Timothy Hain, MD
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(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)
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Edwin Monsell, MD, PhD
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“Properly conducted and supervised vestibular rehabilitation therapy ameliorates a
wide variety of peripheral and central balance disorders in patients of all ages.”
(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.”
Top Doctors…On VR Therapy
 Robert
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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)
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“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.”
Top Doctors…On VR Therapy
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Cochrane Collaboration (2007) Reviewed
Vestibular Therapy for Unilateral Vestibular
Disorders
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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:
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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
Tincture of Time…Wait and See
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What is the optimal time to wait before starting a VR
program?
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Common Statements about VN: Patients will recover
naturally within:
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2 weeks - 6 weeks - 2 months?
6 months to a year?
Is the recovery complete or partial?
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BPPV  Immediately (AAN, 2007; AAO, 2008)
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?
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Physical Therapy
Tincture of Time…Wait and See
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Lucy Yardley, PhD (Department of Psychology – Southampton, UK)
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At 18 months, 24% of respondents were more handicapped
due to dizziness
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Kroenke, K (2000)
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In US, 50% of patients at 3 month follow-ups continued to
complain of symptoms
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20% had recurrent dizziness
20% improved
33% reported handicapped because of symptoms
Conclusion:
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Maybe we should rethink when patients should start therapy.
Medication Management of the
Chronic Dizzy Patient
David Solomon, MD (University of Pittsburg – Neurology
Department)
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“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 and VR
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The goals of vestibular
physical therapy are
(Whitney, S, 2003):
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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 Most
From VR?
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BPPV/BPPV+
Vestibular Neuritis/ Neuronitis/ Labyrinthitis
 Chronic Dizziness (Idiopathic)
Dysequilibrium with Age
Meniere’s Disease (Stable)
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Surgical
Less Than One Attack Per Month
Post Surgical (ANR, PLF)
Central Vestibular (Brainstem, Cerebellar)
Central (MS, PD, Stroke)
BPPV
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When Should This
Treatment Be Prescribed?
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What is the Average
Treatment Time?
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Within the first 1-3 days of
onset if possible (AAN,
2006).
1-4 visits unless atypical
(*BPPV+)
What are
Contraindications?
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Cervical DJD/DDD
VBI
BPPV+ (Pollak, 2002)
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When Should This Treatment
Be Prescribed?
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If BPPV is recalcitrant
Once BPPV resolves, patient
continues to have:
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Oscillopsia
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Dysequilibrium
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Habituation Training
What is the Average
Treatment Time?
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Static/Dynamic Balance
Training
Positioning Dizziness
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Adaptation Training for VOR
2-3 times a week for 6-8 weeks
What are Contraindications?
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None
Unilateral Vestibular Hypofunction
(VN, ANR, post-PLF/Meniere’s
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What Symptoms are You Treating?
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Oscillopsia
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Dysequilibrium
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Once patient has resolved static balance
compensation
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Patient is asymptomatic as long as he/she
does not move
What is the Average Treatment Time?
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Habituation Training
When Should This Treatment Be
Prescribed?
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Static/Dynamic Balance Training
Positioning Dizziness
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Adaptation Training for VOR
2-3 times a week for 6-8 weeks
What are Contraindications?
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None
Dysequilibrium with Age
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What Symptoms are You Treating?
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Oscillopsia (Gaze Instability)
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Unsteady Gait/Instability
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Once disorder is identified with functional balance
testing in office
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TUG, Single Leg Stance
What is the Average Treatment Time?
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Strength/Endurance Training
When Should This Treatment Be Prescribed?
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Habituation Training
Canalith Repositioning Maneuvers
Disuse/Deconditioning
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Static/Dynamic Balance Training
Positioning/Positional Dizziness
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Adaptation Training for VOR paresis
2-3 times a week for 12-24 weeks
What are Precautious/Contraindications?
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Dementia/Alzheimer's Disease
Severe Lumbar Disease
Severe Panic Attack/Fear
What Patients May Not Benefit
From This Treatment?
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Mal De Debarquement Syndrome
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Unstable Meniere’s disease
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Requires a medication management and possibly
Neurotology Consultation for surgical management
Perilymphatic Fistula
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Many times the symptoms are driven by non-vestibular
mechanism
Many patients have behavior overlay that requires medication
Requires a medication management and possibly
Neurotology Consultation for surgical management
Eustachian Tube Dysfunction
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Requires a medication management and possibly
Neurotology Consultation for surgical management
What Devices Do We Use to Monitor
the Medication/Treatment
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Computerized Dynamic Posturography
Improvement in Scores (SOT/MCT) supports
CNS compensation
Improved Scores
Supports CNS
Compensation
and a decrease
in fall risk.
What Devices Do We Use to Monitor
the Medication/Treatment
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Videonystagmography
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Rarely performed after the
initial evaluation…however:
CNS Compensation
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Improved/reduced nystagmus
with spontaneous and
positional nystagmus tests
Resolution of BPPV with
Dix-Hallpike under VNG
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Particularly with OMNIAX
system
Improvement with
Oculomotor responses
What Devices Do We Use to Monitor
the Medication/Treatment
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Vestibular Autorotational Testing (VAT)
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Improved scores (GAIN, PHASE) and a reduction
in Asymmetry (CNS compensation)
Improved Scores Support CNS Compensation
InVision Gaze Testing
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The Computerized Illegible E Test (Mallinson
and Longridge, 2006)
Improved Scores support CNS Compensation
Future Presentations
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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