New Interventions:
Physical Therapy: The
New “Drug” into the
Management of the Dizzy
Patient
Brian K. Werner, MPT
December 15, 2006
CME – Sunrise Grand Rounds
Brian K. Werner, MPT

Master’s Degree in
Physical Therapy


Northern Arizona University –
Flagstaff, AZ
National Certification of
Competency – Vestibular
Assessment and Treatment


Service


Miami School of Medicine:
Physical Therapy Department –
Miami, Fl (2000)
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)
What is Physical Therapy?

Form of exercises designed
to improve functional
independence in patients



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Commonly associated with
pain management.
Treatment of dizziness and falls
is a new modality.
PT’s are licensed clinicians
(Masters/Doctorates) that are
under a board that certifies
licenses annually.
PT’s require 15 CME/CEUs
annually.
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:



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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.
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
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
<1% - Brain Tumor
Don’t most people with dizziness
recover spontaneously?




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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..
It’s all ‘in your head’”…
Learn to live with it…
What is the consensus?
 PT
Opinion: Look at how many fallers we have in our
seniors…I 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
dizziness…I get referrals from less that 1% of the local MDs?
• Where are all the people going…
Why Are We Seeing So May
Patients with Chronic Dizziness?
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Population growth
More aging population – baby boomers
Multiple Medications=Increased Risk for
Dizziness
More Chronic diseases
With Existing Dizzy Patients –
Why aren’t they improving:

MDs not knowing this therapy exists
or actually works
•

Unstable central or peripheral
vestibular system
•

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Causes repeated changes in the functional status of the
system (e.g., Meniere’s,BPPV)
Maladaptive behaviors of avoidance
in movements
•

See attached article by Tee and Chee, 2005
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)
The Need for Therapy – Building
the Case…EBM 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)
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

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Expanded Cawthorne’s 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
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

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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
What is Vestibular Retraining
Therapy (VRT)?

A set of physical therapy
exercises designed to
“re-calibrate” the
balance system through
specific practice of intherapy treatment and
customized home
exercises. These
include:
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Habituation
Adaptation
Static/Dynamic Balance
Strengthening/Endurance
Manual Therapy (Cervical)
Behavioral Therapy
Repositioning Maneuver
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

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Unilateral loss (Neuritis/ Labyrinthitis)
Bilateral Loss (Ototoxicity/ other)
• Persons with fluctuating vestibular loss (help prepare
patient for future surgical treatments)

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Meniere’s disease (slowly fluctuating)
Perilymphatic Fistula
• Experimental treatment where origin of dizziness is
unclear

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Post-traumatic vertigo, CNS Dysfunction
Multisensory dysfunction of aging
• Psychogenic vertigo for desensitization

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Phobic Positional Vertigo
Fear of falling/provocation
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 Meniere’s 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)
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.
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…
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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.
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
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)
Vestibular Therapy – The New
Drug – Key Concepts
 Functional

Balance Testing
What type of testing will you do with my
patients?
•
•
•
•
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Computerized Dynamic Posturography
Dynamic Visual Acuity Testing
Functional Balance Testing (Sharpened Romberg)
Vestibular Auto-Rotational Test (VAT)
Infrared-Video Oculography (ENG)

With Calorics
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

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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
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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 Habituate…to the environment.

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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
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.
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Increased time for older populations
Types of Patients
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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
Does Vestibular Therapy Really
Work?

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Currently no “Gold Standard”
test/outcome – key is symptom
reduction and improved ADL
independence.
Cochrane Review

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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)

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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)
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Purpose: Supervised vs. Home
Program (Used DHI and VAS)
Prospective Study
N=125
Conclusion: Supervised demonstrated
improved DHI and VAS scores
•
Regardless of age, gender, or disability
level
Questions and Answers
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 19:101-114.
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.