New Interventions: Physical Therapy: The New Drug into the Management of the Dizzy Patient

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New InterventionsPhysical Therapy The New
Drug into the Management of the Dizzy Patient

• Brian K. Werner, MPT
• December 15, 2006
• CME Sunrise Grand Rounds

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Brian K. Werner, MPT

• Masters Degree in Physical Therapy
• Northern Arizona University Flagstaff, AZ
• National Certification of Competency Vestibular
  Assessment and Treatment
• Miami School of Medicine Physical Therapy
  Department Miami, Fl (2000)
• Service
• Founder, Director and Lead Clinician of Balance
  Centers of America Las Vegas and Henderson
  (2001-2005) Branch
• Service
• Owner and Lead Clinician of the Werner Institute
  of Balance and Dizziness, Inc. (11/05 to present)

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What is Physical Therapy?

• Form of exercises designed to improve functional
  independence in patients
• Commonly associated with pain management.
• Treatment of dizziness and falls is a new
  modality.
• PTs are licensed clinicians (Masters/Doctorates)
  that are under a board that certifies licenses
  annually.
• PTs require 15 CME/CEUs annually.

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Prevalence of Dizziness

• General Population
• Nazareth, et. al, 1999
• Reported 4 of patients 18 to 65 who consult with
  GP reported persistent symptoms of dizziness
• 3 considered dizziness severely
  incapacitating.
• This is over 15 million Americans
• Yardley, et al, 1998 (follow-up study of
  Nazareth)
• One in 10 people of working age experience
  dizziness with some degree handicap (Yardley, et
  al, 1998).
• 18 months later concluded
• 24 more handicapped
• 20 had recurrent dizziness
• 20 improved
• Kroenke, et al (1992)
• Patient with initial complaint of dizziness
• Two weeks 70 no resolution
• 3 months 63 no resolution
• 11 months 47 no resolution
• CONCLUSION simple observation and reassurance
  are not appropriate in many cases.

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Prevalence of Dizziness

• Older/Aged Population
• 1000 Internal Medicine Clinics reported dizziness
  3rd most common complaint over age 59 with chest
  pain and fatigue noted more (Kroenke, 1989).
• Over age 75 number one complaint (Koch Smith,
  1995)
• Sloan et al, 1989 reported 18.3 of adults over
  60 suffer dizziness significant enough to seek
  physician, take medication, or interfere with
  normal activities a lot during the past year.
• Graying of America (U.S. Census Bureau)
• 65 and over will double over the next few decades
• 20 of the US population
• 85 and over will quadruple

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Prevalence of Dizziness

• Kroenke, et al, 2000 Combined Literature Review
  of 12 Articles on Etiology of Dizziness
• 44 - Vestibulopathy (PNS)
• 11 - Vestibulopathy (CNS)
• 16 - Psychiatric
• 26 - Other conditions
• 13 - Unknown causes
• 6 - Cerebrovascular disease
• 1.5 - Cardiac Arrhythmia
• lt1 - Brain Tumor

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Dont most people with dizziness recover
spontaneously?

• 6-8 weeks?
• others say 6 months to a year
• 80/20
• It is part of old age
• It will go away on its own..
• Its all in your head
• Learn to live with it
• What is the consensus?
• PT Opinion Look at how many fallers we have in
  our seniorsI think we are missing a lot of
  patients.
• 40 of the US Population (40 Million) go to their
  MDs for handicapping dizziness.
• Yesterday I had 38 patients on my schedule with
  chronic dizzinessI get referrals from less that
  1 of the local MDs?
• Where are all the people going

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Why Are We Seeing So May Patients with Chronic
Dizziness?

• Population growth
• More aging population baby boomers
• Multiple MedicationsIncreased Risk for Dizziness
• More Chronic diseases
• With Existing Dizzy Patients Why arent they
  improving
• MDs not knowing this therapy exists or actually
  works
• See attached article by Tee and Chee, 2005
• Unstable central or peripheral vestibular system
• Causes repeated changes in the functional status
  of the system (e.g., Menieres,BPPV)
• Maladaptive behaviors of avoidance in movements
• Creates a stable locus of the lesion (stalls
  compensation (e.g.., intermittent symptoms post
  vestibular neuritis, fear of falling)
• A second disease process interferes with
  compensation (e.g., Anxiety, Migraines, Stroke)
• Chronic use of medication initiated at onset not
  appropriately withdrawn (e.g., Meclizine,
  Benzodiazepines)

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The Need for Therapy Building the CaseEBM is
Paramount!

• Most patients play no active role in their own
  health care
• Rely totally on the Health Care Practitioner
  (HCP) to make decisions.
• Have overly optimistic view of the effectiveness
  of medical treatment
• Rarely question whether the recommended treatment
  has proved effective
• Onus on the HCP to provide treatment that has
  undergone rigorous clinical trials and be
  effective for most patients with a given
  diagnosis.
• Evidence Based Medicine (EBM) means integrating
  individual clinical expertise with the best
  available external clinical evidence from
  systematic research (Sackett, et al., 1996)

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The Need for VRT Building the Case

• Historical Perspective Three Options
• Medical Treatment of Symptoms (Medicate)
• Surgical Stabilization (Reparative or Ablation)
• Observation, Reassurance, and Counseling (Learn
  to Live with It)
• ALTERNATIVE Vestibular Therapy
• Cawthorne and Cooksey, 1945
• Patient who remained sedentary recovered slower
  than those who were more active
• Developed Cawthorne-Cooksey (C-C) exercises
• McCabe, 1970
• Expanded Cawthornes ideas and described
  Labyrinthine Exercises as our most single tool
  in the alleviation of protracted recurrent
  vertigo.
• Hecker, et al, 1974
• Used C-C exercises with vestibular-type patients
• 84 improved symptoms other 16 not improved
  due to lack of patient compliance or emotional
  distress
• Norre, 1988
• Optimal recovery period in animals following
  vestibular injury
• Suppressant medications and/or forced inactivity
  reduces natural compensation

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The Need for VRT Building the Case

• Horak, et al, 1992
• Three groups of patients with chronic vestibular
  complaints (VRT, medication, general activity)
• Those who used VRT showed the greatest
  improvement in functional performance
• General Activity improved to a lesser degree
• Medicated showed the least improvement
• Fujino, 1996
• Two groups Medication and Medication with VRT
• 8-weeks exercise with medication had less
  symptoms
• Shepard, et al, 1990
• Patients taking vestibular suppressants,
  antidepressant, tranquilizers, and
  anticonvulsants achieve the same level of
  compensation as patients not on meds length of
  therapy significantly longer on medications
• Telian and Shepard, 1995
• General VRT versus Customized Programs
• 64 using general therapy had complete resolution
• 85 using a customized had complete resolution

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What is Vestibular Retraining Therapy (VRT)?

• A set of physical therapy exercises designed to
  re-calibrate the balance system through
  specific practice of in-therapy treatment and
  customized home exercises. These include
• Habituation
• Adaptation
• Static/Dynamic Balance
• Strengthening/Endurance
• Manual Therapy (Cervical)
• Behavioral Therapy
• Repositioning Maneuver

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Vestibular Therapy The New Drug Key Concepts

• Referrals
• When Should I Refer for VRT?
• Specific interventions for BPPV (loose calcium in
  canal)
• Epley/Semont maneuvers
• General interventions for vestibular loss
• Unilateral loss (Neuritis/ Labyrinthitis)
• Bilateral Loss (Ototoxicity/ other)
• Persons with fluctuating vestibular loss (help
  prepare patient for future surgical treatments)
• Menieres disease (slowly fluctuating)
• Perilymphatic Fistula
• Experimental treatment where origin of dizziness
  is unclear
• Post-traumatic vertigo, CNS Dysfunction
• Multisensory dysfunction of aging
• Psychogenic vertigo for desensitization
• Phobic Positional Vertigo
• Fear of falling/provocation

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Vestibular Therapy The New Drug Key Concepts

• Indications/Contraindications
• When is this therapy not appropriate for my
  patient ?
• Almost any patient with dizziness associated with
  an inner ear dysfunction can benefit from the
  therapy
• Not Beneficial
• Vertebral Basilar Insufficiency (VBI)
• Unless there is a suspicion of BPPV
• Postural Hypotension
• Reducing/eliminating TIAs or Strokes
• Can help after a TIA/Stroke
• Extremely unstable Menieres disease
• Questionable (might help)
• Mal De Debarquement
• Have seen improvement just not complete
  resolution
• Cerebellar Degenerations
• May improve in strength/endurance
• Motion Intolerance
• Puma Method
• Basal Ganglia Syndromes (PSP, PD may help if
  slowly progressing)

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Vestibular Therapy The New Drug Key Concepts

• Compliance
• How Long will my patient attend the course or get
  home exercises ?
• Analogy Taking full dose of antibiotics
• Twice an week typical some need three depending
  on severity
• 4 to 12 weeks again depending on severity
• All patients get a customized home program.

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Vestibular Therapy The New Drug Key Concepts

• Education
• How do I convince the patient that they need this
  therapy versus medication?
• Probably the hardest thing to do
• Must convince the patient that medications only
  suppress the symptoms not fix the problem.
• Horak et al, 1992 VRT group versus medication
  reports least symptoms in 6 weeks
• VRT re-calibrates and re-organizes the balance
  system naturally without drugs
• Same techniques used by NASA and Military fighter
  pilots to adapt to environments
• Same techniques used to hit a golf ball
• Dizziness is the error message your brain needs
  to learn to overcome your symptoms suppressing
  or avoiding your symptoms only worsens the
  symptoms.

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Vestibular Therapy The New Drug Key Concepts

• Duration of Therapy/Refills/Dosing (twice a week)
• How will I know when to stop the program?
• Stable PNS vestibular disorders 6 to 8 weeks of
  therapy
• Stable CNS vestibular disorders 10 to 14 weeks
  of therapy
• Mixed (PNS/CNS) 14 to 18 weeks of therapy

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Vestibular Therapy The New Drug Key Concepts

• Side Effects/Toxicity
• How do you know the patient is getting the right
  therapy?
• The key is the diagnosis
• Second is proper treatment by a proper provider
• Physical therapists with certifications in
  vestibular disorders are paramount
• Not just any therapist should treat your dizzy
  patient
• Cost
• Do insurances cover this therapy? YES!!!
• The key is diagnosis coding on your part
• Dizziness in most cases in not reimbursable
  (780.4)
• Must use a functional diagnosis code 781.2
  (dysequilibrium)

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Vestibular Therapy The New Drug Key Concepts

• Functional Balance Testing
• What type of testing will you do with my
  patients?
• Computerized Dynamic Posturography
• Dynamic Visual Acuity Testing
• Functional Balance Testing (Sharpened Romberg)
• Vestibular Auto-Rotational Test (VAT)
• Infrared-Video Oculography (ENG)
• With Calorics

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Vestibular Therapy The New Drug Key Concepts

• How do I gauge the effects of the therapy with my
  patient?
• Symptom-mediated
• Dizziness questionnaires improved
• Reduced symptoms improved function
• ADL questionnaires
• Improved balance confidence improved function
• Findings-mediated
• Posturography Scores improved
• VAT scores improved
• Improved gain, phase, asymmetry
• Reduced Nystagmus under infrared
• Improved static/dynamic balance
• Sharpened Romberg
• Single Leg Stance

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How Does Vestibular Therapy Work?

• How does a figure-skater spin?
• How do NASA astronauts go to space or Nellis
  pilots tolerate flying a jet?
• Adapt and Habituateto the environment.
• VRT focuses on the plasticity of the central
  nervous system.
• Does not repair the damaged inner ear or
  brainstem.
• Works on getting the CNS and brain to adapt to
  the asymmetrical input from the VOR and VSR.
• Analogies for Patients
• Alternator and Battery System
• Inner ears Alternators
• Brainstem Battery
• Driving a car with the front end out of alignment
• Take your hands off the steering wheel

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Types of Patients Seen at a Balance Clinic

• Patients ages 10 to 103 years (Werner,2006)
• The Effect of Age on VRT Outcomes (Whitney, et
  al, 2003)
• Conclusion Age does not significantly influence
  the beneficial effects of VRT for persons with
  vestibular disorders.
• Increased time for older populations
• Types of Patients
• Chronic Mobility Disorders
• Dizziness/Dysequilibrium
• Fall Risk Identification Mgmt
• Head Injury/Concussions
• Neuro-Degenerative Diseases (MS, PD)
• Orthopedic (THR/TKR)
• Vestibular Disorders (PNS/CNS)
• Ototoxicity
• Post-Surgical Vestibular
• Workers Compensation
• Medico-Legal
• Performance Enhancement

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Does Vestibular Therapy Really Work?

• Currently no Gold Standard test/outcome key
  is symptom reduction and improved ADL
  independence.
• Cochrane Review
• BPPV Epley Maneuver helps reduce vertigo
• VRT for ULv
• Currently in protocol
• Question How much do you follow the Cochrane
  review in your pt. mgmt?
• Efficacy of Vestibular Rehabilitation (Review)
  (Whitney, et al, 2000)
• Review of 87 articles on VRT
• PNS disorders that are stable demonstrate better
  outcomes than CNS
• PT intervention works in most cases of vestibular
  disorders, regardless of age.

• Efficacy of VRT on Chronic ULV Dysfunction (2003)
• Purpose Supervised vs. Home Program (Used DHI
  and VAS)
• Prospective Study
• N125
• Conclusion Supervised demonstrated improved DHI
  and VAS scores
• Regardless of age, gender, or disability level

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Questions and Answers
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References

• Cawthorne, T. (1944). The physiological basis
  for head exercises. J Chart Soc Physiother 106-7.
• El-Kashlan, HK., et al. (1998). Disability from
  vestibular symptoms after acoustic neuroma.
  American Journal of Otology 19101-114.
• Hain, T. (2006). http//www.dizziness-and-balance.
  com/treatment/rehab.html
• Horak, FB., et al. (1992). Effects of Vestibular
  rehabilitation on dizziness and imbalance.
  Otolaryngology Head and Neck Surgery 106
  175-9.
• Kreb, DE., et al. (2003). Vestibular
  Rehabilitation useful but not universally so.
  Otolaryngology Head and Neck Surgery. 128
  240-50.
• Norre, M. (1988). Vestibular habituation
  training. Archives of Otolaryngology Head and
  Neck Surgery 114 883-86.
• Solomon, D Shepard, N. (2002). Chronic
  Dizziness. Current Treatment Options in
  Neurology Ophthalmology and Otology. 281-288.
• Whitney, et al. (2000). Efficacy of vestibular
  rehabilitation. Otolaryngologic Clinics of North
  America. 33,3 659-673.
• Whitney, et al (2003). The effect of age on
  vestibular rehabilitation outcomes. Laryngoscope.
  112,10 1785-90.