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Treatment of Dizziness with Physical Therapy

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Treatment of Dizziness with Physical Therapy A New Drug for Patient Management University of Arkansas Medical School Neurology Presenter: Brian K. Werner, PT, MPT – PowerPoint PPT presentation

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Title: Treatment of Dizziness with Physical Therapy


1
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

2
Overview
  • 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?

3
The Dizziness Problem (Hain, 2010)
  • Dizziness is the primary complaint in 2.5 all
    primary care visits 8 million/year visits
    (Sloan).
  • Practically, there are far more patients with
    dizziness/ataxia than there are clinic openings
    with doctors with an interest in caring for
    them.

4
The Dizziness Problem (Hain, 2010)
  • There are four substantial causes of dizziness
  • Otologic (40-50)
  • Ex. BPPV, VN, SCD, Menieres
  • Neurologic (10-30)
  • Ex. VBI, Stroke, Migraine, Low CSF
  • General medical (10-30)
  • B12, Orthostatic Hypotension, DM (Hypoglycemia)
  • Psychiatric/undiagnosed causes (15-50)
  • Anxiety, Malingering, Exaggeration, Avoidance
    Behavior

5
Physical Therapist
  • 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)
  • Current PT at WIBD holds her doctorate (DPT)
  • Will be required by 2020 for All Schools

6
Physical Therapist
  • Specializations
  • Geriatric, Neurological, Orthopedic, Pediatric,
    etc.
  • Similar to Medical Schools that provide
    specializations
  • Vestibular
  • Special Interest Group within APTA
  • None yet
  • Herdman Certification at Emory
  • Advanced Certifications
  • Werner Institute Internal Certification Program
  • Annual
  • Working on a ScD in Vestibular Science at UNLV
    (Nevada)
  • Residency Program

7
Dizziness is Like PainNon-Specific
  • Dizziness
  • Vertigo
  • Lightheadedness
  • Giddiness
  • Visual Sensitivity
  • Floating
  • Wooziness
  • Unsteady
  • Dysequilibrium
  • Behavior
  • Fearful, Anxious, Exaggerated, Malingered
  • Pain
  • Sharp
  • Shooting
  • Radiating
  • Dull
  • Burning
  • Aching
  • Behavior
  • Fearful, Anxiety-provoking, Exaggerated,
    Malingered

8
Dizziness (Kroenke, 2001)
Non-Syncope
Added to the list.
9
Why Physical Therapy for the Treatment of
Dizziness?
  • Think of PT as a Medication/Drug
  • You can prescribe it
  • There are several forms of dizziness you can use
    it for
  • There is a frequency and duration of PT
  • There is a dosage
  • There are precautions and contraindications
  • You can overdose with it

10
Why Physical Therapy for the Treatment of
Dizziness?
  • Primary Reason Quality of Life!
  • 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).

11
Why Physical Therapy for the Treatment of
Dizziness?
  • Secondary Reasons
  • Cost-effective medical management
  • Ex. Average treatment for BPPV is 95 weeks, 3-5
    physician referrals, diagnostic (MRI, CAT, Blood
    Work)
  • Dix-Hallpike test at bedside and Epley Maneuver
    about 80
  • Reduce Prolonging Disorder
  • Many patients with dizziness avoid movements or
    activities that trigger their symptomsprolonging
    the disorder PTs are great at getting patients
    to do things they dont want to do

12
Brand Names for Physical Therapy for Dizziness
  • Vestibular Therapy/Rehabilitation (VR)
  • Balance Retraining Physical Therapy (BRPT)
  • Habituation Training
  • Adaptation Training
  • VOR training
  • Canalith Repositioning Maneuvers
  • Epley, Semont, Lempert, Gufoni,
    Asperella-Vanuchi, Nylen-Barany Maneuver
  • VoodooWhat is the Evidence it Works Better than
  • Tincture of Time
  • Medications
  • Combinations of Each

13
What Does This Medication Comprise ofIts Make-up?
  • Adaptation Training
  • Used to assist restoring gaze stability
  • Trains the VOR to work with CNS oculomotors
  • Habituation Training
  • Helps desensitize the patient to
    positions/movements
  • Canalith Repositioning Maneuvers
  • Epley, Semont, Lempert, Gufoni, Apiani
  • Several types need to be specific

14
What Does This Medication Comprise ofIts Make-up?
  • Static and Dynamic Balance Training
  • Gait Training
  • Strengthening/Endurance Training
  • Manual Cervical Therapies
  • Education, Education, Education

15
Top DoctorsOn VR Therapy
  • Timothy Hain, MD (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)
  • Properly conducted and supervised vestibular
    rehabilitation therapy ameliorates a wide variety
    of peripheral and central balance disorders in
    patients of all ages.
  • Edwin Monsell, MD, PhD (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.

16
Top DoctorsOn VR Therapy
  • Robert 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)
  • 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.

17
Top DoctorsOn VR Therapy
  • Cochrane Collaboration (2007) Reviewed Vestibular
    Therapy for Unilateral Vestibular Disorders
  • 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
  • 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

18
Tincture of TimeWait and See
  • What is the optimal time to wait before starting
    a VR program?
  • BPPV ? Immediately (AAN, 2007 AAO, 2008)
  • Common Statements about VN Patients will recover
    naturally within
  • 2 weeks - 6 weeks - 2 months?
  • 6 months to a year?
  • Is the recovery complete or partial?
  • 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?
  • Physical Therapy

19
Tincture of TimeWait and See
  • Lucy Yardley, PhD (Department of Psychology
    Southampton, UK)
  • At 18 months, 24 of respondents were more
    handicapped due to dizziness
  • 20 had recurrent dizziness
  • 20 improved
  • Kroenke, K (2000)
  • In US, 50 of patients at 3 month follow-ups
    continued to complain of symptoms
  • 33 reported handicapped because of symptoms
  • Conclusion
  • Maybe we should rethink when patients should
    start therapy.

20
Medication Management of the Chronic Dizzy Patient
  • David Solomon, MD (University of Pittsburg
    Neurology Department)
  • 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)

21
Goals for Physical Therapy and VR
  • The goals of vestibular physical therapy are
    (Whitney, S, 2003)
  • 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 patients ability to perform
    daily activities.

22
What Diagnoses Benefit the Most From VR?
  • BPPV/BPPV
  • Vestibular Neuritis/ Neuronitis/ Labyrinthitis
  • Chronic Dizziness (Idiopathic)
  • Dysequilibrium with Age
  • Menieres Disease (Stable)
  • Surgical
  • Less Than One Attack Per Month
  • Post Surgical (ANR, PLF)
  • Central Vestibular (Brainstem, Cerebellar)
  • Central (MS, PD, Stroke)

23
BPPV
  • When Should This Treatment Be Prescribed?
  • Within the first 1-3 days of onset if possible
    (AAN, 2006).
  • What is the Average Treatment Time?
  • 1-4 visits unless atypical (BPPV)
  • What are Contraindications?
  • Cervical DJD/DDD
  • VBI

24
BPPV (Pollak, 2002)
  • When Should This Treatment Be Prescribed?
  • If BPPV is recalcitrant
  • Once BPPV resolves, patient continues to have
  • Oscillopsia
  • Adaptation Training for VOR
  • Dysequilibrium
  • Static/Dynamic Balance Training
  • Positioning Dizziness
  • Habituation Training
  • What is the Average Treatment Time?
  • 2-3 times a week for 6-8 weeks
  • What are Contraindications?
  • None

25
Unilateral Vestibular Hypofunction (VN, ANR,
post-PLF/Menieres
  • What Symptoms are You Treating?
  • Oscillopsia
  • Adaptation Training for VOR
  • Dysequilibrium
  • Static/Dynamic Balance Training
  • Positioning Dizziness
  • Habituation Training
  • When Should This Treatment Be Prescribed?
  • Once patient has resolved static balance
    compensation
  • Patient is asymptomatic as long as he/she does
    not move
  • What is the Average Treatment Time?
  • 2-3 times a week for 6-8 weeks
  • What are Contraindications?
  • None

26
Dysequilibrium with Age
  • What Symptoms are You Treating?
  • Oscillopsia (Gaze Instability)
  • Adaptation Training for VOR paresis
  • Unsteady Gait/Instability
  • Static/Dynamic Balance Training
  • Positioning/Positional Dizziness
  • Habituation Training
  • Canalith Repositioning Maneuvers
  • Disuse/Deconditioning
  • Strength/Endurance Training
  • When Should This Treatment Be Prescribed?
  • Once disorder is identified with functional
    balance testing in office
  • TUG, Single Leg Stance
  • What is the Average Treatment Time?
  • 2-3 times a week for 12-24 weeks
  • What are Precautious/Contraindications?
  • Dementia/Alzheimer's Disease
  • Severe Lumbar Disease
  • Severe Panic Attack/Fear

27
What Patients May Not Benefit From This Treatment?
  • Mal De Debarquement Syndrome
  • Many times the symptoms are driven by
    non-vestibular mechanism
  • Many patients have behavior overlay that requires
    medication
  • Unstable Menieres disease
  • Requires a medication management and possibly
    Neurotology Consultation for surgical management
  • Perilymphatic Fistula
  • Requires a medication management and possibly
    Neurotology Consultation for surgical management
  • Eustachian Tube Dysfunction
  • Requires a medication management and possibly
    Neurotology Consultation for surgical management

28
What Devices Do We Use to Monitor the
Medication/Treatment
  • Computerized Dynamic Posturography
  • Improvement in Scores (SOT/MCT) supports CNS
    compensation

Improved Scores Supports CNS Compensation and a
decrease in fall risk.
29
What Devices Do We Use to Monitor the
Medication/Treatment
  • Videonystagmography
  • Rarely performed after the initial
    evaluationhowever
  • CNS Compensation
  • Improved/reduced nystagmus with spontaneous and
    positional nystagmus tests
  • Resolution of BPPV with Dix-Hallpike under VNG
  • Particularly with OMNIAX system
  • Improvement with Oculomotor responses

30
What Devices Do We Use to Monitor the
Medication/Treatment
  • Vestibular Autorotational Testing (VAT)
  • Improved scores (GAIN, PHASE) and a reduction in
    Asymmetry (CNS compensation)

Improved Scores Support CNS Compensation
31
InVision Gaze Testing
  • The Computerized Illegible E Test (Mallinson and
    Longridge, 2006)

Improved Scores support CNS Compensation
32
Future Presentations
  • Bedside Treatment of BPPV
  • Physical Therapy Management of MS
  • Physical Therapy Management of PD
  • Vestibular Diagnostics in Neurology
  • Videonystagmography
  • Computerized Dynamic Posturography
  • Rotational Testing

33
References
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