Vestibular Rehabilitation:Vestibular Rehabilitation:Las Vegas, NVLas Vegas, NV

Presenter: Brian K. Werner, PT, Presenter: Brian K. Werner, PT, MPTMPT

Werner Institute of Balance and Werner Institute of Balance and Dizziness, Inc.Dizziness, Inc.

www.nomorevertigo.comwww.nomorevertigo.com

Presentation OverviewPresentation Overview• Statistics of Dizziness in the Statistics of Dizziness in the

CommunityCommunity• Current problems with dizziness Current problems with dizziness

management…management…• Basic Anatomy and Physiology Basic Anatomy and Physiology

review of Balancereview of Balance– The vestibular system The vestibular system

specificallyspecifically• What is dizziness?What is dizziness?• What is vestibular rehabilitation?What is vestibular rehabilitation?• Is There a need for specialized Is There a need for specialized

centers that work exclusively centers that work exclusively with dizziness?with dizziness?

• When to make a cross referral to When to make a cross referral to the Werner Institute?the Werner Institute?

• What is new to the Werner What is new to the Werner Institute?Institute?

• Questions and AnswersQuestions and Answers

Brian Werner, PT, MPTBrian Werner, PT, MPT• B.S. – Exercise PhysiologyB.S. – Exercise Physiology

– Summa Cum Laude GraduateSumma Cum Laude Graduate• Northern Arizona University (NAU)Northern Arizona University (NAU)

• Master’s Degree – Physical Master’s Degree – Physical TherapyTherapy– With Honors from NAUWith Honors from NAU

• National Certification of National Certification of Competency – Vestibular Competency – Vestibular Disorders - 2000Disorders - 2000– University of Miami School of University of Miami School of

MedicineMedicine• Started – Balance Center of Started – Balance Center of

Las Vegas and Henderson – Las Vegas and Henderson – 2001 & 20032001 & 2003– Left BCLV in 2005Left BCLV in 2005

• Own and operate – Werner Own and operate – Werner Institute of Balance and Institute of Balance and Dizziness, Inc.Dizziness, Inc.

• Opened the Henderson location in Opened the Henderson location in 2008.2008.

StatisticsStatistics• By the age of 40, 40% of the population goes to By the age of 40, 40% of the population goes to

their PCP for complaints of dizziness – this is 90 their PCP for complaints of dizziness – this is 90 million people on average annuallymillion people on average annually– Less than 1% ever get therapy for dizzinessLess than 1% ever get therapy for dizziness

• By the age of 65, the 3By the age of 65, the 3rdrd leading PCP visit is leading PCP visit is imbalance/dizzinessimbalance/dizziness– By 75, it is the number one reason for a visit!!!By 75, it is the number one reason for a visit!!!

Current Problems with Current Problems with Dizziness ManagementDizziness Management

• We are seeing an over-medication of our We are seeing an over-medication of our patients with vestibular suppressantspatients with vestibular suppressants– 70% of all patients coming into a PCP office with 70% of all patients coming into a PCP office with

c/o dizziness get Meclizine (Burke, 1994) c/o dizziness get Meclizine (Burke, 1994) regardless regardless of history of dysfunction.of history of dysfunction.

– Barber, 1994 study found chronic use of Barber, 1994 study found chronic use of Meclizine equals a blood alcohol level of 0.04 Meclizine equals a blood alcohol level of 0.04 to 0.06to 0.06• You wonder why it would be prescribed – especially You wonder why it would be prescribed – especially

in seniorsin seniors– Known to inhibit natural CNS compensationKnown to inhibit natural CNS compensation

• If patient with dysequilibrium, you may be doing more harm as If patient with dysequilibrium, you may be doing more harm as Meclizine causes lethargy/fatigue and may increase fall risk.Meclizine causes lethargy/fatigue and may increase fall risk.

Current Problems with Current Problems with Dizziness MgmtDizziness Mgmt

• We are under-utilizing physical therapy We are under-utilizing physical therapy services, especially balance retraining services, especially balance retraining physical therapy.physical therapy.– Why?Why?

• We don’t understand the therapy and how it worksWe don’t understand the therapy and how it works– VRT has been used since the 1940’s with Cawthorne-VRT has been used since the 1940’s with Cawthorne-

Cooksey ExercisesCooksey Exercises Military started use of exercises in WWII for Concussion Military started use of exercises in WWII for Concussion

InjuriesInjuries

• Most patients get better over time with a Most patients get better over time with a vestibular disorder is the assumptionvestibular disorder is the assumption

– Yardley, et al. 1993 reported 20% of patients had full Yardley, et al. 1993 reported 20% of patients had full recovery of symptoms after a one year reviewrecovery of symptoms after a one year review

At two years, 60% of population had recurrent At two years, 60% of population had recurrent symptoms symptoms

Basic Anatomy of the Balance Basic Anatomy of the Balance SystemSystem Postural Stability

Gaze Stability

Integration

Over 80% of Classic Dizziness Over 80% of Classic Dizziness Originates from a Vestibular DisorderOriginates from a Vestibular Disorder

• Two Primary Two Primary SensorsSensors– Semicircular CanalsSemicircular Canals

• Function: Angular Function: Angular accelerometeraccelerometer

– Roll over in bedRoll over in bed– Turn head up/downTurn head up/down

– Three pairs of canalsThree pairs of canals• Work with the oppositeWork with the opposite

– Sensors act like a sail in Sensors act like a sail in the windthe wind• Push/Pull on the sensor Push/Pull on the sensor

due to flow of fluiddue to flow of fluid– Pattern of movement is Pattern of movement is

what brain recognizes what brain recognizes as motionas motion

Vestibular System:Vestibular System:SensorsSensors• Primary SensorsPrimary Sensors

– Otolithic SystemOtolithic System• Controls linear stabilityControls linear stability

– Forward/backward in Forward/backward in carcar

– Up/Down in elevatorUp/Down in elevator

• Sensitive to gravity Sensitive to gravity through Otoliths through Otoliths (crystals) bending hair (crystals) bending hair cellscells

• Abnormal Function can Abnormal Function can create dizziness and create dizziness and disorientationdisorientation

What is Dizziness?What is Dizziness?• Non-specific symptom in the Non-specific symptom in the

treatment of balance treatment of balance disorders.disorders.

• Categorized in five types:Categorized in five types:– VertigoVertigo

• Objective and SubjectiveObjective and Subjective– Tilting; whirlingTilting; whirling

– LightheadednessLightheadedness• Pre-syncopePre-syncope

– Motion SicknessMotion Sickness• Self or surroundingsSelf or surroundings

– DysequilibriumDysequilibrium• Imbalance to severe gait ataxiaImbalance to severe gait ataxia

– Floating (Psychogenic)Floating (Psychogenic)• Fear (provoking) and/or anxietyFear (provoking) and/or anxiety

What Can Be Done for the What Can Be Done for the Dizzy Patient Medically?Dizzy Patient Medically?• NothingNothing

– ““learn to live with it”learn to live with it”– ““It will go away over time”It will go away over time”

• MedicateMedicate– SuppressiveSuppressive

• Inhibition of vestibular Inhibition of vestibular signalsignal

– Meclizine – antihistamineMeclizine – antihistamine– Valium/Klonapin – CNS Valium/Klonapin – CNS

suppressantsuppressant• Reduction of fluid volume Reduction of fluid volume

in the bodyin the body– Diuretics for Meniere’s Diuretics for Meniere’s

diseasedisease

• SurgeriesSurgeries– Ablative – Meniere’s diseaseAblative – Meniere’s disease– Repairs – Perilymphatic Fistula; Repairs – Perilymphatic Fistula;

Superior Canal DehiscenceSuperior Canal Dehiscence– Removals – Acoustic NeuromasRemovals – Acoustic Neuromas

• Extremely rare in general to Extremely rare in general to surgically treat dizzinesssurgically treat dizziness

• TherapiesTherapies– AllopathicAllopathic

• Evidence Based MedicineEvidence Based Medicine– NaturopathicNaturopathic

• Herbal Herbal – HomeopathicHomeopathic

• RemediesRemedies– ChiropracticChiropractic

• CVRCVR• Spinal ManipulationSpinal Manipulation

– OtherOther

When to Send to When to Send to Specialized Physical Specialized Physical Therapy for DizzinessTherapy for Dizziness• Severe fall risk patientsSevere fall risk patients

– Use ceiling full-body harness systemsUse ceiling full-body harness systems• Complex Balance DisordersComplex Balance Disorders

– Use NASA and Navy based technology to determine origin of dizzinessUse NASA and Navy based technology to determine origin of dizziness– Will have the Epley OMNIAX chair to assess and treat complex BPPVWill have the Epley OMNIAX chair to assess and treat complex BPPV

• When patients are just not improvingWhen patients are just not improving– We work closely with local specialist ENTs that understand vestibular disorders We work closely with local specialist ENTs that understand vestibular disorders

Need for Specialized Need for Specialized Centers for Dizziness Centers for Dizziness ManagementManagement• ““I know as a PT clinician we all want to I know as a PT clinician we all want to

be able to treat whatever comes be able to treat whatever comes through the door – the generalist.”through the door – the generalist.”– Not always set-up for every disorder in Not always set-up for every disorder in

clinicclinic

• Sub-specialization within the field of PT Sub-specialization within the field of PT is commonis common– Seen in most medical practices across all Seen in most medical practices across all

disciplinesdisciplines– APTA - Neurological SectionAPTA - Neurological Section

• Vestibular and Balance special interest groups Vestibular and Balance special interest groups (SIG)(SIG)

Specialized Testing in a Specialized Testing in a Balance Center – Audiology Balance Center – Audiology TestingTesting• VideonystagmographVideonystagmograph

y (VNG):y (VNG):– Allows the clinician to Allows the clinician to

visualize the function of visualize the function of the vestibular system the vestibular system through the eyesthrough the eyes• Uses infrared video Uses infrared video

technology to see eyes technology to see eyes in the darkin the dark

– Visualizing eye Visualizing eye movement = front-end movement = front-end out of alignment on carout of alignment on car

– Helps to determine if the Helps to determine if the balance disorder is PNS balance disorder is PNS or CNS in originor CNS in origin

Normal VNG

Abnormal VNGAbnormal VNG

BPPV – Posterior BPPV – Posterior CanalCanal

Brainstem Vestibular Brainstem Vestibular InjuryInjury

Left-sided Left-sided VestibulopathyVestibulopathy

Horizontal BPPV - CupulolithiasisHorizontal BPPV - Cupulolithiasis

Vestibular Rehabilitation - Vestibular Rehabilitation - Historical ReviewHistorical Review• Started in WWII in the 1940’sStarted in WWII in the 1940’s

– Observed by two physicians - Cawthorne and CookseyObserved by two physicians - Cawthorne and Cooksey• Post-concussion injuries in soldiersPost-concussion injuries in soldiers

– Those who got up and moved early on got over their dizziness and imbalance Those who got up and moved early on got over their dizziness and imbalance faster than those who were medicated or stayed bed bound.faster than those who were medicated or stayed bed bound.

• Mid 50’s to 70’sMid 50’s to 70’s– Brandt-Daroff and Habituation NorrBrandt-Daroff and Habituation Norréé Exercises Exercises

• Mid- 1980’s to Late 1990’sMid- 1980’s to Late 1990’s – Shepard, AuD and Telian, MDShepard, AuD and Telian, MD

• Review Paper: Programmatic Vestibular RehabilitationReview Paper: Programmatic Vestibular Rehabilitation– Shepard, AuD and Solomon, MDShepard, AuD and Solomon, MD

• Review Paper: Chronic DizzinessReview Paper: Chronic Dizziness– Susan Herdman, PT, PhD and Susan Whitney, PT, ATC, PhDSusan Herdman, PT, PhD and Susan Whitney, PT, ATC, PhD

• Started Competency Based Course for:Started Competency Based Course for:– PT, OT, AuD, and MD/DOPT, OT, AuD, and MD/DO

• Who Else is getting involved in VR Who Else is getting involved in VR

Vestibular RehabilitationVestibular Rehabilitation• The Old Turf Battle Again (remember ATCs) The Old Turf Battle Again (remember ATCs)

• AUDIOLOGIST!!!AUDIOLOGIST!!!

– Practice Act from AAA states that audiologists are Practice Act from AAA states that audiologists are able to perform vestibular therapy – billing 97112.able to perform vestibular therapy – billing 97112.

• CHIROPRACTORS!!!CHIROPRACTORS!!!– Trademarked: Trademarked: Chiropractic Vestibular TherapyChiropractic Vestibular Therapy (CVR): (CVR):

• Most fall prevention programs are central to a non-Most fall prevention programs are central to a non-pharmaceutical approach that is in concert with the practice pharmaceutical approach that is in concert with the practice of chiropractic.of chiropractic.

– Would seem more in concert with PT?Would seem more in concert with PT?• ““Chiropractors who are trained in Vestibular Rehabilitation Chiropractors who are trained in Vestibular Rehabilitation

will have the tools necessary to establish themselves as will have the tools necessary to establish themselves as expertsexperts in the discipline in their community.” in the discipline in their community.”

• A review of the literature identifies chiropractic care as an A review of the literature identifies chiropractic care as an appropriate intervention for the patient with Meniere’s appropriate intervention for the patient with Meniere’s disease, vertigo and abnormal nystagmus; all which are disease, vertigo and abnormal nystagmus; all which are symptoms of vestibular brainstem imbalances. symptoms of vestibular brainstem imbalances.

Most Common Vestibular Most Common Vestibular Dysfunction in your Clinic: BPPVDysfunction in your Clinic: BPPV• Sediment from Utricle Sediment from Utricle

loosens in the semicircular loosens in the semicircular canal makes them canal makes them responsive to gravityresponsive to gravity– Assessed with the Hallpike-Dix Assessed with the Hallpike-Dix

TestTest

• Treatment of choice:Treatment of choice:– Epley ManeuverEpley Maneuver

• Canalith Repositioning Canalith Repositioning ManeuverManeuver

– Omniax Chair Omniax Chair

• (80-90% improvement in (80-90% improvement in vertigo in 1-4 visits)vertigo in 1-4 visits)

• NOTE: BPPV+ NOTE: BPPV+ – (VRT + Epley) in 70% of patients(VRT + Epley) in 70% of patients

Canaliths Moving Through Canaliths Moving Through Posterior Canal…Posterior Canal…

What’s Coming to Las What’s Coming to Las VegasVegas

• OMNIAX is almost OMNIAX is almost here!!!here!!!– Designed by the doctor Designed by the doctor

who determined the who determined the treatment for BPPVtreatment for BPPV• John Epley, MDJohn Epley, MD

– Only Seven (7) Systems Only Seven (7) Systems in the worldin the world• Werner Institute is Werner Institute is

going the have the 8going the have the 8thth system.system.

• Will be available to Will be available to see during open house see during open house during CSM 2009 at during CSM 2009 at Summerlin clinicSummerlin clinic

Questions and AnswersQuestions and Answers