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

Physical Therapy  in Northern Arizona University – Flagstaff, AZ

National Certification of Competency

– Vestibular Assessment and Treatment  Miami School of Medicine: Physical Therapy Department – Miami, Fl (2000)

Service

 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     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

et al, 1998).

of working age experience dizziness with some degree handicap (Yardley, • 18 months later concluded:    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 3 rd most common complaint

pain and fatigue noted more (Kroenke, 1989).

•

Over age 75

over age 59 with chest

– 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?

        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?

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

•

See attached article by Tee and Chee, 2005 Unstable central or peripheral vestibular system

• Causes repeated changes in the functional status of the system (e.g., Meniere’s,BPPV)

Maladaptive behaviors of avoidance in movements

• 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

1996) (EBM) means integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sackett, et al.,



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

active • Developed Cawthorne-Cooksey (C-C) exercises than those who were more

McCabe, 1970

 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



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 in therapy treatment and customized home exercises. These include:        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

 Unilateral loss (Neuritis/ Labyrinthitis)  Bilateral Loss (Ototoxicity/ other) •

Persons with fluctuating vestibular loss (help prepare patient for future surgical treatments)

 Meniere’s disease (slowly fluctuating)  Perilymphatic Fistula •

Experimental treatment where origin of dizziness is unclear

  Post-traumatic vertigo, CNS Dysfunction Multisensory dysfunction of aging •

Psychogenic vertigo for desensitization

  Phobic Positional Vertigo Fear of falling/provocation

Vestibular Therapy – The New Drug – Key Concepts

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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

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Education



How do I convince the patient that they need this therapy versus medication?

• Probably the hardest thing to do… 

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

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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

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Functional Balance Testing



What type of testing will you do with my patients?

• • • • • 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

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How do I gauge the effects of the therapy with my patient?

 

Symptom-mediated

• Dizziness questionnaires improved  Reduced symptoms = improved function • ADL questionnaires  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   Sharpened Romberg Single Leg Stance

    

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.

VRT focuses on the

plasticity

the central nervous system.

of 

Does not repair

brainstem. the damaged inner ear or  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.

 Increased time for older populations

Types of Patients

            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?

Currently no “Gold Standard” test/outcome – key is symptom reduction and improved ADL independence.

Cochrane Review



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)

 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)

    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.