Vestibular Rehabilitation: Las Vegas, NV

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Vestibular RehabilitationLas Vegas, NV

• Presenter Brian K. Werner, PT, MPT
• Werner Institute of Balance and Dizziness, Inc.
• www.nomorevertigo.com

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Presentation Overview

• Statistics of Dizziness in the Community
• Current problems with dizziness management
• Basic Anatomy and Physiology review of Balance
• The vestibular system specifically
• What is dizziness?
• What is vestibular rehabilitation?
• Is There a need for specialized centers that work
  exclusively with dizziness?
• When to make a cross referral to the Werner
  Institute?
• What is new to the Werner Institute?
• Questions and Answers

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Brian Werner, PT, MPT

• B.S. Exercise Physiology
• Summa Cum Laude Graduate
• Northern Arizona University (NAU)
• Masters Degree Physical Therapy
• With Honors from NAU
• National Certification of Competency Vestibular
  Disorders - 2000
• University of Miami School of Medicine
• Started Balance Center of Las Vegas and
  Henderson 2001 2003
• Left BCLV in 2005
• Own and operate Werner Institute of Balance and
  Dizziness, Inc.
• Opened the Henderson location in 2008.

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Statistics

• By the age of 40, 40 of the population goes to
  their PCP for complaints of dizziness this is
  90 million people on average annually
• Less than 1 ever get therapy for dizziness
• By the age of 65, the 3rd leading PCP visit is
  imbalance/dizziness
• By 75, it is the number one reason for a visit!!!

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Current Problems with Dizziness Management

• We are seeing an over-medication of our patients
  with vestibular suppressants
• 70 of all patients coming into a PCP office with
  c/o dizziness get Meclizine (Burke, 1994)
  regardless of history of dysfunction.
• Barber, 1994 study found chronic use of Meclizine
  equals a blood alcohol level of 0.04 to 0.06
• You wonder why it would be prescribed
  especially in seniors
• Known to inhibit natural CNS compensation
• If patient with dysequilibrium, you may be doing
  more harm as Meclizine causes lethargy/fatigue
  and may increase fall risk.

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Current Problems with Dizziness Mgmt

• We are under-utilizing physical therapy services,
  especially balance retraining physical therapy.
• Why?
• We dont understand the therapy and how it works
• VRT has been used since the 1940s with
  Cawthorne-Cooksey Exercises
• Military started use of exercises in WWII for
  Concussion Injuries
• Most patients get better over time with a
  vestibular disorder is the assumption
• Yardley, et al. 1993 reported 20 of patients had
  full recovery of symptoms after a one year review
• At two years, 60 of population had recurrent
  symptoms

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Basic Anatomy of the Balance System
Postural Stability
Integration
Gaze Stability
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Over 80 of Classic Dizziness Originates from a
Vestibular Disorder

• Two Primary Sensors
• Semicircular Canals
• Function Angular accelerometer
• Roll over in bed
• Turn head up/down
• Three pairs of canals
• Work with the opposite
• Sensors act like a sail in the wind
• Push/Pull on the sensor due to flow of fluid
• Pattern of movement is what brain recognizes as
  motion

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Vestibular SystemSensors

• Primary Sensors
• Otolithic System
• Controls linear stability
• Forward/backward in car
• Up/Down in elevator
• Sensitive to gravity through Otoliths (crystals)
  bending hair cells
• Abnormal Function can create dizziness and
  disorientation

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What is Dizziness?

• Non-specific symptom in the treatment of balance
  disorders.
• Categorized in five types
• Vertigo
• Objective and Subjective
• Tilting whirling
• Lightheadedness
• Pre-syncope
• Motion Sickness
• Self or surroundings
• Dysequilibrium
• Imbalance to severe gait ataxia
• Floating (Psychogenic)
• Fear (provoking) and/or anxiety

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What Can Be Done for the Dizzy Patient Medically?

• Nothing
• learn to live with it
• It will go away over time
• Medicate
• Suppressive
• Inhibition of vestibular signal
• Meclizine antihistamine
• Valium/Klonapin CNS suppressant
• Reduction of fluid volume in the body
• Diuretics for Menieres disease

• Surgeries
• Ablative Menieres disease
• Repairs Perilymphatic Fistula Superior Canal
  Dehiscence
• Removals Acoustic Neuromas
• Extremely rare in general to surgically treat
  dizziness
• Therapies
• Allopathic
• Evidence Based Medicine
• Naturopathic
• Herbal
• Homeopathic
• Remedies
• Chiropractic
• CVR
• Spinal Manipulation
• Other

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When to Send to Specialized Physical Therapy for
Dizziness

• Severe fall risk patients
• Use ceiling full-body harness systems
• Complex Balance Disorders
• Use NASA and Navy based technology to determine
  origin of dizziness
• Will have the Epley OMNIAX chair to assess and
  treat complex BPPV
• When patients are just not improving
• We work closely with local specialist ENTs that
  understand vestibular disorders

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Need for Specialized Centers for Dizziness
Management

• I know as a PT clinician we all want to be able
  to treat whatever comes through the door the
  generalist.
• Not always set-up for every disorder in clinic
• Sub-specialization within the field of PT is
  common
• Seen in most medical practices across all
  disciplines
• APTA - Neurological Section
• Vestibular and Balance special interest groups
  (SIG)

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Specialized Testing in a Balance Center
Audiology Testing

• Videonystagmography (VNG)
• Allows the clinician to visualize the function of
  the vestibular system through the eyes
• Uses infrared video technology to see eyes in the
  dark
• Visualizing eye movement front-end out of
  alignment on car
• Helps to determine if the balance disorder is PNS
  or CNS in origin

Normal VNG
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Abnormal VNG
Brainstem Vestibular Injury
Left-sided Vestibulopathy
BPPV Posterior Canal
Horizontal BPPV - Cupulolithiasis
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Vestibular Rehabilitation - Historical Review

• Started in WWII in the 1940s
• Observed by two physicians - Cawthorne and
  Cooksey
• Post-concussion injuries in soldiers
• Those who got up and moved early on got over
  their dizziness and imbalance faster than those
  who were medicated or stayed bed bound.
• Mid 50s to 70s
• Brandt-Daroff and Habituation Norré Exercises
• Mid- 1980s to Late 1990s
• Shepard, AuD and Telian, MD
• Review Paper Programmatic Vestibular
  Rehabilitation
• Shepard, AuD and Solomon, MD
• Review Paper Chronic Dizziness
• Susan Herdman, PT, PhD and Susan Whitney, PT,
  ATC, PhD
• Started Competency Based Course for
• PT, OT, AuD, and MD/DO
• Who Else is getting involved in VR ?

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Vestibular Rehabilitation

• The Old Turf Battle Again (remember ATCs) ?
• AUDIOLOGIST!!!
• Practice Act from AAA states that audiologists
  are able to perform vestibular therapy billing
  97112.
• CHIROPRACTORS!!!
• Trademarked Chiropractic Vestibular Therapy
  (CVR)
• Most fall prevention programs are central to a
  non-pharmaceutical approach that is in concert
  with the practice of chiropractic.
• Would seem more in concert with PT?
• Chiropractors who are trained in Vestibular
  Rehabilitation will have the tools necessary to
  establish themselves as experts in the discipline
  in their community.
• A review of the literature identifies
  chiropractic care as an appropriate intervention
  for the patient with Menieres disease, vertigo
  and abnormal nystagmus all which are symptoms of
  vestibular brainstem imbalances.

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Most Common Vestibular Dysfunction in your
Clinic BPPV

• Sediment from Utricle loosens in the semicircular
  canal makes them responsive to gravity
• Assessed with the Hallpike-Dix Test
• Treatment of choice
• Epley Maneuver
• Canalith Repositioning Maneuver
• Omniax Chair
• (80-90 improvement in vertigo in 1-4 visits)
• NOTE BPPV
• (VRT Epley) in 70 of patients

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Canaliths Moving Through Posterior Canal
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Whats Coming to Las Vegas

• OMNIAX is almost here!!!
• Designed by the doctor who determined the
  treatment for BPPV
• John Epley, MD
• Only Seven (7) Systems in the world
• Werner Institute is going the have the 8th
  system.
• Will be available to see during open house during
  CSM 2009 at Summerlin clinic

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Questions and Answers