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? Why Physical Therapy for the Treatment of Dizziness? How do We Define Dizziness in Our Patients? How do We Define Dizziness in Our Patients? What Patients Benefit from this Treatment? What Patients Benefit from this Treatment? Why is this Treatment prescribed/for what types of patients? Why is this Treatment prescribed/for what types of patients? What are the Goals for Physical Therapy? What are the Goals for Physical Therapy? When Should This Treatment Be Prescribed? When Should This Treatment Be Prescribed? How should this Treatment be used? How should this Treatment be used? What special precautions should be followed? What special precautions should be followed? What should the patient do if they forget a dose? What should the patient do if they forget a dose? What side effects can this Treatment cause? What side effects can this Treatment cause? Can My Patient Overdose on this Medication? Can My Patient Overdose on this Medication? What other information should I know? 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). 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.” “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, Meniere’s 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 Not a personal trainer or massage therapist All physical therapist must now attain a post-bachelor college graduate from Accredited Physical Therapy Schools All physical therapist must now attain a post-bachelor college graduate from Accredited Physical Therapy Schools Minimal Masters degrees Minimal Masters degrees MSPT – Research Masters MSPT – Research Masters MPT – Clinical Masters MPT – Clinical Masters Doctorate of Physical Therapy (AR) Doctorate of Physical Therapy (AR) Current PT at WIBD holds her doctorate (DPT) Current PT at WIBD holds her doctorate (DPT) Will be required by 2020 for All Schools Will be required by 2020 for All Schools

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

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

8. Dizziness (Kroenke, 2001) Dizziness Vertigo Dysequilibrium LightheadednessPre-SyncopeBehavioral ***Motion Intolerance Non-Syncope *** Added to the list.

9. Why Physical Therapy for the Treatment of Dizziness? Think of PT as a Medication/Drug Think of PT as a Medication/Drug You can prescribe it You can prescribe it There are several forms of dizziness you can use it for… There are several forms of dizziness you can use it for… There is a frequency and duration of PT There is a frequency and duration of PT There is a dosage There is a dosage There are precautions and contraindications There are precautions and contraindications You can overdose with it 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). 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 symptoms…prolonging the disorder – PT’s are great at getting patients to do things they don’t want to do

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

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

14. What Does This Medication Comprise of…Its Make-up? Static and Dynamic Balance Training Static and Dynamic Balance Training Gait Training Gait Training Strengthening/Enduranc e Training Strengthening/Enduranc e Training Manual Cervical Therapies Manual Cervical Therapies Education, Education, Education… Education, Education, Education…

15. Top Doctors…On VR Therapy Timothy Hain, MD (Rehabilitation Institute of Chicago) 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.” “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) 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.” “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) 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.” “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) 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.” “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 Doctors…On VR Therapy Robert Baloh, MD (UCLA School of Medicine) 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… 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) 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.” “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 Doctors…On VR Therapy Cochrane Collaboration (2007) Reviewed Vestibular Therapy for Unilateral Vestibular Disorders Cochrane Collaboration (2007) Reviewed Vestibular Therapy for Unilateral Vestibular Disorders 32 Randomized Clinical Studies Identified – 11 excluded (Total - 21) 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. Studies addressed the effectiveness of vestibular rehabilitation against control/sham interventions, non-vestibular rehabilitation interventions, or other forms of vestibular rehabilitation. Two Primary Findings: Two Primary Findings: 1. Repositioning Maneuvers should be used with BPPV versus VR 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 2. There is moderate to strong evidence that VR is a safe, effective management for unilateral peripheral vestibular dysfunction

18. Tincture of Time…Wait and See What is the optimal time to wait before starting a VR program? What is the optimal time to wait before starting a VR program? BPPV  Immediately (AAN, 2007; AAO, 2008) BPPV  Immediately (AAN, 2007; AAO, 2008) Common Statements about VN: Patients will recover naturally within: Common Statements about VN: Patients will recover naturally within: 2 weeks - 6 weeks - 2 months? 2 weeks - 6 weeks - 2 months? 6 months to a year? 6 months to a year? Is the recovery complete or partial? 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 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? What is the most cost-effective approach to management? Physical Therapy Physical Therapy

19. Tincture of Time…Wait and See Lucy Yardley, PhD (Department of Psychology – Southampton, UK) Lucy Yardley, PhD (Department of Psychology – Southampton, UK) At 18 months, 24% of respondents were more handicapped due to dizziness At 18 months, 24% of respondents were more handicapped due to dizziness 20% had recurrent dizziness 20% had recurrent dizziness 20% improved 20% improved Kroenke, K (2000) Kroenke, K (2000) In US, 50% of patients at 3 month follow-ups continued to complain of symptoms In US, 50% of patients at 3 month follow-ups continued to complain of symptoms 33% reported handicapped because of symptoms 33% reported handicapped because of symptoms Conclusion: Conclusion: Maybe we should rethink when patients should start therapy. 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 patient’s ability to perform daily activities.

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

23. BPPV When Should This Treatment Be Prescribed? When Should This Treatment Be Prescribed? Within the first 1-3 days of onset if possible (AAN, 2006). Within the first 1-3 days of onset if possible (AAN, 2006). What is the Average Treatment Time? What is the Average Treatment Time? 1-4 visits unless atypical (*BPPV+) 1-4 visits unless atypical (*BPPV+) What are Contraindications? What are Contraindications? Cervical DJD/DDD Cervical DJD/DDD VBI 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/Meniere’s What Symptoms are You Treating? What Symptoms are You Treating? Oscillopsia Oscillopsia Adaptation Training for VOR Adaptation Training for VOR Dysequilibrium Dysequilibrium Static/Dynamic Balance Training Static/Dynamic Balance Training Positioning Dizziness Positioning Dizziness Habituation Training Habituation Training When Should This Treatment Be Prescribed? When Should This Treatment Be Prescribed? Once patient has resolved static balance compensation Once patient has resolved static balance compensation Patient is asymptomatic as long as he/she does not move Patient is asymptomatic as long as he/she does not move What is the Average Treatment Time? What is the Average Treatment Time? 2-3 times a week for 6-8 weeks 2-3 times a week for 6-8 weeks What are Contraindications? What are Contraindications? None None

26. Dysequilibrium with Age What Symptoms are You Treating? 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? 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? What is the Average Treatment Time? 2-3 times a week for 12-24 weeks What are Precautious/Contraindications? What are Precautious/Contraindications? Dementia/Alzheimer's Disease Dementia/Alzheimer's Disease Severe Lumbar Disease Severe Lumbar Disease Severe Panic Attack/Fear Severe Panic Attack/Fear

27. What Patients May Not Benefit From This Treatment? Mal De Debarquement Syndrome Mal De Debarquement Syndrome Many times the symptoms are driven by non-vestibular mechanism Many times the symptoms are driven by non-vestibular mechanism Many patients have behavior overlay that requires medication Many patients have behavior overlay that requires medication Unstable Meniere’s disease Unstable Meniere’s disease Requires a medication management and possibly Neurotology Consultation for surgical management Requires a medication management and possibly Neurotology Consultation for surgical management Perilymphatic Fistula Perilymphatic Fistula Requires a medication management and possibly Neurotology Consultation for surgical management Requires a medication management and possibly Neurotology Consultation for surgical management Eustachian Tube Dysfunction Eustachian Tube Dysfunction Requires a medication management and possibly Neurotology Consultation for surgical management 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 Computerized Dynamic Posturography Improvement in Scores (SOT/MCT) supports CNS compensation 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 Videonystagmography Rarely performed after the initial evaluation…however: Rarely performed after the initial evaluation…however: CNS Compensation CNS Compensation Improved/reduced nystagmus with spontaneous and positional nystagmus tests Improved/reduced nystagmus with spontaneous and positional nystagmus tests Resolution of BPPV with Dix-Hallpike under VNG Resolution of BPPV with Dix-Hallpike under VNG Particularly with OMNIAX system Particularly with OMNIAX system Improvement with Oculomotor responses Improvement with Oculomotor responses

30. What Devices Do We Use to Monitor the Medication/Treatment Vestibular Autorotational Testing (VAT) Vestibular Autorotational Testing (VAT) Improved scores (GAIN, PHASE) and a reduction in Asymmetry (CNS compensation) 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) The Computerized Illegible E Test (Mallinson and Longridge, 2006) Improved Scores support CNS Compensation

32. Future Presentations Bedside Treatment of BPPV Bedside Treatment of BPPV Physical Therapy Management of MS Physical Therapy Management of MS Physical Therapy Management of PD Physical Therapy Management of PD Vestibular Diagnostics in Neurology Vestibular Diagnostics in Neurology Videonystagmography Videonystagmography Computerized Dynamic Posturography Computerized Dynamic Posturography Rotational Testing Rotational Testing

33. References