2/8/2017

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WHERE ARE WE?

East Amherst

East Aurora

Hamburg

West Seneca

Williamsville

Boulevard

2/8/2017

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MY GOAL TODAY….

1. Provide a quick overview on falls

2. How our balance systems work

3. What treatments are available (rehab)

4. The best methods to improve your balance

THE FEAR OF FALLING

• Rate increases with age

• At age 50 chance doubles every 5-6 years

• 50% of ♀ who reach age 90 will have

suffered a hip fracture from falling

• ♀ who are 5’8” tall are 2x more likely than ♀

who are 5’2” tall or less

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EXPANDING THE FEAR: HIP FRACTURES

• Only 25% will make a full recovery

• 40% will require nursing home care

• 50% will need a cane or walker

• 24% of those over the age of 50 will die

within 12 months of suffering a hip fracture.

• This costs nearly $30,000 per event

WHAT MAKES UP OUR BALANCE?

VISUAL

PROPRIOCEPTIONVESTIBULAR

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VISIONConstant Feedback

Gaze Stablization

Walking

Movement in the

environment

Smooth pursuit

Saccades

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WHAT MAKES UP OUR BALANCE?

VISUAL

PROPRIOCEPTIONVESTIBULAR

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VESTIBULAR SYSTEM

Saccule

Elevator

Utricle

Airplane

Semi-Circular Canals

360 Head Movement

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TRAINING THE VESTIBULAR SYSTEM

Habituation Exercises

Practice what makes you dizzy

Findings suggest that 59% of patients willhave a dramatic improvement, after which their vestibular symptoms no longer cause any restriction in their lifestyles. An additional 23% of patients note considerable improvement.

Epley Maneuver

Telian SA, Shepard NT, Smith-Wheelock M, Kemink JL. Habituation Therapy for

Chronic Vestibular Dysfunction: Preliminary Results. Otolaryngol Head Neck

Surg: 1990;103(1):89-95].

WHAT MAKES UP OUR BALANCE?

VISUAL

PROPRIOCEPTIONVESTIBULAR

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PROPRIOCEPTION / SENSATION

- Muscles, joints, and skin have touch,

pressure, and stretch receptors that change

mechanical stimuli into nerve signals

-When do we use this system?

PROPRIOCEPTION / BALANCE

Study suggests that there is a relationship

between chronic neck pain, somatic

dysfunction, muscle atrophy and standing

balance.

Neck strategies for balance

Neck range of motion to stimulate the

vestibular system

If you don’t use it, you lose it.

McPartland JM1, Brodeur RR, Hallgren RC. Chronic neck pain,

standing balance, and suboccipital muscle atrophy--a pilot study.

J Manipulative Physiol Ther. 1997 Jan;20(1):24-9.

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WHAT MAKES UP OUR BALANCE?

VISUAL

PROPRIOCEPTIONVESTIBULAR

IMPROVING YOUR BALANCE THROUGH EXERCISE…

What’s best to improve your balance?

McPartland JM1, Brodeur RR, Hallgren RC. Effect of Tai Chi

Exercise on Fall Prevention in Older Adults: Systematic Review

and Meta-analysis of Randomized Controlled Trials. International

Journal of Gerontology. 2016 Dec;10(4).

Weight Lifting

Tai Chi

Doing NothingRiding a bike

Aqua Therapy Yoga

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YOUR FUTURE EXERCISE PROGRAM

TAI CHIWEIGHT

LIFTINGWALKING YOGA

OTHER FOCUSES POINTS TO IMPROVE BALANCE

Use it or lose it

Train the weak systems

Glasses

External Support

Balance Exercises

Standing vs. Sitting Exercise

Substantial evidence to support the use of strength and balance training

for older adults at risk for falls

Vestibular rehabilitation therapy resulted in a statistically significant

improvement in Berg balance test scores. Referring diagnosis, age, and

gender had no impact on outcome.

Tofthagen C, Visovsky C, Berry D. Strength and

Balance Training for Adults With Peripheral

Neuropathy and High Risk of Fall: Current Evidence

and Implications for Future Research. Oncology

Nursing Society. Sept 2012;39(5):E416-E424.

Macias J, Massingale S, Gerkin R. Efficacy of

Vestibular Rehabilitation Therapy in Reducing Falls.

Otolaryngol Head Neck Surg. 2005 Sep;133(3):323-5.

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PUBLIC ENEMY: PROTECT YOURSELF

Berg W, Alessio H, Mills E, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing (1997) 26 (4): 261-268.

1

Lixin Zhang, MD, PhD

Medical Director

Dizziness, Balance & Tinnitus Center

Dent Neurologic Institute

Feb 8rd, 2017

Dizziness, Tinnitus & Imbalance

Dizziness is Common, Dangerous, and Expensive

9.6% of general population

#3 most common complaint at age 60+

#1 reason for a doctor visit at age 75+

1/3 of patients age of 65+ may experience falls

Fall related injuries cost 20 Billions annually

2

Growth of Dizziness Center

744

975

1287 12801248

550

786

1127

13281365

0

200

400

600

800

1000

1200

1400

10/1/09-9/30/10 10/1/10-9/30/11 10/1/11-9/30/12 10/1/12-9/30/13 10/1/13-9/30/14

VNG Tests

Consults

Prior to DENT Visit

Average months: 55 mos

Consulted 1.37 MDs

Had an ER visit 37.5%

Meclizine 35.9%

Average Imaging Done 1.26

(June 2010-62 Dizzy Patients)

Number of Solutions Found

Prior to Dizziness Center Contact: 0

3

Dizziness Improved in 90% Patients

at Dent Dizziness and Balance Center

65%8%

27%

Improve

Non-Improve

Not Sure

89%

11%

Improve

Non-Improve

Specific Vertigo needs Specific Tx

Diagnosis TreatmentBenign paroxysmal positional

vertigo (BPPV)

Repositioning

Phobic postural vertigo (PPV) Anti-anxiety meds

Central vestibular vertigo VT

Migraine Associated Vertigo Lamotrigine

Vestibular neuritis VT

Meniere's disease Lamotrigine

Bilateral vestibular VT

Post-Concussive Dizziness Lamotrigine

Vestibular paroxysmia Carbamazepine

Perilymph fistula Surgery

Superior Canal Dehensence Surgery

Unknown etiology 4.2

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What is Dizziness/Vertigo ?

Etiologies of Dizziness/Vertigo

56%

16%

7%

1%

13%

7%Vestibular

Psychiatric

Cerebral or

cardiovascular

Brain tumor

Unknown

Other

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Classifications of Vertigo/Dizziness

BPPV 18.3%Vestibular Neuritis 7.9%LabrynthitisBilateral Vestibular Hypofunction 7.8%

Peripheral Meniere’s disease 7.8%Vestibular Paroxysmia 2.9%Superior Canal DehiscencePerilymph fistula 0.4%Vestibular schwannoma

Migraine Associated Vertigo 9.6%Phobic postural vertigo/Chronic Subjective Dizziness 19.5%Stroke

Central TumorMultiple Sclerosis 13.5%Chiari MalformationDegeneration (atrophy due to age or toxic agents)

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CNS “Dizziness Threshold “ Theory

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Rotary Chair Testing

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Computerized Dynamic Posturography

Case #1 BPPV

•73-year-old female, who started complaining of dizziness 3 months ago.

•One morning she woke up with room spinning

•The dizziness usually lasts 20 seconds when she is laying down or getting up; looking up or bending down

•Dizziness Handicap Index was 26/100

•She denies headaches, or nausea

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Left BPPV

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$159

$347

$952

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000

Primary Specialist ER

Av

era

ge

Co

st P

er

Pa

tie

nt

BPPV Patient Referral

Cost of Tests Prior to Consultation

Delayed Referral BPPV may

Cost 6 times More

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85 y/o male

Progressive imbalance and lightheadedness over past

5 years (current: 2-3 days bouts of imbalance per week)

Denied true vertigo; Denied hx of migraines

Denied anxiety or depression although reported some

life stressors

Denied fluctuation in hearing

Uses a cane and/or walker

MRI results showed no abnormal findings

Completed 4-5 weeks of vestibular therapy with no

significant improvement

Case #2

Vestibular Pattern on Rotary Chair and CDP

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Age-related neuronal degeneration in the vestibular system

YOUNG ADULT > 75 YEARS OLD DECREASES

SEMICIRCULAR

CANAL 7600 4600 40%

SACCULE 18,800 14,200 25%

UTRICLE 33,100 26,100 20%

VIII FIBERS 18,000 11,000 40%

Tinnitus

Hearing lossAnxiety/Stress

TMJNeck painInsomnia

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DENT Comprehensive

Dizziness and Balance Center

Audiogram/VNG

Rotary Chair

CT/MRIPosturography

Audiology ENT Dentist

Diz

zin

ess

Vertig

o

Gait

abnormal

FallsTinnitus

Hyperacusis

Vestibular therapy

Fall

PreventionPT

Concussion

TinnitusAssessment

Research

Psychiatrist/

Psychologist