Assessment & Management of Patients with Dizziness and Imbalance Sample A Sample, DPT, AIB-VR Company Name Address Phone Email Web Address Your Logo Here Introduction of (Practice Name), number of years, convenient locations, latest technology, etc. Member of the American Institute of Balance Affiliate Network of vestibular specialists. Trey is certified in Vestibular Assessment and Management by The American Institute of Balance Education Foundation. This means that we use proven ways to not only identify dizziness and balance problems but also treat these problems.

Dizzy Patients are Challenging Start Meniere’s disease Vestibular Neuritis Normal Successful Outcome Oscillopsia Vertigo Imbalance Uncompensated UVD No Auditory Sx Labyrinthitis MRI Acoustic Neuroma Normal VEMP Caloric Weakness HFHS Nystagmus Migraine Meclizine Superior Canal Dehiscence Vestibulotoxicity CT Scan VRT PST DVA Finish Vestibular Neuritis Uncompensated UVD VRT Normal PST DVA Start Vertigo Imbalance Oscillopsia Normal VEMP HFHS Nystagmus Caloric Weakness No Auditory Sx Successful Outcome VRT When we think about patients with dizziness, a number of things come to mind—Meniere’s disease, vestibular neuritis, labyrinthitis—Which patients really have vestibular problem and which need imaging studies? Should I get an MRI on all of these patients? In other words, these patients are not only Challenging but they are also time-consuming. Given today’s climate of healthcare reimbursement—more patients must be seen in the same amount of time to generate the same amount of revenue. Dizzy patients tend to be a drain on time of most practitioners. —At Montgomery Physical Therapy we are able to find the pathway through the maze of the dizzy patient Finish

Vestibular & Equilibrium Evaluation Right Left Both Sides Active Uncompensated Compensated Peripheral Vestibular Dx Central Nervous System (CNS) MRI MRA Further Medical Evaluation Patients who present with dizziness, lightheadedness, vertigo, unsteadiness or a history of falls represent an increasingly large segment of the patient population. These patients often are perplexing and time consuming for the physician, especially when all of their diagnostic studies, including imaging prove negative. Vestibular & Equilibrium evaluation provides a fast, non-invasive and economical answer to the origin of a patient’s symptoms. Evaluation should tell you if the problem is vestibular or CNS. If there is a vestibular involvement, you should be able to determine if there is active pathology, if the patient is compensated to the labyrinthine problem or uncompensated.

Medical Triage Evaluation results, along with your comprehensive medical evaluation, allow for triage of patients regarding management. This provides the practitioner with direction and management options for what often has been a challenging patient. In other words, Montgomery Physical Therapy can help you triage which patients should be imaged, which patients need Vestibular Rehabilitation, which patients need balance therapy, etc.. If the patient has BPPV, we can fix it.

Case History Symptoms: History: Acute Chronic Duration Days Frequency Precipitating Auditory Vertigo Dizziness Visual Headache Balance Speech Nausea Days Weeks Months Constant or episodic Sx Otologic Trauma Migraine Motion Sensitivity Vascular Metabolic Neurologic Diabetes Stroke History: There are many areas of consideration we take into account during the Case History: We know that 85% of patients with true vertigo have a vestibular problem, but you may not realize that 44% of patients with migraine actually also have a vestibular problem. We want to know if the Sx are Acute or Chronic? Is there an auditory component, etc. [I would not go into all of these but hit some high points.]

Vestibular Neuritis Second most common cause of vertigo Cause: Thought to cause 15% of all vertigo Cause: Viral infection (Herpes simplex virus) Other: occlusion of anterior vestibular artery, cerebellar infarction, toxic & allergic agents (seasonal aspect) Intense vertiginous attack with nausea & vomiting No auditory changes (except possibly ultra-high Freq.) Duration of episode is hours (48 - 72 hrs.) May develop BPPV – repositioning maneuver May be uncompensated – Vestibular Rehabilitation Let’s take a look at a few common problems that we often see [Do not cover every aspect, but do dwell on the fact that these patients may need VR and may have BPPV that needs to be treated. --Extra Information-- Location of problem: Superior portion of vestibular nerve & also Scarpa’s Ganglion No involvement of end organ Medical Treatment: Acute Attack - suppressants initially, then stop Recurrent Attacks - Antiviral medications (acyclovir, valtrex, etc.) Research Note: Recent studies of temporal bones of people diagnosed with Meniere’s Disease showed twice the level of herpes virus compared to controls (Vrabec, 2003)

Benign Paroxysmal Positional Vertigo (BPPV) Most common cause of vertigo Common in patients over 40; 50% of people >70 years will experience an attack Bilateral in 15% of patients Women > men 1.6:1 Key symptoms: Sudden, intense vertigo with head movements Short duration Diaphoresis & emesis Mild postural instability between attacks [Hit the high points but do not instruct them how to identify it or how to treat it. Explain that it can affect any of the three semicircular canals—you Explain that with your expertise, you are able to assess any person for BPPV affecting any of the three semicircular canals.] BPPV does not respond to pharmacological management BPPV is very common in the older population. This may trouble patients for years and can contribute to imbalance. --Extra Information-- Historical Perspective: First described by Barany (1921), Termed BPPV by Dix & Hallpike (1952), pathophysiology explained by Schuknecht (1969), revised by Parnes & McClure (1992), treatment option by Brandt & Darroff (1980), treatment option by Semont, Freyss, & Vitte (1988), treatment option by Epley (1992) Pathophysiology: Displacement of utricular otoconia into SCC (predominantly posterior canal) Canalithiasis or cupulolithiasis, distorts sensitivity of SCCs

Migraine Prevalence: 22,000 out of 100,000 3:1 female prevalence Aura: an abnormal sensory perception Vertigo: experienced as an aura in 25-30% of migraineurs Hearing Loss: 5% fluctuant or permanent Tinnitus Phonophobia: 75% hypersensitivity to sound (misophonia) Photophobia: 75% hypersensitivity to light Vestibulopathy in 44% of migraineurs Meniere’s disease is 2x more prevalent in this pop’n BPPV is 3x more prevalent in this pop’n Migraine is extremely common. Now notice that 30% of migraineurs experience vertigo as an aura. [Again, hit the high points but do not dwell for too long] There is also a high prevalence of peripheral vestibular problems in migraineurs. Meniere’s disease and BPPV are quite common as you can see. Evaluation at Montgomery Physical Therapy is imperative to help you identify and separate the migraine issues from any BPPV from any Meniere’s disease. --Extra Information-- Migraine by the Numbers: 12 categories of migraine (International Headache Society, 1988); 25 million Americans are migraineurs; only 41% of migraineurs receive a prescription for their migraine; 57% of migraineurs use OTC which may cause rebound headaches; 65% report lifelong Hx of motion intolerance Not all forms of migraine present with headache Causes: Genetic basis; vasoconstriction; abnormal electrochemical function; triggers such as MSG, sodium nitrates, tannins, etc.; Hormonal influence - onset in females around puberty Some forms of migraine recede with onset of menopause Alternatively, other forms actually begin at menopause Types of migraine that mimic a stroke: Familial hemiplegic migraine & Sporadic hemiplegic migraine With both, patient may experience dysarthria, & hemiparesis (numbness) FHM is diagnosed if patient has a family member with similar symptoms SHM is diagnosed if the patient is the only one in the family with these symptoms Medical Treatment: Verapamil; Topamax

Common Symptoms Following Vestibular Neuritis Trouble reading or focusing with head motion, i.e. oscillopsia May be provoked with specific direction or plane of movement Trouble reading signs when walking Side to side head turns i.e. sitting at a 4-way stop or shopping at the grocery store One important aspect of vestibular function is maintaining visual perception during head movement. When someone has a vestibular problem, they may develop blurred vision while walking, running, eating, driving, etc. This is called oscillopsia. In fact, research has shown that vision may degrade from 20/20 to 20/200 in patients who experience oscillopsia.

Common Balance Symptoms Associated with Vestibular Problems Unsteadiness History of Falls Surface Dependence Difficulty on dynamic or uneven surfaces Of course, the vestibular system is a key component of the system of equilibrium. When a patient has a vestibular problem, they may begin to experience imbalance. They may notice greater difficulty with ambulation outside compared to inside their homes. They may notice greater imbalance when they are ambulating in darkened environments or when showering.

Functional Impact & Prognosis BPPV UVD High Freq Partial Total BVD Multifactorial Functional Impact Low High Prognosis Excellent Poor When we think about different vestibular problems, in general the functional impact occurs along a continuum. BPPV, though extremely intense and unsettling for patients tends to have a lower functional impact than a total vestibular problem on one side which has a lower functional impact than a bilateral vestibular problem. Patients with vestibular problems, who have comorbid factors like orthopedic issues, Hx of stroke, macular degeneration, etc. tend to have the greatest functional impact. Of course we also see that prognosis is inversely related to functional impact. We know how to fix BPPV 80% of the time with a single treatment. Patients with mulitfactorial dysequilibrium should be referred for physical therapy to address their balance and/or vestibular issues. In some cases, because of the functional impact, assistive devices like a quad cane or walker may ultimately be the best for management of the patient.

Vestibular Treatment Options BPPV Repositioning Vestibular Rehabilitation UVD/BVD Balance Multifactorial So what are some of the options for treatment? Going into great detail is beyond the scope of our discussion today but I want you to understand one thing, at Montgomery Physical Therapy our job is to help you identify and manage your patients with dizziness and balance issues. If we identify BPPV, we are going to use a repositioning maneuver. The actual therapy technique varies depending on the involved semicircular canal, as well as specific patient characteristics—older patient vs. younger patient, recent hip replacement, rotator cuff, limited range of motion, etc. Repositioning [May mention a few of these, but no great detail] Appiani Canalith Casani Gans Semont For patients with uncompensated vestibular problems, Vestibular Rehabilitation is the route to go. For multifactorial patients, balance retraining is the route to take. The important part is in the evaluation. Vestibular patients do not improve with balance therapy and balance patients do not improve with vestibular therapy. Appropriate assessment from the beginning is the most efficient pathway to resolution of the patient’s symptoms. Of course, this is also the most cost-effective route to management. Vestibular Rehabilitation Adaptation Habituation Substitution Balance Strengthening Conditioning Fall Prevention ADLs

Who Should be Referred for Vestibular and Equilibrium Evaluation?  Patients with: 1. Vertigo 2. Lightheadedness 3. Recurrent dizziness 4. Imbalance or unsteadiness 5. Positional vertigo 6. History of falls According to researchers at Johns Hopkins, 85% of all vertigo may be attributed to a vestibular problem. So patients with a history of vertigo obviously need to be evaluated. Patients with positional vertigo must also be evaluated—the good news is that we can fix that in a very short period of time. As I said previously, patients with lightheadedness may have an uncompensated vestibular problem, but they could also have postural hypotension—we can help tease this out Patients with recurrent dizziness may have Meniere’s disease, recurrent vestibular neuritis, Migraine, among many other causes. Let us help you determine the origin so appropriate intervention can begin. Certainly patients with a history of falls and imbalance could have an underlying vestibular problem. We can help determine the appropriate management strategy.

“Learn to Live With it” The high success rate of treatment of Benign Paroxysmal Positioning Vertigo (BPPV) and successful Vestibular Rehabilitation and Balance Therapy has resulted in the recognition that patients do not have to learn to live with their symptoms. Patients do not like to be told “Learn to Live with It” – This is like telling the person they are old and they should feel blessed for every day they wake up alive! [May or may not want to say that depending on the crowd] The reality is that BPPV is extremely common in the older population—recall that 50% of people 70 and older will have BPPV at least once AND we know how to identify and manage this for you.

Vestibular & Balance Therapy Once an active or acute medical condition is excluded, the patient may benefit from Vestibular or Balance therapy. This has become the gold standard in the non-medical treatment of chronic Vestibular disorders. Vestibular rehabilitation, as well as balance therapy work—but you have to use these intervention approaches in the correct patients to demonstrate successful outcome.

Why is this important? As of January 1st, 2006, a new 60 year old is celebrating a birthday every 7 seconds. These celebrations will continue every seven seconds for the next 18 years!

The United States will look more like Florida Year # Americans 65 + % 1940 16.2 Million 9.2% 2000 35 Million 12% 2040 80 Million 20% In 1940 the majority of the U.S. population was under 30 years of age. Our community and the US, as a whole, is going to begin to look more like FL! We already said that BPPV is extremely common in older patients, but what are some other issues that we can help with? How about falls? [Go to Next slide]

Keeping Seniors Safe From Falls Act 110th Session of Congress, 2006 Balance problems may lead to: Hip and Limb Fracture Head Trauma Reduced Mobility Decreased Independence Falls leading cause of injury deaths among individuals who are over 65 years of age Hospital Admissions for Hip Fractures among the Elderly 1988 1999 2040 231,000 332,000 >500,000 --Extra Information you may want to use (at least a few) as talking points at first-- Falls leading cause of injury deaths among individuals who are over 65 years of age By 2030, population 65 years or older will double. By 2050, population 85 years of age or older will quadruple In 2000, falls among elderly accounted for 10,200 deaths and 1,600,000 ER visits 60% of fall-related deaths occur among individuals who are 75 years of age or older 25% of elderly who sustain a hip fracture die within 1 year This is such a huge issue that Congress has tried to address it with the Keeping Seniors Safe From Falls Act. If we look at projected hospital admissions for hip fractures only, we see some incredible numbers.

United States Congressional Findings Costs to Medicare and Medicaid programs and society as a whole from falls by elderly persons continue to climb. By 2020 direct costs alone will exceed $32,000,000,000. What about the costs? The numbers are staggering This is why Medicare and MCOs are becoming extremely cost-sensitive to the needs to dizzy & balance patients. The fact is that many patients end up have extensive, costly testing that is unnecessary or they go through inappropriate therapy—all at great expense. Implementing the appropriate strategies for assessment and management with an appreciation of cost is essential. Montgomery Physical Therapy can do this.

Vestibular Rehabilitation Program Ideal for vestibular patients with ongoing symptoms or significant imbalance. Improves activities of daily living at work or at home. Cost effective. Requires motivated patient willing to have therapy 2-3 times per week for 30-90 days. 5. Treatment efficacy as successful as clinician-directed. VRT may be delivered either through a self or clinician directed model. Here are some advantages of the self directed program. For certain of your patients, this would be the route to take. (hit high-points) For other patients, it may be more appropriate to implement a clinician-directed program of vestibular rehabilitation.

Adaptation Saccades Targets Circle Sways Focusing While Turning Head These are some examples of Adaptation exercises developed by Richard Gans of The American Institute of Balance. The goal here is to essentially “recalibrate” the CNS to the vestibular problem. Gans, R. (1996). Vestibular Rehabilitation: Protocols and Programs. AIB Education Foundation Press.

Habituation Ball Circles Horizontal Head Movements Gait with Head Turns Ball Circles Head Circles With Habituation exercises, we are attempting to eliminate the negative symptoms associated with the vestibular problem (dizziness, nausea, imbalance, fatigue, etc.) through repetition. Gans, R. (1996). Vestibular Rehabilitation: Protocols and Programs. AIB Education Foundation Press.

Results 95.6% cleared of Positional Vertigo after two GRM treatments This is simply some data on the Gans Repositioning Maneuver that was recently published. As you can see, we can clear 80% of patients with PC-BPPV in a single treatment. 95.6 in two treatments. A smaller percentage need additional treatment. Roberts, R., Gans, R., and Montaudo, R. (2006). “Efficacy of a new treatment for posterior canal benign paroxysmal positional vertigo”, Journal of the American Academy of Audiology, 17, 598-604.

Your Patients Do Not have to “Learn to Live With It” Let us help your patients with dizziness & balance problems Sample A Sample, DPT, AIB-VR Company Name Address Phone Email Web Address Your Logo Here Regardless of your dizziness or balance problem, you do not have to learn to live with it. (Practice Name) can determine what the problem is and how to fix it.