1. Vestibular Rehabilitation: Las Vegas, NV
Presenter: Brian K. Werner, PT, MPT
Werner Institute of Balance and Dizziness, Inc.

2. 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

3. Brian Werner, PT, MPT B.S. – Exercise Physiology
Summa Cum Laude Graduate
Northern Arizona University (NAU)
Master’s Degree – Physical Therapy
With Honors from NAU
National Certification of Competency – Vestibular Disorders
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.

4. 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!!!

5. 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.

6. Current Problems with Dizziness Mgmt
We are under-utilizing physical therapy services, especially balance retraining physical therapy.
Why?
We don’t understand the therapy and how it works
VRT has been used since the 1940’s 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 reported 20% of patients had full recovery of symptoms after a one year review
At two years, 60% of population had recurrent symptoms

7. Basic Anatomy of the Balance System
Postural Stability
Integration
Gaze Stability

8. 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

9. Vestibular System: Sensors
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

10. 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

11. 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 Meniere’s disease
Surgeries
Ablative – Meniere’s 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

12. 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

13. 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)

14. 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

15. Brainstem Vestibular Injury Left-sided Vestibulopathy
Abnormal VNG
Brainstem Vestibular Injury
Left-sided Vestibulopathy
BPPV – Posterior Canal
Horizontal BPPV - Cupulolithiasis

16. Vestibular Rehabilitation - Historical Review
Started in WWII in the 1940’s
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 50’s to 70’s
Brandt-Daroff and Habituation Norré Exercises
Mid- 1980’s to Late 1990’s
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 

17. Vestibular Rehabilitation
The Old Turf Battle Again (remember ATCs) 
AUDIOLOGIST!!!
Practice Act from AAA states that audiologists are able to perform vestibular therapy – billing
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 Meniere’s disease, vertigo and abnormal nystagmus; all which are symptoms of vestibular brainstem imbalances.

18. 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

19. Canaliths Moving Through Posterior Canal…

20. What’s 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

21. Questions and Answers